Public opinion analysis regarding the uses of master settlement agreement (MSA) funds R.H. Friis a, *, A.M. Safer b , G.M. Piane a a Department of Health Science, California State University, Long Beach, 1250 Bellflower Boulevard, Long Beach, CA, USA b Department of Statistics, California State University, Long Beach, 1250 Bellflower Boulevard, Long Beach, CA, USA Received 18 March 2003; received in revised form 20 August 2003; accepted 4 September 2003 KEYWORDS Tobacco; Health policy; CART analysis Summary Objectives. In the present research, we assessed the relationship between characteristics of the residents of Long Beach, California, a typical city in America, and their opinions regarding the uses of master settlement agreement (MSA) funds. Methods. The statistical analyses used in the present research included univariate frequency distributions, cross-tabulations, and classification and regression trees. Results. The results indicate that the majority of Long Beach residents share the opinion that the MSA funds should be allocated to health programmes. They do not, however, feel that these funds need to be earmarked solely for smoking prevention or cessation. Conclusions. Due to state budget deficits, legislators may strongly advocate for the MSA funds to be used for non-health purposes. Our findings provide support for community advocates who wish to bring the current uses of MSA funds and tobacco taxes to the forefront of national and international public debate. Q 2003 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. The master settlement agreement (MSA) is unpre- cedented for its potential impact on smoking- related mortality in the USA. The MSA provided the state courts with jurisdiction over implemen- tation and enforcement of the settlement, and also placed no restrictions on the use of funds. 1 Despite the funding that is available for programmes that target smoking prevalence and the health-associ- ated consequences of smoking, media accounts of government spending plans suggest that MSA funds are being diverted from these uses. The MSA was signed on 23 November 1998 by attorneys general representing 46 of the 50 states, the District of Columbia and the five US territories. The agreement with the four major cigarette companies (Brown and Williamson Tobacco Corpor- ation, Lorillard Tobacco Company, Philip Morris Incorporated and RJ Reynolds Tobacco Company) settled more than 40 pending lawsuits against the tobacco industry. The states will receive annual payments totalling $206 billion by 2025 in exchange for dropping their lawsuits and agreeing not to sue in the future. 2 The arguments used in the original lawsuits that led to the MSA claimed that the tobacco companies should reimburse the states for tobacco-related healthcare expenses. 3 In his speech on 17 Septem- ber 1997 regarding broad tobacco legislation and Public Health (2004) 118, 190–200 0033-3506/$ - see front matter Q 2003 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2003.09.008 * Corresponding author. Tel.: þ 1-562-985-1537. E-mail address: [email protected]
Transcript
Public opinion analysis regarding the uses of mastersettlement agreement (MSA) funds
R.H. Friisa,*, A.M. Saferb, G.M. Pianea
aDepartment of Health Science, California State University, Long Beach, 1250 Bellflower Boulevard, LongBeach, CA, USAbDepartment of Statistics, California State University, Long Beach, 1250 Bellflower Boulevard, Long Beach,CA, USA
Received 18 March 2003; received in revised form 20 August 2003; accepted 4 September 2003
KEYWORDSTobacco; Health policy;
CART analysis
Summary Objectives. In the present research, we assessed the relationship betweencharacteristics of the residents of Long Beach, California, a typical city in America,and their opinions regarding the uses of master settlement agreement (MSA) funds.
Methods. The statistical analyses used in the present research included univariatefrequency distributions, cross-tabulations, and classification and regression trees.
Results. The results indicate that the majority of Long Beach residents share theopinion that the MSA funds should be allocated to health programmes. They do not,however, feel that these funds need to be earmarked solely for smoking prevention orcessation.
Conclusions. Due to state budget deficits, legislators may strongly advocate for theMSA funds to be used for non-health purposes. Our findings provide support forcommunity advocates who wish to bring the current uses of MSA funds and tobaccotaxes to the forefront of national and international public debate.Q 2003 The Royal Institute of Public Health. Published by Elsevier Ltd. All rightsreserved.
The master settlement agreement (MSA) is unpre-cedented for its potential impact on smoking-related mortality in the USA. The MSA providedthe state courts with jurisdiction over implemen-tation and enforcement of the settlement, and alsoplaced no restrictions on the use of funds.1 Despitethe funding that is available for programmes thattarget smoking prevalence and the health-associ-ated consequences of smoking, media accounts ofgovernment spending plans suggest that MSA fundsare being diverted from these uses.
