CALCULATION OF STATE GRADES

Since State of Tobacco Control 2009 uses the updated CDC-recommended spending levels, grades in this category are not comparable to the State of Tobacco Control 2007 or earlier reports.

Limitation of Grading System on State Tobacco Control Expenditures

The American Lung Association evaluates neither the expenditure each state makes in each of the CDC categories nor the efficacy of any element of any state’s program. Therefore, a state may receive a high grade but be significantly underfunding a component or components of a comprehensive program. It also may be true that a state with a low grade is adequately funding a specific component or program in one community. The CDC recommends a comprehensive program and simply funding an element of the program will not achieve the needed results. The CDC explicitly calls for programs that are comprehensive, sustainable and accountable. The American Lung Association agrees with the CDC and believes the total funding is a fair basis for grading state programs and a state’s tobacco control funding performance.

Smokefree Air Laws

The smokefree air laws grading system is based on criteria developed by an advisory committee convened by the National Cancer Institute with some modification to reflect the current policy environment. The criteria were presented in the article, “Application of a Rating System to State Clean Indoor Air Laws (USA)” (J.F. Chriqui et al., Tobacco Control, 2002; 11:26-34). This approach provides scoring in nine categories: Government Workplaces, Private Workplaces, Schools, Child Care Facilities, Restaurants, Retail Stores, Recreational/Cultural Facilities, Penalties and Enforcement. All laws are open to interpretation and our analysis may differ from those of the authors noted in the above study.

To reflect the current policy environment, two additions have been made to the advisory committee’s recommended categories of smokefree establishments.
One additional category for bars has been added to all states. A second category, Casinos/Gaming Establishments, was added to the states which allow casinos or gaming establishments. Adding these categories became necessary after the committee made its recommendations in 2002, because, a number of states have prohibited smoking in bars and casinos/gaming establishments since then. And states need to be recognized in the grading system for protecting workers in these places from secondhand smoke. Due to the addition of these categories in 2008, Smokefree Air grades for this year’s report are not comparable to grades from the State of Tobacco Control 2007 or earlier reports.

The smokefree air grade for each state is based on a total of all points received in all categories. The grades are based on a maximum score of 40 if the state has no casinos or gaming establishments, or 44 if the state has casinos or gaming establishments. Both these high scores have been attained by states in this year’s report. The maximum score of 40 or 44 becomes the denominator, and the state’s total points serve as the numerator. The percentage was calculated and grades were assigned following a standard grade school system. States receiving scores in the top 10 percent of the range (90 to 100 percent) earned an A. Those receiving scores falling between 80 and 89 percent got a grade of B, between 70 and 79 percent a C and between 60 and 69 percent a D. Those that fell below 60 percent received an F. The points break down as follows:

There are two situations that create exceptions to the grading system:

• Preemption: State preemption of stricter local ordinances is penalized by a reduction of one letter grade. States with preemption that have a score of 40 points or higher (or 44 points or higher dependent on whether the Casinos/Gaming Establishments category is applicable for that state) are not penalized for preemption.

• Local Ordinances: Strong local smokefree air ordinances that include most workplaces, all restaurants and bars are considered according to the percentage of population covered in a given state. States with over 90 percent of their population covered by comprehensive smokefree ordinances will receive an A, over 80 percent a B, over 65 percent a C, over 50 percent a D and anything under 50 percent will not be considered.¹

Key to Smokefree Laws Ratings by Category

For all categories, laws that require that smoking be permitted or laws without any restrictions for the particular category receive a score of zero (0).

1) Government Workplaces (4 points): Target is “state and local government workplaces are 100 percent smokefree, no exemptions.” Score was lowered if restriction depended on type of ventilation and/or location of smoking area. A bonus point (+1) was available if the laws met the target criteria and required the grounds or a specified distance from entries or exits to be smokefree.

2) Private Workplaces (4 points): Target is “private workplaces are 100 percent smokefree, no exemptions.” Score was lowered if restriction depended on type of ventilation, location of smoking area and/or number of employees. A bonus point (+1) was available if the laws met the target criteria and required the grounds or a specified distance from entries or exits to be smokefree.

3) Schools (4 points): Target is “no smoking permitted in public and non-public schools during school hours or while school activities are being conducted.” Score was lowered if restriction depended on school hours, type of ventilation and/or location of smoking area. A bonus point (+1) was available if the laws met the target criteria and extended the law/policy to any time in school facilities, on school grounds, and at school-sponsored activities.

