Why increasing North Dakota’s tobacco prices is part of BreatheND’s State Plan to “Save Lives and Save Money” and where we’re at with accomplishing that goal.

Last updated 8.15.16 Is tobacco still a problem?

Yes

Tobacco use is STILL the leading cause of preventable death and disease, killing approximately 1,000 adults in ND each year from their own smoking.

Current Tobacco Use Rates – N.D. vs U.S.

Approx. 116,000 25% North Dakotans 22.3% N.D. 19.9% 20% U.S.

15.1% 15% 13.4% 11.7% 10.8% 10.6% 10% 7.3%

5%

0% ADULT SMOKING RATE HIGH SCHOOL STUDENT HIGH SCHOOL E- HIGH SCHOOL STUDENT SMOKING RATE CIGARETTE RATE SMOKELESS USE RATE Tobacco Use by ND High School Students

Cigarettes Smokeless Tobacco E-cigarettes 25% 22.3% 22.1% 22.4% 21.1% 19.4% 20% 19.0%

15.3% 15% 13.6% 13.8% 11.2% 11.7% 11.7%

10% 11.2%

5%

0% 2005 2007 2009 2011 2013 2015 Source: 2005-2015 Youth Risk Behavior Survey ND Population Groups Who Smoke (and are hardest hit by the health and economic consequences of tobacco)

Also: Pregnant women (15% smoking rate vs. 10% nationally)

Source: NDQuits, BRFSS Survey U.S. Preventable Causes of Death Source: 4Behavioral Health & Wellness Program, U of CO School of Medicine Increasing Low-Income Smokers’ Access to and Utilization of Cessation Treatment, Chad Morris, PhD

Why does tobacco impact these populations more than others?

 Tobacco industry targeting/marketing/sponsorships  Free supplies/samples (ex. Military rations in the past)  Lack of social norming and policy changes at the local level  Lack of access to evidence-based cessation treatment  Economic/cultural barriers – distrust of “systems”, mobility, food insecurity  Higher density of tobacco outlets strategically placed in low- socio-economic areas

What works best to significantly reduce & prevent tobacco use?

Now that we can SEE that tobacco use is still a problem, what do we do about it? The 3-legged stool for tobacco prevention policy according to CDC Best Practices

A COMPREHENSIVE TOBACCO PREVENTION PROGRAM (BreatheND) funded at or above CDC STRONG SMOKE-FREE LAW recommended levels Passed by that includes access to 2012 ND voters cessation services ✓ (ND DoH). ✓ Passed by HIGH TOBACCO PRICES 2008 ND voters Measure 4 on the ✗ 2016 ballot Verified by American Lung Assn’s “State of Tobacco Control” Report Card

 Released in Feb 2016  Grades:  A – Program Funding  A – Smoke-free Air  C – Access to Cessation Services  F – Tobacco taxes

For more info: http://www.lung.org/our-initiatives/tobacco/reports-resources/sotc/ How low are ND tobacco taxes?

 Current ND tobacco taxes:  Cigarette taxes: $0.44/pack  Snuff: $0.60/oz (weight-based taxing)  Pipe tobacco/cigars: 28% of wholesale purchase price

 ND’s cigarette tax rates rank 47th lowest in the nation. Only Georgia ($.37), Virginia ($.30) and Missouri ($.17) are lower.

 Since 2002, 47 states and DC have increased their cigarette tax rates 126 times.

 North Dakota last increased its tobacco taxes in 1993.

How low are ND tobacco taxes?

 Overall All States’ Average: $1.65/pack.  Major Tobacco States’ Average: $0.485/pack.  Other States’ Average: $1.80/pack.  Highest combined state-local tax rate:

Chicago, IL: New York City, NY: $6.16/pack $5.85/pack How does that compare regionally?

Average of surrounding states: $2.08/pack. Do tobacco price increases work?

In every single state that has significantly raised its cigarette tax rates, pack sales have gone down sharply. Take Minnesota, for example… Within the first two weeks after their cigarette tax increase (from $1.60 to $2.83) went into effect, calls into their state quit line increased by 256%, and hits on their quit plan website received an increase of 286% in traffic. Are you sure it works?

Increasing the price of tobacco is proven to be one of the most effective policies to reduce tobacco use and encourage quitting among adults, and even better, to prevent young people from ever starting.

“If prices were 10% higher, 12-17 incidence [youth smoking] would be nearly 12% lower.” -R.J. Reynolds Executive

If tobacco price increases didn’t work to reduce use and prevent kids from starting, the industry wouldn’t spend millions to fight it. It’s not ALL about price, but price increases definitely impact consumption. Reminder, the best results don’t just come from ONE policy. The most effective way to prevent tobacco use is to enact all 3 legs of the stool. If it works, why doesn’t ND do it?

IT’S NOT FOR LACK OF PUBLIC SUPPORT. From past to recent polling (Dec. 2015), nearly 70% of North Dakotans supported a significant increase in tobacco taxes:  Across Party Lines (D, I, R, and Tea Party)  Across Geographic Regions (NW, NE, SW, SE)  Across Demographics – Age, Gender, Income If it works, why doesn’t ND do it?

IT’S NOT FOR LACK OF TRYING.  2013 House bill to increase from $0.44 to $1.00/pack –defeated in House (19 Y – 72 N).  2015 House bill to increase from $0.44 to $1.54/pack – defeated in House (34 Y – 56 N).  2015 Senate bill to increase from $0.44 to $2.00/pack – defeated in Senate (17 Y – 30 N). If it works, why doesn’t ND do it?

OUR BIGGEST BARRIERS: • Current make-up of the legislature • Black-and-white stances like “no new tax” pledges taken by candidates and policymakers • Powerful tobacco industry – money and influence to stop this health policy from being enacted Who is trying to help?

