# Presentation: 214308

## Tobacco and Chronic Disease: Building Effective Coalitions to Impact Policy Change

**Beverly J. May, Director**
- Campaign for Tobacco Free Kids

## Overview

-    Using Colorado’s Amendment 35 experience as a case study, I will:
- Explain importance of positioning tobacco control as part of larger policy discussion on healthcare and chronic disease prevention/treatment.
- Point to strategic keys for building tobacco control and healthcare/chronic disease coalitions to impact policy
- Identify key messages that connect tobacco control and chronic disease management

## 
Positioning Tobacco Control 
as Part of Larger Policy Discussion 
on Healthcare

- Positioning Tobacco Control
- as Part of Larger Policy Discussion
- on Healthcare

## Shared Challenge: Broadening the Issue Beyond Tobacco

- Some complacency with tobacco prevention issues
- Need to give the issue immediacy, urgency
- Broaden public appeal and allied support
- Healthcare is a major priority for voters
- National research shows Americans’ concern about healthcare is second only to “jobs/the economy” and equal to “national security”
- All recent successful tobacco tax ballot campaigns tied tobacco to healthcare
- WA in 2001; OR & AZ in 2002; CO in 2004
**Need a “middle class sell” beyond healthcare for the poor**

## Case Study  Campaign for a Healthier Colorado

- _Colorado-Specific Challenges_
- Legislature can’t pass taxes w/o voter approval (increasing expense and uncertainty)
- No tax increase approved by voters since TABOR (1992)
- Significant “baggage” with other constitutional amendments
- Industry previously successful in blocking tax increase (spent more than $5M in 1994)
- 2002 poll showed weak support for tobacco tax measure

## 
Strategic Keys
for a Successful Effort

- Strategic Keys
- for a Successful Effort

## 

Strategic Key #1
What you do in the months leading up to the campaign is as important – or more important – than what you do during the campaign

- Strategic Key #1
- What you do in the months leading up to the campaign is as important – or more important – than what you do during the campaign

## Case Study Campaign for a Healthier Colorado

- We spent 18 months...
- Researching efforts in other states
- Gauging interest from healthcare, advocacy groups
- Learning priorities of community stakeholders
- Building the coalition
- Researching public opinion
- Anticipating potential pitfalls and trying to address them before “going public”
- Negotiating the proposal
- Going through title-setting with Secretary of State’s office to smoke out industry opposition and familiarize ourselves with process

## 

Strategic Key 
Engage a broad coalition 
and involve them early and often

- _Strategic Key _
**Engage a broad coalition **
**and involve them early and often**

## Case Study Campaign for a Healthier Colorado

- _Building the coalition_
- Cast a wide net, identified all possible stakeholders
- Met with all potential stakeholders to learn what needs, priorities and concerns were
- Involved them early and often
- Built trust
- Had them invest early (staff time/resources, sharing in costs for research, etc.)

## Case Study Campaign for a Healthier Colorado

- Core workgroup began meeting in early 2003
- Met with dozens of high profile individuals and groups for informational interviews
- Written recaps of informational interviews to create record
- Polling done month prior to first steering committee meeting
- helped direct / focus steering committee work

## Case Study Campaign for a Healthier Colorado

- Convened coalition in summer 2003...
- Provided them with research
- Made the case for linking tobacco taxes and healthcare
- Let them see each other in a room together
- High profile location helped create sense of buy-in

## Involving the Chronic Disease Community

- University of Colorado Cancer Center
- International Society for the Study of Lung Cancer
- Colorado Prevention Center
- National Jewish Medical and Research Center (#1 Respiratory Hospital in America)
- AHA, ACS, ALA
- Colorado Cancer Coalition (Indirectly Involved)

## 

Strategic Key 

Write a policy-sound, simple 
and politically viable measure

_**Strategic Key **_
**Write a policy-sound, simple **
**and politically viable measure**