4) Child Care Facilities (4 points): Target is “no smoking permitted during operating hours in childcare facilities (explicitly including licensed, home-based facilities).” Score was lowered if restrictions depended on ventilation standards, location of smoking areas and/or exemptions for certain types of facilities.

5) Restaurants (4 points): Target is “restaurants (explicitly including bar areas of restaurants) are 100 percent smokefree.” Score was lowered if restriction depended on type of ventilation, location of smoking areas and/or exemptions for some restaurants. A bonus point (+1) was available if the laws met the target criteria and extended the law/policy to outdoor seating areas of restaurants.

6) Bars/Taverns (4 points): Target is “bars/taverns and similar types of establishments are 100 percent smokefree.” Score was lowered if restriction depended on ventilation standards and/or location of smoking area and/or if laws only applied to some but not all bars/taverns. A bonus point (+1) was available if the laws met the target criteria and extended the law/policy to private clubs or similar establishments at all times.

7) Casinos/Gaming Establishments (4 points): Target is “casinos/gaming establishments are 100 percent smokefree.” Score was lowered if restriction depended on ventilation standards and/or location of smoking area, and if laws only applied to some but not all casinos/gaming establishments. This category does not apply to states that do not have casinos/gaming establishments.

8) Retail Stores (4 points): Target is “retail stores or retail businesses open to the public are 100 percent smokefree.” Score was lowered if restriction depended on ventilation standards and/or location of smoking area, and if laws only applied to some but not all retail stores or businesses.

9) Recreational/Cultural Facilities (4 points): Target is “recreational and cultural facilities are 100 percent smokefree.” Score was lowered if restriction depended on ventilation standards and/or location of smoking area, and if laws only applied to some but not all recreational and/or cultural facilities.

10) Penalties (4 points): Target is “penalties or fines, applicable to smokers and to proprietors or employers, for any violation of clean indoor air legislation.” Score was lowered if penalties included possibilities for delay, exceptions for either the smokers or the proprietors/employers, or penalties that only applied to some but not all offenses. Intent requirement or affirmative defenses reduced the score by one (1) point. A bonus point (+1) was available if the laws met the target criteria and the penalties or fines were graduated for repeated violations.

11) Enforcement (4 points): Target is “designate an enforcement authority for clean indoor air and require sign posting.” Score was lowered if there was no requirement for sign posting, enforcement authority only applied to some sites, or an enforcement authority or sign requirement existed, but not both. A bonus point (+1) was available if the laws met the target criteria and required the enforcement authority to conduct compliance inspections.

State Cigarette Excise Tax

Establishing a basis to grade state cigarette excise taxes begged a question: “What is the appropriate level to tax cigarettes to protect public health?” Research shows that as the price of cigarettes increases, consumption decreases. For each 10 percent price increase, consumption drops by about 7 percent for youth and 4 percent for adults.² The CDC reported that each pack of cigarettes sold in this country costs the economy $10.47 in direct medical costs and lost productivity.³ So the answer for the cigarette excise tax is simple: The higher the better.

The cigarette tax grades are based on the average (mean) of all state taxes as the midpoint, or the lowest C. The average cigarette tax was chosen because it is often seen as an indication of where states are in their cigarette taxing policies. The average state excise tax on January 1, 2010 was $1.34 per pack. The range of state excise taxes ($0.07 to $3.46) is divided into quintiles.

The excise tax grades break down as follows:

This methodology reflects the dynamic nature of cigarette excise taxes and the need to continue increasing taxes to keep up with inflation and decrease consumption. For instance, in 2002 Massachusetts had the highest cigarette tax at $1.51 per pack, a value that would put them only in the middle of the states in 2009. As cigarette taxes rise in the future, the mean will change and the grades will be adjusted to reflect the new mean.

Cessation Treatment Coverage

3) States receive up to 10 points for providing coverage without barriers: 1 to 2 points are deducted for each barrier to coverage that exists in a state. Deductions vary based on type of barrier and severity.

State Employee Health Plans (10 points): Target is barrier-free coverage of all Guideline-recommended medications and counseling for all of a state’s employees and dependents.

Standards for Private Insurance Coverage (5 bonus points): Target is a legislative or regulatory standard requiring coverage of all PHS-recommended medications and counseling in all private insurance plans within the state.