Richard Watts and Rebecca Ryan For the Free Press
Published 6:04 AM EST Nov 19, 2018
Fifty years ago almost half of Vermont adults smoked. Today that number is 18 percent. At one time close to 35 percent of high school kids in Vermont smoked cigarettes, today that number is closer to nine percent.
Thirty years ago, Vermonters smoked in restaurants, libraries and even at the Department of Health. The campaign to reduce tobacco use started in Vermont with the first Clean Indoor Act — aimed at reducing smoking in public places — one step in the long battle to reduce tobacco use in the state.
Here we tell that story.
The early years: Philip Morris rules
In March of 1988, tobacco giant Philip Morris sent a calendar to every legislator in Vermont. On the January page, a businessman in a dark suit smiles from the top of a set of marble steps. The man has one hand on his hip, a cigarette in the corner of his mouth and a hand-lettered sign to his left that reads: “Men’s Club. Women, Dogs and Vagrants need not apply.”
After receiving her copy of the calendar, freshman legislator Ann Seibert, D-Norwich, stood up on the floor of the House to request a moment of personal privilege. Her voice quavered as she addressed her fellow representatives for the first time, waving the calendar she said: “How can we accept these gifts when lung cancer has passed breast cancer as the leading cause of death for women?” Seibert penned a letter of protest signed by over 60 lawmakers and sent it along with a box of the offensive calendars to Phillip Morris.
This action received a high level of media attention, including an article in the New York Times. It was a turning point in the now more than 30-year battle by Vermont’s tobacco control advocates and legislators to shine a spotlight on the tobacco industry. A spotlight that also illuminated the thousands of deaths and tens of millions of government expenditures related to tobacco-related death and disease in Vermont.
In the 1980s that started to change. And Vermont was an early leader.
‘Cancer by the Carton’
Researchers trace the first skirmish in the 60-year battle to reduce tobacco use to a 1953 Reader’s Digest article linking smoking and cancer, titled “Cancer by the Carton.” Instead of admitting their culpability the tobacco industry took out full page ads in 400 newspapers rejecting the link and pledging to safeguard the public’s health. The tobacco industry had two main strategies, the first was to cast doubt on the evidence linking smoking to cancer. As an internal tobacco company memo in the late 1960s explained it:
“Doubt is our product since it is the best means of competing with the “body of fact” that exists in the mind of the general public. It is also the means of establishing a controversy. If we are successful in establishing a controversy at the public level, then there is an opportunity to put across the real facts about smoking and health” (emphasis added).
A second strategy was to link smoking with individual freedom and personal choice. In this narrative, smoking is a decision made freely by adults. As an industry memo from the late 1960s put it: “It’s more than cigarettes being challenged here. It’s freedom.” The industry also seeded distrust in government’s effort to regulate the industry, raising the concepts of the “nanny state” and slippery slope; e.g. “freedom dies a bit at a time.” This strategy also framed government regulatory approaches as criminalizing smokers, leading to industry funded campaigns to promote “smokers’ rights.”
These strategies were successful through the 1970s and early 1980s in defeating a number of public health initiatives. Starting in the 1980s, tobacco control efforts, led by the public health community, began to see some success. In 1982, the excise tax on cigarettes was increased for the first time since 1951 (from 8 cents to 16 cents). In 1984, Congress required the rotation of four warning labels on cigarettes, i.e. “smoking is dangerous to your health.” Smoking was limited and then banned on airplane flights (1988). Laws requiring better policing of underage cigarette sales were enforced (Synar amendment, 1992).
Although there was increased interest and advocacy at the federal level most of the action was at the state, county and municipal level. In 1977, Berkeley passed the first smoking control ordinance restricting smoking in work-places. San Francisco (1983) and hundreds of other cities and towns followed, despite industry opposition. And California voters in 1988 passed proposition 99, increasing cigarette taxes $.25 cents a pack and allocating the resulting $600 million in new revenues to state tobacco control and research. These early efforts led to the State saving $134 billion in healthcare costs between 1989 and 2008.
Tobacco activists and Vermont
In parallel with the national story, tobacco control measures started to gain some ground in Vermont in the 1980s. In 1983, the state’s Department of Health (DOH) provided local communities small grants to work on tobacco cessation programs under the direction of a public health coordinator. Early tobacco control programs were focused on helping smokers quit, (a policy today seen as widely ineffective). Community partners were to work on quit smoking programs for one-quarter of the year and other public health measures for the remainder of the year. The lack of consistent follow-through undercut the program.
In the mid-1980s, the Centers for Disease Control and Prevention (CDC) established new guidelines prioritizing prevention measures over cessation. Getting people not to start was much more effective than trying to get them to quit.
