State Tobacco Control Policies Research Articles

Abstract 15711: Association Between State Tobacco Surcharge Policy and Health Insurance Enrollment, Health Care Utilization, and Smoking Cessation Behaviors

Introduction: The Patient Protection and Affordable Care Act allows insurers to charge up to 50% higher premiums to people who use tobacco. Several states have outlawed tobacco surcharges or capped the surcharges to lower levels. Evidence on the impact of state policies limiting tobacco surcharges is limited. This study aims to examine the association between state tobacco surcharge policies and individuals’ health insurance enrollment, health care utilization, and smoking cessation behaviors. Methods: This study used data from the Population Assessment of Tobacco and Health (PATH) Study Wave 6 (Mar-Nov 2021). The study sample was adults 18-64 years old who reported smoking cigarettes 20 or more days in the past 30 days (N=4,235). Exposure was living in states limiting tobacco surcharges (outlawed or capped). Outcome variables were currently covered by health insurance, seen a health professional in the past 12 months, intention to quit within 12 months, and any quit attempt in the past 12 months. Single-wave sample weights and balanced repeated replication method were applied to generate representative estimates and variances. Multivariate logistic regressions were used to estimate the associations between exposure and outcomes, controlling for socio-demographic variables, other tobacco use status, and state Medicaid expansion and tobacco control policies. Results: Among study sample, 19.8% (95% CI: 16.0%-24.3%) lived in states limiting tobacco surcharges. Bivariate associations showed that people living in states limiting surcharges were more likely to be covered by health insurance (84.5%, 95% CI: 81.2%-87.3% vs. 75.0%, 95% CI: 72.9%-77.1%, p < 0.001). After adjusting for covariates, the association between state policies and health insurance coverage became statistically insignificant (adjusted odds ratio, aOR=1.09, 95% CI: 0.80-1.47). Participants living in states limiting surcharges were less likely to have intention to quit within 12 months (aOR=0.78, 95% CI: 0.65-0.94). Other associations were not statistically significant. Conclusions: This study indicated that people living in states limiting tobacco surcharges had lower intention to quit smoking. More studies are needed to evaluate the impact of tobacco surcharge policies.

A Comprehensive Program to Reduce Tobacco-related Cancers Through Actions by a National Cancer Institute-designated Cancer Center.

Tobacco use accounts for 30% of all cancer-related deaths worldwide and 20% in the US, despite effective, evidence-based interventions for reducing tobacco use and tobacco-related cancers and deaths. In 2012, to reduce the burden of tobacco-related cancer and associated population-level risks across Texas, The University of Texas MD Anderson Cancer Center initiated the EndTobacco® program to promote statewide cancer control activities. We created evidence-based initiatives, established selection criteria, and implemented actions involving policy, education, and tobacco treatment services. As a result, EndTobacco has supported, educated, and convened local and state coalitions in policymaking; provided tobacco treatment education to health professionals; implemented Texas' only certified tobacco treatment training program; and led an initiative to enhance the tobacco-free culture of the state's publicly funded university system. Supported by commitments from MD Anderson, we developed and implemented evidence-based actions for tobacco control tailored to the center's mission, values, expertise, resources, and partnerships. By 2021, the adult smoking rate in Texas dropped from 19.2% (2014) to 13.2%. Contributors to this drop include state tobacco control policies, programs and services from multiple agencies and associations, and EndTobacco activities that complement the statewide effort to prevent youth smoking initiation and increase quit attempts among youth and adults.

Association of state tobacco control policies with active smoking at the time of intervention for intermittent claudication