## Case Study Campaign for a Healthier Colorado

- Steering committee started with list of 17 programs
- Through facilitated discussion and using guiding principles list was reduced to 7 programs
- Policy papers ‘made the case’ for each of the 7 programs
- Program / principle matrix summarized information in policy papers into format based on guiding principles

## Guiding Principles

- 1.	Fund sound programs that benefit the health of Coloradans.  Funded programs must:
- Be cost effective
- Have evaluation and accountability mechanisms
- Have a proven track record
- 2.	Build a politically viable package.  The package must be:
- Supported by the public
- Able to attract the necessary resources to support the campaign
- Clear and concise, limited to 3 or 4 areas of funding
- Favor programs that leverage money from governmental or non-governmental agencies
- 4.	Do not duplicate or supplant existing funding

## Case Study Campaign for a Healthier Colorado

- _Ended up with_
- Constitutional amendment increasing tobacco excise tax by 64 cents/pack and 20% on other products
- Revenue would be divided as follows:
- 46% for public health insurance expansion (CHP+/Medicaid)
- 19% for comprehensive primary care through clinics
- 16% for prevention, detection & treatment of cancer, cardiovascular and pulmonary diseases
- 16% for comprehensive tobacco control
- 3% hold-harmless provision

## Case Study Campaign for a Healthier Colorado

- _Research_
- June 2002 poll of 713 likely voters (determine public support)
- June 2003 poll of 600 likely voters (determine public support; amount of tax increase; revenue allocations)
- June 2004 focus groups (2 groups, suburban men & women)
- August 2004 poll* of 600 likely voters (test messages)
- No tracking polls

## 

2004 Poll

_**2004 Poll**_

## Eight in ten voters agree that funding cancer prevention and treatment could benefit everyone.

**Putting tobacco tax funds into cancer prevention and treatment could benefit all of us one day.**

**If we increase the tobacco tax and fund tobacco education and cessation, we might be able to help prevent people from getting heart and lung disease.**

***If we raise cigarette taxes and fund a tobacco prevention program, we can deter kids from starting to smoke.**

***If we raise cigarette taxes and fund a tobacco prevention program, we can convince kids who have already started smoking to stop.**

- 8. First, I’m going to read you a series of statements.  After I read each one, please tell me whether you agree or disagree. *Split Sample

**The State Legislature can be trusted to spend tobacco tax funds on health care and tobacco education programs.**

**80%**

**72%**

**58%**

**45%**

**43%**

## Health care programs are the most appealing components of the measure.

***Expanding access to health care for low-income children and families through Medicaid and the Children’s Health Insurance Plan**

***Creating a statewide, comprehensive prevention, early detection and treatment program for cancer, cardiovascular and pulmonary diseases**

***Providing comprehensive primary care through Community Health Centers and other clinics serving a high portion of uninsured and medically indigent**

***Increasing the tobacco tax in Colorado by 64 cents per pack of cigarettes**

- 10. Now I am going to read you a list of the individual components of this ballot measure.  After I read each one, please tell me whether you support or oppose that component of the measure.  *Split Sample

## Among four major funding areas, voters are divided about the most important use of the tobacco tax funds.

- 11. Now, I’m going to read you a list of the four _main_ ways that money from this measure would be used.  Regardless of how you might be voting on the measure, tell me which of the four items is the most important use of money from the measure. And which do you think is the _second-most important_ use of money from the measure?

| Usage of Money | 1st Choice | 2nd Choice |
| --- | --- | --- |
| Funding prevention, early detection and research programs for heart disease, lung disease, cancer and stroke | 28% | 19% |
| Supporting community health centers and clinics throughout the state that provide family doctors to Colorado families, especially low-income families | 24% | 25% |
| Education and prevention programs to reduce and prevent tobacco use, especially among children and teenagers | 23% | 20% |
| Expanding health insurance coverage for low-income children and families | 19% | 28% |
| All/None/DK/NA | 6% | 6% |

## Voters believe that those with a history of disease, low-income people, and Colorado’s youth will benefit most.  

- 13. Now I’m going to read you a list of some different groups of people in Colorado.  After I read each one, please tell me how much you think that group will benefit from the programs and services provided by this tobacco tax measure.  Will that group benefit a great deal, somewhat, just a little, or not at all from this measure and the health care and tobacco prevention programs it funds?

