Reactions to Cigarette Taxes and Related Messaging: Is the South Different?

The average state cigarette tax is $1.53 per pack in the United States (US).1 However, the southeastern states are among those states having the lowest cigarette excise taxes. In the southeastern states, particularly those in Region 4 as defined by the US Department of Health and Human Services (ie, Alabama, Florida, Georgia, Kentucky, North Carolina, Mississippi, South Carolina, Tennessee), cigarette taxes range from $.37 in Georgia to $1.34 in Florida, with the remainder being below $.70 (the average being $.65 in these states).1 Increasing the unit price of tobacco, usually accomplished by federal, state, or local public policies applying excise taxes on tobacco, is an evidence-based strategy to reduce purchase and consumption of tobacco, particularly among those most vulnerable to tobacco use.2 Increased tobacco prices increase the number of tobacco users who quit and reduce the prevalence of tobacco use, the initiation of tobacco use among young people, the total amount of tobacco consumed, tobacco-related morbidity and mortality, and healthcare costs.3,4 As data indicate, states in the southeastern US are among those with the highest prevalence of tobacco use. Whereas the national average smoking prevalence is 19.0%, the average in this region is 22.0%, with prevalence as high as 26.5% in Kentucky.5 Unfortunately, the southeastern states also have among the highest proportions of their populations living at or below the federal poverty level, greater differences between the highest and lowest income groups, a larger proportion of the state population comprised of persons with less than a high school education, and greater racial and ethnic diversity than other regions of the US.6 Lower income individuals, those without a college education, and racial and ethnic minorities are more likely to be targeted by tobacco marketing and to use tobacco products than other populations,4 making tobacco use prevention a particular challenge in the southeastern states. Adding to the challenges in this region, the southeastern US has a strong history of reliance on agriculture as an economic driver and historically has produced larger amounts of tobacco than other areas of the US. In particular, North Carolina, Kentucky, Virginia, Tennessee, South Carolina, and Georgia have produced more tobacco than other US states.7 However, the role of tobacco farming in the US economy and in the so-called tobacco states’ economies has been shrinking rapidly for some time8 as US cigarette companies are using more foreign tobacco in manufacturing.9 The decreasing economic dependence upon growing tobacco in the South may create new opportunities for raising tobacco excise taxes. Lawmakers are concerned with the needs and perceptions of the electorate, as well as interest groups and contributors to their campaigns.10 Political acceptability of proposed legislation, including proposals to increase tobacco taxes, is measured by public opinion and response to various policy arguments in favor or against policy proposals.10 Relatedly, research indicates that responses to anti-tobacco industry media campaigns11 and coverage of tobacco policies12 are similar in tobacco-producing states compared to other states. Arguments from stakeholders in support of or in opposition to tobacco control policies, such as increased excise taxes on cigarettes, are often focused around several major themes and ideals – health, economic impact, youth prevention, individual rights, and morality.13-15 The ways that messages are framed can affect public support for policy.16 As such, it is important to understand which tobacco-related messaging strategies are the most persuasive within any population, particularly vulnerable populations like those residing in the southeastern US. Southeasterners have documented differences in political and social opinions. The 2013 Nielsen PRIZM data regarding households in the US document that the southeastern US has a greater proportion of individuals who might value individual rights, are married with children, attend religious services, or value hospitality (ie, engage with or entertain neighbors and guests).17 Thus, we hypothesized that appealing to the ideals of youth prevention, individual rights and responsibilities, religion and morality, or hospitality might be particularly effective messaging strategies targeting southeastern states. Given the aforementioned literature, we used a national panel survey to examine: (1) differences between Southeasterners and non-Southeasterners in relation to participant characteristics and their attitudes/knowledge regarding tobacco taxation; (2) participant sociodemographic, political, and smoking behavior characteristics in relation to overall support for increased tobacco taxation; and (3) differences between Southeasterners and non-Southeasterners in relation to perceived persuasiveness of messaging strategies about increased cigarette excise taxation.