ObjectiveActive smoking among patients undergoing interventions for intermittent claudication (IC) is associated with poor outcomes. Notwithstanding, current levels of active smoking in these patients are high. State-level tobacco control policies have been shown to reduce smoking in the general US population. We evaluated whether state cigarette taxes and 100% smoke-free workplace legislation are associated with active smoking among patients undergoing interventions for IC. MethodsWe queried the Vascular Quality Initiative database for peripheral endovascular interventions, infrainguinal bypasses, and suprainguinal bypasses for IC. Active smoking at the time of intervention was defined as smoking within one month of intervention. We implemented difference-in-differences analysis to isolate changes in active smoking owing to cigarette taxes (adjusted for inflation) and implementation of smoke-free workplace legislation. The difference-in-differences models estimated the causal effects of tobacco policies by adjusting for concurrent temporal trends in active smoking unrelated to cigarette taxes or smoke-free workplace legislation. The models controlled for age, sex, race/ethnicity, insurance type, diabetes, chronic obstructive pulmonary disease, state, and year. We tested interactions of taxes with age and insurance. ResultsData were available for 59,847 patients undergoing interventions for IC in 25 states from 2011 to 2019. Across the study period, active smoking at the time of intervention decreased from 48% to 40%. Every $1.00 cigarette tax increase was associated with a 6-percentage point decrease in active smoking (95% confidence interval, −10 to −1 percentage points; P = .02), representing an 11% decrease relative to the baseline proportion of patients actively smoking. The effect of cigarettes taxes was greater in older patients and those on Medicare. Among patients aged 60 to 69 and 70 to 79 years, every $1.00 tax increase resulted in 14% and 21% reductions in active smoking relative to baseline subgroup prevalences of 53% and 29%, respectively (P < .05 for both); however, younger age groups were not affected by tax increases. Among insurance groups, only patients on Medicare exhibited a significant change in active smoking with every $1.00 tax increase (an 18% decrease relative to a 33% baseline prevalence; P = .01). The number of states implementing smoke-free workplace legislation increased from 9 to 14 by 2019; however, this policy was not significantly associated with active smoking prevalence. At follow-up (median, 12.9 months), $1.00 tax increases were still associated with decreased smoking prevalence (a 25% decrease relative to a 33% baseline prevalence; P < .001). ConclusionsCigarette tax increases seem to be an effective strategy to decrease active smoking among patients undergoing interventions for IC. Older patients and Medicare recipients are the most responsive to tax increases.

The Affordable Care Act Medicaid Expansion and Smoking Cessation Among Low-Income Smokers

This study sought to empirically evaluate whether the Medicaid expansion under the Affordable Care Act increased smoking cessation among low-income childless adult smokers. The effects of the Medicaid expansion on smoking quit attempts and the probability of 30- and 90-day smoking cessation were evaluated using logistic regression and data from the 2010-2011 and 2014-2015 waves of the Tobacco Use Supplement to the Current Population Survey. Using boosted logistic regression, the Tobacco Use Supplement was restricted to an analytic sample composed of childless adults with high probability of being <138% of the federal poverty level. Propensity score weighting was used to compare changes in smoking cessation among a sample of current and past smokers in states that expanded Medicaid with a control sample of current and past smokers in states that did not expand Medicaid with similar sociodemographic characteristics and smoking histories. This study additionally controlled for state socioeconomic trends, welfare policies, and tobacco control policies. Analysis was conducted between January 2018 and June 2019. After weighting by propensity score and adjusting for state socioeconomic trends, welfare policies, and tobacco control policies, the Medicaid expansion was not associated with increases in smoking quit attempts or smoking cessation. The Medicaid expansion did not appear to improve smoking cessation, despite extending health insurance eligibility to 2.3 million low-income smokers. Greater commitments to reducing barriers to cessation benefits and increasing smoking cessation in state Medicaid programs are needed to reduce smoking in low-income populations.

The Association Between School Tobacco Control Policies and Youth Smoking Behavior.

While U.S. tobacco control policy has focused mainly on tobacco excise taxes, product advertising bans, and state tobacco control policies such as indoor/outdoor smoking bans, little attention has been paid to school tobacco control policies and their impact on youth smoking behavior. Thus, the objective of this study is to examine the impact of school tobacco control policies on smoking behavior among teenagers and young adults in the USA. Using logistic regression approach, this study examines the effect of school tobacco control policies on individuals ever trying smoking and ever being a regular smoker using data from waves I, II, and III of the National Longitudinal Study of Adolescent Health. Findings indicate that school tobacco control policies targeting both students and employees of the school are associated with a reduced odds of smoking initiation among youth, but do not have much effect on youth becoming regular smokers. If implemented properly, school tobacco control policies could play a vital role in preventing youth smoking and help reduce youth smoking rates in the country, addressing a key public health issue.