## The Strongest Arguments in Favor of the Measure.....

**Some of the top causes of death in Colorado are cancer, heart disease, lung disease and stroke.  This measure will help to prevent, detect, and treat these deadly diseases and save lives in Colorado.**

**More than one-third of Colorado high-schoolers use tobacco.  This measure will increase the tax on tobacco and fund tobacco education and prevention programs—two proven ways to stop teenagers from beginning to smoke.  And for every three kids who are prevented from smoking, there is one less smoking death in the future.**

**This initiative includes strict accountability measures including guaranteed financial and performance audits, regular spending reports listed on the Internet and in local libraries across the state, and a blue ribbon panel of experts to ensure that the money is spent efficiently, effectively and as promised.**

- 14. Next, I am going to read you a list of statements made by people who _support_ the tobacco tax ballot measure.  After I read each one, please tell me whether it makes you more inclined to _support_ the measure.  *Split Sample

**This measure will provide additional funding for community health centers in large cities and rural areas, which play a critical role in providing family doctors to Colorado families who would not otherwise have access to high-quality health care.**

**66%**

**64%**

**63%**

**62%**

## 
Key Messages 
that Connect Tobacco Control 
and Healthcare/ Chronic Disease

- Key Messages
- that Connect Tobacco Control
- and Healthcare/ Chronic Disease

## Case Study Campaign for a Healthier Colorado

- National messages
- Public wants to see connection between “cause” and where the money goes
- Impact on youth
- Locally tested messages
- Leading causes of death, chronic disease prevention (66%)
- Reducing youth consumption (64%)
- Strict accountability measures, money “guaranteed” (63%)
- Lowest excise tax in nation (60%)

## Case Study Campaign for a Healthier Colorado

- Used these messages throughout paid media:
- Website
- 1 radio ad (targeted mostly in rural and western Colorado)
- 2 TV ads (ran in all 3 TV markets in CO.)
- 3 pieces of direct mail (targeted to early voters) and all grassroots printed materials

## So, What Happened on Election Day? 

- A35 passed with more than 61% voter support becoming Colorado’s first statewide tax increase in over 10 years
- Carried traditionally Republican and Democratic strong-holds

## Case Study Campaign for a Healthier Colorado

- _Ended up with_
- Constitutional amendment increasing tobacco excise tax by 64 cents/pack and 20% on other products
- Revenue would be divided as follows:
- 46% for public health insurance expansion (CHP+/Medicaid)
- 19% for comprehensive primary care through clinics
- 16% for prevention, detection & treatment of cancer, cardiovascular and pulmonary diseases
- 16% for comprehensive tobacco control
- 3% hold-harmless provision

## After the Campaign

- Coalition decided to stick together through the legislative session to ensure that Amendment 35 is implemented as intended (Nov. ’04 – May ’05)
- Helped draft implementing language, found sponsors, lobbied the bill, passed it through House and Senate
- Governor signed bill into law on June 2, 2005

## The Legislation

- Included Review Committees for Tobacco Prevention and Chronic Disease
- Chronic disease $ goes to comprehensive grant program
- Fought off attempts to earmark most of the chronic disease $ to treatment and specific diseases
- Treatment capped at 10% of funds (After $5.5 million for breast and cervical cancer treatment)
- Tobacco Control and chronic disease required by law to follow existing state plans (Cancer, CVD, Stroke)

## Beverly J. May M.P.A.	Campaign for Tobacco-Free Kids

- Regional Director, Western States & Ohio
- _[bmay@tobaccofreekids.org](mailto:bmay@tobaccofreekids.org)_
- 801-824-0084
- 202-481-9384