In 1985, Stanton Glantz, one of the nation’s most out-spoken anti-tobacco advocates and a leader in efforts to restrict smoking in public places, spoke at a conference in Vermont. Glantz ridiculed the Vermont Department of Health’s cessation approach, instead promoting the idea of clean indoor air laws to restrict work-place smoking. A 1986 voluntary effort to restrict smoking within the Department was met with strong opposition. The Department’s then communications director remembers thinking that it seemed a bit unfair to the smokers to force them to smoke outside
But change started to come incrementally. In 1987, the Vermont Legislature passed a law to limit smoking in the workplace. After three years of effort, led by the effective and extremely persistent Rep. Seibert, the Vermont Legislature passed the Clean Indoor Air Act – one of the nation’s first.
The new law restricted smoking in public buildings, reduced the public placement of cigarette vending machines and called for the prohibition of lighted tobacco products in “the common areas of all enclosed indoor places of public access and publicly owned buildings and offices.” Restaurants were given two years to become smoke-free. The law contained one major loophole, establishments where alcohol sales topped food sales could apply for a license to operate a cabaret where smoking was allowed. Cabaret licenses grew from a handful to more than 400. It took lawmakers and advocates another 14 years to close this exemption.
Coalition for a Tobacco Free Vermont
During the 1980s, a Department of Health staffed statewide coalition acted as an advocate for tobacco control. Then (and now) staff at the Department of Health are restricted in their advocacy efforts, restrained by the policies of the incumbent governor and state and federal regulations. In the early 1980s, the Tobacco Coalition took a careful, middle of the road approach. Stronger voices on the Coalition were often out-voted and the Department’s chosen chair, a retired physician, sided with the health professionals at the Health Department. For example, efforts to embarrass the Department of Liquor Control’s weak attempts to enforce under-age cigarette sales were essentially tabled at Coalition meetings in the mid-80s.
In the late 1980s this started to change as money and support from the Robert Wood Johnson Foundation increased, forceful legislators took center stage and policy advocacy trumped caution. At the same time, the big three public health groups, the American Cancer Society (ACS), American Lung Association (ALA) and the American Heart Association (AHA) became more activist oriented in their approaches both nationally and at the state level. Tobacco control leadership in the state passed from the Department of Health to these groups, including the direction of the Tobacco Coalition. Confrontation rather than conciliation became the approach.
At the same time, there was increasing outrage over the actions of Big Tobacco and the 300,000 deaths each year to tobacco-related disease. And court cases and leaks from inside the industry began to provide increasing evidence that Big Tobacco had long known the addictive qualities of nicotine, the cancer-causing nature of their products and had been purposefully targeting children as “replacement smokers” to replace the hundreds of thousands that died each year.
The three Vermont public health groups pooled funds and hired a contract lobbyist, Michael Sirotkin (now a Vermont legislator), to advocate for the Clean Indoor Air Act (1991). One clear lesson to those involved; advocacy and grass-roots organizing worked. Success in tobacco control would require hiring professional expertise, i.e. lobbyists or political organizers.
Furthermore, public health advocates and state officials were increasingly convinced that success required policy measures, not education and voluntary behavioral changes. Rules and laws that would make it harder to get cigarettes and tax policy that would make it much more expensive. To do that, organizational actors were needed who could lobby, promote policies and provide direct advocacy. At the same time they needed to avoid being a target for what was called “Team Tobacco” a cadre of 10-12 skilled lobbyists that worked the Statehouse for the tobacco industry. For this reason the Coalition was purposefully kept “very loose” so that it would be “nimble, difficult to track, and defend against.”
In 1994, these efforts received a major boost when the Robert Wood Johnson Foundation (RWJF) issued an “implementation grant” to the Vermont Coalition for $200,000. This was a serious amount of money that allowed the Coalition to amp up its efforts. And the policy advocacy orientation of the funds had an immediate impact. From the beginning RWJ stressed “advocacy” encouraging state tobacco coalitions “to be activists — to try to bring about social change rather than doing research” — a departure from previous RWJ tobacco control funding.
The funds were allocated to the Coalition for a Tobacco-Free Vermont. But because the Coalition was not a formal entity, funds were passed through the Vermont branch of the American Cancer Society, bypassing the Vermont Department of Health. ACS, ALA and AHA provided matching funds for “lobbying” and other activities restricted by the RWJ foundation. This first grant was followed by further commitments totaling more than $750,000.
By 1996, the Coalition had an annual budget of $250,000 a full-time staff of three, two contract lobbyists and a professional media consultant. The Coalition also had a powerful ally in Attorney General Bill Sorrell, absolutely committed to the issue, motivated in part by the fact that his mother had died of smoking related cancer. In 1994 Vermont was one of the first states to join Mississippi in suing the tobacco industry — in Sorrell’s first month on the job.
At the national level, the Coalition took its direction from the Campaign for Tobacco-Free Kids (TFK), using TFK tactics and materials and attending TFK trainings. The TFK also hired a Vermont organizer, spending $40,000 a year to increase organizing efforts in the state with a laser-like focus on advocacy and policy results and hiring skilled activists like Jennifer Wallace-Brodeur.
By the late 1990s, the Coalition was filling the role, exactly as RWJF envisioned it, of being the central advocate for policy change in the state, under the leadership of a cadre of talented women, including Julie Arel, Tina Zuk, Rebecca Ryan and Philene Taormina. In July 2000 RWJF broadened this SmokeLess States initiative to all fifty states, allocating $52 million with a “focus solely on advocacy regarding tobacco policy.”