The downstream effects of state tobacco control policies on maternal smoking during pregnancy and birth outcomes

BackgroundResearch has demonstrated that the implementation of tobacco control policies is associated with improved birth outcomes. Ascertainment of prenatal smoking on the US birth certificate has changed over the past decade to record smoking across each trimester. MethodsUsing 2005–2015 birth certificate data on 26,436,541 singletons from 47 states and DC linked to state-level cigarette taxes and smoke-free legislation, we conducted conditional mixed-process models to examine the impact of tobacco control policies on prenatal smoking and quitting, then on the associated changes in birth outcomes. We included interactions between race/ethnicity, education, and taxes and present average marginal effects. ResultsAmong white and black mothers with less than a high school degree, 36.0% and 14.1%, respectively, smoked during the first trimester and their babies had the poorest birth outcomes. However, they were the most responsive to cigarette taxes. Every $1.00 increase in taxes was associated with a 3.45 percentage point decrease in prenatal smoking among white mothers and a 1.20 percentage point decrease among black mothers. These reductions translated to increases in birth weight by 4.19 g for babies born to white mothers and 0.89 g for babies born to black mothers. Among smokers, there was some evidence that taxes increased quitting and improved birth outcomes, although most associations were not statistically significant. We found limited effects of smoke-free legislation on smoking, quitting or birth outcomes. ConclusionsCigarette taxes continue to have important downstream effects on reducing prenatal smoking and improving birth outcomes among the most vulnerable mothers and infants.

Impact of state tobacco control policies on birth defects

While research has demonstrated the effects of tobacco control policies on birth outcomes, there is little known about their impact on birth defects. Using 2005–2015 natality data on 26,334,854 singletons from 47 US states and District of Columbia linked to state-level cigarette taxes and smoke-free restaurant legislation, we examined the impact of tobacco control policies on birth defects by maternal race/ethnicity and education. We found that among white women with less than a high school degree, every $1.00 increase in cigarette taxes reduced prenatal smoking by 3.48 percentage points and reduced the risk of their infant having any birth defect by 0.0023 percentage points. Tax increases also reduced the risk of cyanotic heart defects, cleft palate, gastroschisis, and limb reduction. We found no evidence for associations between the enactment of smoke-free legislation, prenatal smoking and birth defects. Our findings suggest that state cigarette taxes are a population-level intervention that can help reduce prenatal smoking and the risk of birth defects.

The Relationship between Tobacco Retailer Density and Neighborhood Demographics in Ohio

Studies from various parts of the country suggest that tobacco-related health disparities are exacerbated by disparities in the distribution of tobacco retailers (convenience stores, tobacco shops, etc.). The purpose of the present study was to use advanced spatial modeling techniques for count data to estimate current disparities in tobacco retailer density in Ohio. We identified and geocoded 11,392 tobacco retailers in Ohio. Next, we obtained census tract-level information on race/ethnicity, poverty, and age and obtained county-level information on whether an area was Urban, Suburban, or Rural. Finally, we used negative binomial generalized linear models, adapted for residual spatial dependence, to determine the association between per capita tobacco retailer density and demographic characteristics-summarized by adjusted rate ratios. There were more (from 1.4-1.9 times as many) retailers per capita in high-poverty, vs. low-poverty tracts. Poverty also interacted with age: the association between high poverty and high retailer density was stronger for tracts with a low youth population. Density was also greater in tracts with a high (vs. low) prevalence of African Americans (1.1 times as many) and Hispanics (1.2 times as many). Finally, density was generally greater in rural (vs. suburban or urban) tracts, although the effect was modified by a three-way interaction: density was particularly high for rural tracts that also had both a high prevalence of poverty and a low youth population. Overall, our findings indicate that Ohio's vulnerable populations are exposed to a greater per capita density of tobacco retailers. There is a need for state and local-level tobacco control policies that will improve equity and reduce health disparities.

Did Slowdown on Taxes and Program Impact California's Smoking Decline?

Author(s): Pierce, John P; Shi, Yuyan; Hendrickson, Erik; White, Martha; Noble, Madison; Kealey, Sheila; Strong, David | Abstract: Objective: In this paper, we examine whether a slowdown in implementing tobacco control policies in California after 2000 influenced trends in smoking behavior. Methods: We assessed the strength of state tobacco control policies using excise tax data (1990-2014), tobacco control expenditures per capita, and workplace and home smoking restrictions (from the Tobacco Use Supplement of the Current Population Survey, 1992-2015). Smoking prevalence was assessed with the National Health Interview Survey, 1985-2015. We compared trends between California and the rest of the US using split regression models with a knot at 2000. Results: Throughout the 1990s, compared to the rest of the US, California had higher cigarette excise taxes, higher expenditures on tobacco control, more smoke-free workplaces, and more smokers with smoke-free homes. Except for smoke-free homes, these differences disappeared after 2000. During the 1990s, smoking prevalence declined much faster in California than in the rest of the US, but the decline slowed significantly after 2000. Conclusions: Smoking prevalence is sensitive to continued implementation of tobacco control policies.

