tobacco tax initiative supporters and opposition before a failed timing and themes by tobacco control Tobacco coverage in print media : the use of

Objective Tobacco control policies gained ground nationwide in 2006, with voters in nine states approving legislation to strengthen clean indoor air policies and increase tobacco excise taxes. Despite having the second lowest cigarette tax rate in the nation, Missouri was unsuccessful in passing its 2006 ballot initiative to raise the tax. An important way to encourage healthrelated policy change such as increasing tobacco taxes is through media coverage of tobacco issues. We examined how tobacco issues were presented in Missouri’s print media leading up to the 2006 election. Methods This study analysed 1263 articles with tobacco content published in 187 Missouri newspapers in the year before the election. Articles were coded for general and tobacco-related characteristics including article type (news story, editorial, letter to the editor), tobacco control position (pro, neutral, anti) and article theme (economic, health, political). Results Most articles were news stories (73.6%) and pro-tobacco control (63.8%). The proportion of antitobacco control articles increased significantly (c1⁄4104.9, p<0.001) the month before the election, driven by an increase in economically themed articles. Economic articles were published more often in counties with less voter support for the tax (F1⁄45.68, p<0.01). Finally, tobacco control position varied significantly across article types (c1⁄4148.3, p<0.01), with letters to the editor being anti-tobacco control most often. Conclusion The media have a critical role in promoting public health goals and presenting health issues which influences formation of health policies. Tobacco control advocates must consider public opinion, opposition pressure, timing and themes in tobacco-related media coverage when promoting policy change. INTRODUCTION Tobacco control policies gained ground nationwide during the 2006 election cycle, with voters in nine statesdArizona, Arkansas, Colorado, Hawaii, Louisiana, Nevada, New Jersey, Ohio and Utah, as well as the District of Columbia and Puerto Ricodapproving legislation to strengthen clean indoor air policies and increase tobacco excise taxes. These state policy strategies have been shown to be among the most effective ways to reduce tobacco usedthe leading cause of preventable death in the USAdand follow the 20-year trend in state tobacco control strategies which increasingly target the social environment. Since 1988, 22 statewide ballot initiatives to raise the cigarette/tobacco tax have been sent to the voters of nine states. Eight of these initiatives have failed, including two introduced in 2006. Despite having one of the lowest cigarette tax rates in the nation, Missouri was one of the two unsuccessful states in 2006. Garnering support for tobacco control policy is an important public health objective in states like Missouri, where 24.6% of adults, 23.8% of high school students and 18.3% of pregnant women are current smokers. While Missouri is not a tobacco-growing state, it has the fourth highest adult smoking rate and the sixth highest lung and bronchus cancer incidence rate in the country. As of 2006, Missouri’s cigarette excise tax ranked second lowest in the USA at $0.17 per pack, and less than 1% of Missouri’s population was covered by clean indoor air legislation. Currently, Missouri is still behind the curve in strengthening tobacco control policy with no change in the cigarette excise tax since 1993 and just 13.3% of workers protected by smoke-free workplace policies. Media coverage of public health issues is an important way to encourage health-related policy change. 16 Media advocacy plays a critical part in promoting public health goals 18 and is an important component of comprehensive tobacco control programmes. 19 20 Furthermore, framing of health-related issues has a central role in successful public health policy advocacy, in particular in the formation of tobacco control policies. As tobacco control efforts increasingly emphasise policy-based strategies, it is important to understand how tobacco issues are presented in the media and how such presentation can influence policy outcomes. 18 Studies have shown that the American public is interested in health-related news topics, especially those related to tobacco. Also, coverage of tobacco in news media tends to emphasise successes, lending support to tobacco control. For example, one study of tobacco coverage in rural Kentucky found that articles about tobacco control were more prominent in communities where clean indoor air policy was being promoted. While media coverage can sometimes hinder the successful adoption of tobacco policies, it has played a part in the success of clean indoor air ordinances nationwide and in enacting international smoking control legislation. 26 Previous studies have examined coverage of tobacco control issues in the media throughout Australia, Mexico and the USA, 18 20 21 including print media coverage of the smoke-free bar law in California; the effects of a clean indoor air campaign on media coverage of tobacco in Kentucky; and the effects of a media campaign on tobacco use in Center for Tobacco Policy Research, Saint Louis University School of Public Health, St Louis, Missouri, USA Center for Tobacco Policy Research, George Warren Brown School of Social Work, Washington University in St Louis, St Louis,