• Some efforts are not new: • Local public health & BreatheND have educated legislators about the health benefits of tobacco price increases for years as part of the BreatheND State Plan . • Some efforts ARE new: • Raise it for Health ND coalition: first organized in January 2014, re- organized in January 2016. • Announced a ballot initiative in March 2016 to increase ND’s tobacco taxes. • Petitions circulated, signatures collected April – June 2016. • Submitted over 22,000 signatures on July 7, 2016 to ND SoS. • Approved as Measure 4 on the November 2016 ballot. Raise it for Health ND Coalition Partners

• ND Veterans Coordinating Council  AARP North Dakota • American Lung Association in ND  ND United • American Cancer Society Cancer Action  ND Chapter of the American Academy of Network Pediatrics • ND Association of Counties  Heartview Foundation, Bismarck • ND Medical Association  March of Dimes • ND Nurses’ Association  Campaign for Tobacco Free Kids • CHI (Catholic Health Initiatives)  Tobacco Free North Dakota • Essentia Health  Anne Carlson Center • Blue Cross Blue Shield of ND  ND Oral Health Coalition • Mental Health of America of ND  Dakota Boys and Girls Ranch • ND Federation of Families for Children’s  Dakota OutRight Mental Health  Minot, Kenmare Safe Communities • ND Public Health Association Coalitions • ND Rural Health Association  Bismarck Tobacco Free Coalition • ND Society for Respiratory Care  Richland-Wilkin Kinship  Sincere Smiles, Williston

Raise it for Health ND’s 2016 Ballot Initiative to Increase Tobacco Taxes

 What will it do?  Increase cigarette tax from $0.44/pack to $2.20/pack.  Eliminate weight-based taxing of tobacco products.  Increase tax on all other tobacco products, including liquid nicotine, from 28% of wholesale purchase price to 56% of wholesale purchase price.  How much new revenue will that generate? Estimates have shown approximately $200 million per biennium (diminishing over time as tobacco rates drop). Raise it for Health Ballot Initiative Facts New Revenue Allocations (Estimated at $200 Million / Biennium Raise it for Health Ballot Initiative Facts New revenue distribution & dedication

50% to a 50% to the Veterans Community Tobacco Tax Fund Health Trust Fund • Administered by 15-member, • 70% to support a comprehensive Governor-appointed state plan for mental health & Administrative Committee on addiction, administered by the Veterans Affairs (ACOVA) Behavioral Health Planning Council • Programs/services tied to • 20% to counties for delivery of local strategic plan (ex. Service health unit services established by dogs, TBI/PTSD/Agent Orange the State Health Council treatment, adaptive • 10% to chronic disease detection, housing/vehicle grants, post- prevention, and control programs war trust fund recovery through ND Dept. of Health Raise it for Health Ballot Initiative Facts

 NOTE: No new revenues generated from this measure are dedicated to tobacco prevention or cessation.

 REASON: The Center for Tobacco Prevention & Control Policy (BreatheND) and the NDQuits program are already fully-funded by a small portion of the Master Tobacco Settlement Agreement (MSA), NOT by tobacco taxes. What are the benefits of this measure?

Estimates from Campaign for Tobacco Free Kids/American Cancer Society Cancer Action Network2 show…

 YOUTH PREVENTION – More than 80% of adult smokers begin smoking before age 18. This proposed measure is estimated to decrease youth initiation by 20% and prevent 5,800 ND youth under age 18 from ever starting. What are the benefits of this measure?

Estimates from Campaign for Tobacco Free Kids/American Cancer Society Cancer Action Network show…

 HEALTH CARE SAVINGS – In long-term health care costs, ND is estimated to save nearly $247 million from reductions in adult and youth tobacco use. What are the benefits of this measure?

Estimates from Campaign for Tobacco Free Kids/American Cancer Society Cancer Action Network show…  HEALTH PROGRAM FUNDING – At a time of budget cuts and reduced revenues, this measure would provide funding for North Dakota veterans’ and public health services and programs for individuals with mental health issues, addiction disorders, and chronic disease. Summary

 Tobacco IS still a problem.  The best approach to combat tobacco death and disease is to use the 3-legged stool of CDC Best Recommended Practices.  ND has one of the lowest tobacco tax rates in the country.  Significant increases in the price of tobacco are proven to:  Prevent youth initiation and decrease adult tobacco use.  Save millions in long-term health care costs.  Generate additional revenue even when attributing for a reduction in tobacco use.

Why we do what we do

"If we [do] not act decisively, a hundred years from now, our grandchildren and their children [will] look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked.”

-Former World Health Organization Director-General Gro Harlem Brundtland, M.D., M.P.H Sources:

 U.S. Centers for Disease Control and Prevention  Campaign for Tobacco Free Kids/ACS CAN  Toll of Tobacco in North Dakota  State Cigarette Excise Tax Rates & Rankings (July 2016)  New Revenues, Public Health Benefits & Cost Savings (Jan 2016)  North Dakota Center for Tobacco Prevention & Control Policy  ND Quits, BRSFF Survey (https://ndquits.health.nd.gov/we-can-help/)  North Dakota DPI Youth Risk Behavior Survey (YRBS)  Behavioral Health & Wellness Program, University of Colorado School of Medicine  Increasing Low-Income Smokers’ Access to and Utilization of Cessation Treatment, Chad Morris, PhD For questions pertaining to the ballot measure:

Please contact:

RAISE IT FOR HEALTH ND COALITION Kristie Wolff, American Lung Association 212 N 2nd St, Bismarck, ND 58501 701-223-5613 [email protected] www.raiseitforhealthnd.com