The effects of assurances of voluntary compliance on retail sales to minors in the United States: 2015–2016

Multiple state attorneys generals have entered assurances of voluntary compliance (AVCs) with numerous national retail chains as an application of consumer protection laws to help prevent tobacco sales to minors. Little is known about the effectiveness of AVCs in reducing the violations of tobacco retailers for underage sales. We collected inspection data involving minors (n=53,832) on tobacco retailers in 2015 and 2016 from the Food and Drug Administration (FDA) compliance check database. Inspections on 13 national retail chains were classified into four categories: gas stations from oil companies, convenience stores, pharmacy stores, and supermarkets. Multilevel logistic regression models were performed to examine the effectiveness of AVCs, adjusted for state tobacco control policies, state youth smoking rates, and socio-economic status (SES) at census tracts. Overall the Retail Violation Rate for sales to minors (RVRm) significantly varied by retail category from 7.7% in pharmacy stores to 18.9% in gas stations from oil companies. Retailers that entered an AVC had lower odds of underage sales violations in convenience stores (aOR=0.75, 95% CI [0.61–0.93]) and supermarkets (aOR=0.74, 95% CI [0.59–0.93]). For gas stations from oil companies and pharmacy stores, there were no significant differences in RVRm between stores with an AVC and stores without an AVC. We found that entering into AVCs is associated with fewer retail violations of underage sales for convenience stores and pharmacy stores. Continued efforts to strengthen the enforcement of AVCs and to expand AVCs to more states and other retail chains may improve youth tobacco control.

The differential impact of state tobacco control policies on cessation treatment utilization across established tobacco disparities groups

Tobacco control policies are effective in promoting quit attempts and increase the likelihood that smokers use evidence-based cessation treatments (e.g., nicotine replacement therapies (NRT), non-NRT medications, behavioral treatment, and/or quitlines). However, what is less clear is how these policies might differentially impact different groups of smokers, perhaps in some cases even widening disparities in the use of evidence-based tobacco dependence treatments. This paper examined how different state-level tobacco control policies impact the use of evidence-based cessation treatments by race/ethnicity, gender, socio-economic status (SES), age, and smoking history. Participants included 9110 adult smokers reporting a past-year quit attempt within the 2010–2011 Tobacco Use Supplement to the Current Population Survey. Lasso regression modeling was used to identify a subset of interactions between tobacco policies and individual smoker characteristics that predicted use of evidence-based cessation treatment. Significant interactions were fitted via participant-weighted generalized linear models to determine effect sizes and relations to each cessation treatment outcome. Results highlighted that various state level tobacco control policies differentially impacted the reported use of both prescription and non-prescription stop smoking medications by race/ethnicity, age, and SES. The relationship between state level tobacco control policies and the use of behavioral treatments and quitlines did not differ by smoker characteristics. In sum, tobacco control policies differentially impact the use of FDA approved stop smoking medications across different race/ethnicity, age, and SES groups. Understanding such effects can help to target interventions to ensure equal access to evidence-based tobacco dependence treatments.

The Relationship of E-Cigarette Use to Cigarette Quit Attempts and Cessation: Insights From a Large, Nationally Representative U.S. Survey.

While cessation from cigarettes is a top priority for public health, controversy surrounds the role of e-cigarettes for quitting cigarettes. This study examines the role of e-cigarettes in quit attempts and 3-month cigarette abstinence using a large, recent nationally representative US sample. Data from the 2014/15 Tobacco Use Supplement-Current Population Survey (TUS-CPS) on cigarette and e-cigarette use and individual characteristics were supplemented with information on state tobacco control policies. We estimated frequencies and multivariate logistic equations for making a quit attempt among those who smoked 1 year earlier and for remaining abstinent at least 3 months among those making a quit attempt. These two outcomes were related to demographic characteristics, tobacco control policies and different frequency measures of e-cigarette use (ever, at least 1, 5, 20 of the last 30 days, a continuous measure of days use). Having made a quit attempt was more likely among smokers using e-cigarettes than non-users. Among those making at least one quit attempt, quit success was lower among ever users, but higher among those with at least 5 days use of e-cigarettes in the last month. Both quit attempts and quit success were linearly related to the frequency of e-cigarette use. Consistent with randomized trials and those observational studies that measure frequency of e-cigarette use, both quit attempts and quit success were positively associated with increased frequency of e-cigarette use. Frequency of e-cigarette use was important in gauging the nature of these relationships. Previous studies have obtained mixed results regarding the relationship of e-cigarette use to cigarette smoking cessation. This study provides a more precise methodology for considering the relationship of e-cigarette use to quit attempts and to quit success, and finds that quit attempts and quit success increase with the number of days use in the past month.