New laws restricting smoking and making it harder for underage smokers to get cigarettes were all having an impact. At the same time, work in the schools with kids and effective counter-advertising were also started to show results.
As Vermont’s organizing ramped up, national events continued to provide added impetus. Courts began to order damages in lawsuits against the tobacco industry as more and more information came out about their purposeful targeting of kids and inside knowledge of the death and destruction caused by their product. To stave off the government’s lawsuit, the companies cut a deal that would pump more than $2 billion into fighting tobacco use, also resulting in higher prices for cigarettes.
Much of this money would flow down to the states. So, in 1999, the state’s Legislature convened a Tobacco Task Force to invite public comment on the expected infusion of $30 million a year from the so-called Master Settlement Agreement. The task-force included Attorney General Sorrell and a powerful group of key legislators (e.g. Jim Leddy, Karen Kitzmiller, Helen Rhiele and others) spending all summer in a series of seven well-publicized public hearings discussing the toll of tobacco and research-based policy solutions. Thousands of Vermonters participated and thousands more read about the debate in newspapers and TV and radio broadcasts. As Department of Health Commissioner Jan Carney would say later, “Tobacco was in the news all summer long.”
Eventually, Vermont would allocate about a third of the settlement funds ($8 million) to attacking tobacco use, placing the state in the top five states in the initial allocation of settlement funds for tobacco control. Over then Gov. Howard Dean’s objections, legislators also created an independent Tobacco Evaluation & Review Board to evaluate state tobacco control programs and recommend funding levels.
While the 1998 settlement represented a major victory and infusion of cash to in-state tobacco control efforts, effective tobacco control programs require price increases – taxes—to reduce demand. Twenty-five years of research – based on actual behavior changes — indicates that higher prices coupled with comprehensive tobacco control programs reduce smoking rates.
Price increases have to be high enough to be a shock to the system, above 10 percent of the pack price at a minimum. And furthermore, effective tobacco control requires higher prices to be coupled with clean indoor air laws and a well-funded tobacco control program, including robust mass-reach health communications.
Tobacco taxes in Vermont
Starting in the mid-1990s, the Vermont advocates focused their legislative initiatives on campaigns to increase taxes. The first victory came in 1995, when legislators and advocates were able to effectively double the state cigarette excise tax from $.20 to $.44. After several years of effort, advocates in 2003 succeeded in a phased in two-year $.75 increase. Noticeable in the debate was the strength of the Coalition.
Since then the Legislature has passed incremental excise cigarette tax increases – not high enough to impact smoking rates – leading to the current tax of $3.08 per pack. Over the years, the excise tax on other tobacco products, including snuff and some cigars, has increased to equal the cigarette tax.
At the same time as tobacco prices increased, Vermont continued to spend from $4 to $6 million a year on efforts to prevent kids from starting to smoke and reducing overall smoking rates. The Vermont Department of Health’s professional team is key to these efforts. And, for most of the ten years between 2002 and 2017, Vermont has been ranked between 8 and 12th in the nation for tobacco control spending and the effectiveness of that spending. While appropriations for the program has been on the decline for several years, this year lawmakers gave the program a boost by adding $1 million from the one-time $28 million Vermont received from the tobacco industry. This marks the first increase to the program since fiscal year 2012.
There has been a gradual decline in adult smoking to today’s rate of 18 percent, placing Vermont a bit higher than the national smoking rate of 15 percent but well below previous levels. The better news is that the youth smoking rate has dropped from 40 percent in 1995 to 9 percent in 2017. A combination of higher tobacco prices and effective research-based tobacco control policies have all contributed to this success.
Unfortunately, the tobacco industry continues to find ways to recruit new customers. The ever-growing popularity of electronic cigarettes, including JUUL has hooked a new generation of kids on nicotine. Currently 12 percent of Vermont kids in grades 9-12 use e-cigarettes and 34 percent have used them at least once. One way to help address this epidemic is to sharply raise the price through taxes – as has been successfully done with cigarettes. And to borrow other lessons from the success in reducing cigarette smoking rates.
A well-trained and skilled cadre of health professionals and activists continues to fight tobacco use. But the battle now has shifted to the electronic cigarettes. Let’s hope it does not take another 30 years.
Richard Watts is the director of the Center for Research on Vermont. In the 1980s and 1990s, he was a member of the Tobacco Coalition and staffed the 1999 public hearings for the Tobacco Task Force. Rebecca Ryan, is division director, Health Promotion at American Lung Association, Eastern Division.
None of this work would have been possible without the strong leadership and skills of a number of advocates and legislators including Tina Zuk, Rebecca Ryan, Ann Seibert, Brian Flynn, Jim Leddy, Helen Rheile, Kelly Stoddard, Philene Taormina, Julie Arel, Ann Pugh and Jennifer Wallace-Brodeur and many others.
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