Availability of tobacco cessation services in substance use disorder treatment programs: Impact of state tobacco control policy

ObjectiveGiven the high prevalence of smoking among substance use disorder (SUD) patients, the specialty SUD treatment system is an important target for adoption and implementation of tobacco cessation (TC) services. While research has addressed the impact of tobacco control on individual tobacco consumption, largely overlooked in the literature is the potential impact of state tobacco control policies on availability of services for tobacco cessation. This paper examines the association between state tobacco control policy and availability of TC services in SUD treatment programs in the United States. MethodsState tobacco control and state demographic data (n=51) were merged with treatment program data from the 2012 National Survey of Substance Abuse Treatment Services (n=10.413) to examine availability of TC screening, counseling and pharmacotherapy services in SUD treatment programs using multivariate logistic regression models clustered at the state-level. ResultsApproximately 60% of SUD treatment programs offered TC screening services, 41% offered TC counseling services and 26% offered TC pharmacotherapy services. Results of multivariate logistic regression showed the odds of offering TC services were greater for SUD treatment programs located in states with higher cigarette excise taxes and greater spending on tobacco prevention and control. ConclusionsFindings indicate cigarette excise taxes and recommended funding levels may be effective policy tools for increasing access to TC services in SUD treatment programs. Coupled with changes to insurance coverage for TC under the Affordable Care Act, state tobacco control policy tools may further reduce tobacco use in the United States.

Contextual Influences and Campaign Awareness Among Young Adults: Evidence from the National truth® Campaign

Mass media campaigns have been found to shape the public's knowledge, attitudes, beliefs, and behavior around tobacco. This study examines the influence of contextual factors with respect to awareness of the national truth® campaign, a mass media, branded tobacco use prevention campaign, among a sample of young adults (n = 2,804) aged 24–34 years old; these respondents were within the age range for both the primary and secondary targets of the campaign during the period (2000–2007) when the campaign was airing television advertising at consistently high levels. Mulitvariable models reveal lower educational attainment and Hispanic ethnicity as significant contextual factors predictive of lower campaign awareness, controlling for media use. In contrast, gender, state tobacco control policy, sensation-seeking, current smoking status, and community-level SES variables were not significantly associated with campaign awareness. Further research is needed to identify the mechanisms through which public education campaigns operate, particularly among disadvantaged communities.

Impact of state cigarette taxes on disparities in maternal smoking during pregnancy.

We evaluated the impact of state tobacco control policies on disparities in maternal smoking during pregnancy. We analyzed 2000-2010 National Vital Statistics System natality files with 17 699 534 births from 28 states and the District of Columbia that used the 1989 revision of the birth certificate. We conducted differences-in-differences regression models to assess whether changes in cigarette taxes and smoke-free legislation were associated with changes in maternal smoking during pregnancy and number of cigarettes smoked. To evaluate disparities, we included interaction terms between maternal race/ethnicity, education, and cigarette taxes. Although maternal smoking decreased from 11.6% to 8.9%, White and Black women without a high school degree had some of the highest rates of smoking (39.7% and 16.4%, respectively). These same women were the most responsive to cigarette tax increases, but not to smoke-free legislation. For every $1.00 cigarette tax increase, low-educated White and Black mothers decreased smoking by nearly 2 percentage points and smoked between 14 and 22 fewer cigarettes per month. State cigarette taxes may be an effective population-level intervention to decrease racial/ethnic and socioeconomic disparities in maternal smoking during pregnancy.

Tobacco Control Policies, Birth Outcomes, and Maternal Human Capital

Smoking during pregnancy can have significant adverse health effects for babies, yet many women smoke during pregnancy. In this paper, we examine whether state tobacco control policies lead to improved birth outcomes and to what extent the success of these policies depends on accumulated maternal human capital. We use data from the Pregnancy Risk Assessment Monitoring System in a time period when states significantly changed their tobacco control policies. Results show that the smoking policies are limited in their effectiveness. The largest improvements in birth outcomes from higher cigarette prices are among babies of women who have accumulated the least human capital.

A Comprehensive Examination of the Influence of State Tobacco Control Programs and Policies on Youth Smoking

We examined the influence of tobacco control policies (tobacco control program expenditures, smoke-free air laws, youth access law compliance, and cigarette prices) on youth smoking outcomes (smoking susceptibility, past-year initiation, current smoking, and established smoking). We combined data from the 2002 to 2008 National Surveys on Drug Use and Health with state and municipality population data from the US Census Bureau to assess the associations between state tobacco control policy variables and youth smoking outcomes, focusing on youths aged 12 to 17 years. We also examined the influence of policy variables on youth access when these variables were held at 2002 levels. Per capita funding for state tobacco control programs was negatively associated with all 4 smoking outcomes. Smoke-free air laws were negatively associated with all outcomes except past-year initiation, and cigarette prices were associated only with current smoking. We found no association between these outcomes and retailer compliance with youth access laws. Smoke-free air laws and state tobacco control programs are effective strategies for curbing youth smoking.

The effects of smoking-related television advertising on smoking and intentions to quit among adults in the United States: 1999-2007.

We investigated whether state-sponsored antitobacco advertisements are associated with reduced adult smoking, and interactions between smoking-related advertising types. We measured mean exposure to smoking-related advertisements with television ratings for the top-75 US media markets from 1999 to 2007. We combined these data with individual-level Current Population Surveys Tobacco Use Supplement data and state tobacco control policy data. Higher exposure to state-sponsored, Legacy, and pharmaceutical advertisements was associated with less smoking; higher exposure to tobacco industry advertisements was associated with more smoking. Higher exposure to state- and Legacy-sponsored advertisements was positively associated with intentions to quit and having made a past-year quit attempt; higher exposure to ads for pharmaceutical cessation aids was negatively associated with having made a quit attempt. There was a significant negative interaction between state- and Legacy-sponsored advertisements. Exposure to state-sponsored advertisements was far below Centers for Disease Control and Prevention-recommended best practices. The significant negative relationships between antismoking advertising and adult smoking provide strong evidence that tobacco-control media campaigns help reduce adult smoking. The significant negative interaction between state- and Legacy-sponsored advertising suggests that the campaigns reinforce one another.

Two New ACS Reports Show Public Health, Economic Benefits of Vigorous State Tobacco Control Policies

Two New ACS Reports Show Public Health, Economic Benefits of Vigorous State Tobacco Control Policies

Changes in smoking prevalence among U.S. adults by state and region: Estimates from the Tobacco Use Supplement to the Current Population Survey, 1992-2007.

BackgroundTobacco control policies at the state level have been a critical impetus for reduction in smoking prevalence. We examine the association between recent changes in smoking prevalence and state-specific tobacco control policies and activities in the entire U.S.MethodsWe analyzed the 1992-93, 1998-99, and 2006-07 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) by state and two indices of state tobacco control policies or activities [initial outcome index (IOI) and the strength of tobacco control (SOTC) index] measured in 1998-1999. The IOI reflects cigarette excise taxes and indoor air legislation, whereas the SOTC reflects tobacco control program resources and capacity. Pearson Correlation coefficient between the proportionate change in smoking prevalence from 1992-93 to 2006-07 and indices of tobacco control activities or programs was the main outcome measure.ResultsSmoking prevalence decreased from 1992-93 to 2006-07 in both men and women in all states except Wyoming, where no reduction was observed among men, and only a 6.9% relative reduction among women. The percentage reductions in smoking in men and women respectively were the largest in the West (average decrease of 28.5% and 33.3%) and the smallest in the Midwest (18.6% and 20.3%), although there were notable exceptions to this pattern. The decline in smoking prevalence by state was correlated with the state's IOI in both women and men (r = -0.49, p < 0.001; r = -0.31, p = 0.03; respectively) and with state's SOTC index in women(r = -0.30, p = 0.03 0), but not men (r = -0.21, p = 0.14).ConclusionState level policies on cigarette excise taxes and indoor air legislation correlate strongly with reductions in smoking prevalence since 1992. Strengthening and systematically implementing these policies could greatly accelerate further reductions in smoking.