The MSA was signed on 23 November 1998 byattorneys general representing 46 of the 50 states,
the District of Columbia and the five US territories.The agreement with the four major cigarettecompanies (Brown and Williamson Tobacco Corpor-ation, Lorillard Tobacco Company, Philip MorrisIncorporated and RJ Reynolds Tobacco Company)settled more than 40 pending lawsuits against thetobacco industry. The states will receive annualpayments totalling $206 billion by 2025 in exchangefor dropping their lawsuits and agreeing not to suein the future.2
The arguments used in the original lawsuits thatled to the MSA claimed that the tobacco companiesshould reimburse the states for tobacco-relatedhealthcare expenses.3 In his speech on 17 Septem-ber 1997 regarding broad tobacco legislation and
Public Health (2004) 118, 190–200
0033-3506/$ - see front matter Q 2003 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.puhe.2003.09.008
the proposed settlement, President Clinton saidthat the main objective was to reduce smokingrather than simply to extract money from thetobacco industry.4 States and local governmentshave diverted the MSA funds away from the originalintent by using the funds for highway construction,tax cuts and reimbursing tobacco farmers.2 Publichealth officials have argued for the use of thesefunds for tobacco control programmes. There aredivergent views relative to the actual use of MSAfunds, the original intent of the lawsuits, the publichealth perspective and the will of the public.
The MSA represents a very different legalenvironment than the previous lawsuits in the pastthree decades. The powerful tobacco lobby with itsmoney and strong influence on legislators blockedanti-tobacco legislation. The tobacco industry’slawyers easily won early lawsuits, including thefirst one filed in 1954 and every major suit beforethe 1990s. Laws have recently changed so that adefendant can be held partially liable and made topay a corresponding proportion of damages.5
The MSA called for the tobacco industry to createa national foundation that develops an advertisingand education programme to counter tobacco use.The MSA has also restricted advertisements that usecartoons, which target youth, as well as outdoorcigarette advertising, and distribution of appareland merchandise with cigarette brand name logos.Lobbyists for the tobacco industry are prohibitedfrom opposing laws that would limit youth accessand use of tobacco products. The National TobaccoGrowers’ Settlement Trust Fund was created inwhich four tobacco companies will pay $5.15 billioninto the trust fund over the next 12 years tocompensate tobacco farmers and quota holders forfinancial losses that are expected to be incurreddue to decreases in cigarette consumption. The 14tobacco-producing states that receive this moneyreceive funds based on the 1998 production levels.More than 500 MSA-related bills have been intro-duced in 49 states since the MSA was signed. Manyof the bills establish trust funds from which themoney can be allocated to specific areas such aschildren’s health, smoking cessation, education orhighway construction.2
The Centers for Disease Control and Prevention(CDC) have recommended that at least 25% of theMSA money should be spent on smoking- educationand -cessation programmes.6 If the monies werespent according to the guidelines and recommen-dations of the CDC, the prospect for continuedimprovement in public health would be positive. Sofar, despite strong public support for tobaccocontrol policies and programmes, most states
appear to be planning to spend little, if anything,on tobacco control.3
The setting for the present research is the stateof California, which has developed many innovativeprogrammes for tobacco control. For example, thestate enacted a 50-cent/pack tax on cigarettes inorder to fund research on tobacco-related diseases,media campaigns and other control programmes. InJanuary 1998, the state implemented a law thatbans smoking in alcohol-serving establishments.
California will receive an estimated $25 billionby 2025, the highest percentage (12.8%) of any ofthe states participating in the agreement. The stateand local governments will divide the $25 billionevenly, with the local share being distributed basedon population to counties and four specified cities.7
The state funds in California have all been allocatedto health care by increasing the number of childrenenrolled in the Healthy Families programme, and byfunding other initiatives. However, none of thefunds are being spent on programmes for theprevention of tobacco use. California has notplaced restrictions on the use of the MSA funds bythe local governments; this flexibility has resultedin great variation in allocation of these funds. Toillustrate, we note the diversity in proposals for useof the funds in California counties. Despite a clearmessage from voters in Orange County to designate80% of the funds to health care,8 the County Boardof Supervisors filed a lawsuit to overturn the ballotmeasures and subsequently allocated only half ofthe funds to health care and half to debtreduction.9 Numerous California counties havevoted to issue tax-free bonds backed by the revenuefrom the MSA.10 In the southern California regionsof Ventura County, San Bernardino County and thecity of Los Angeles, allocation of the funds has ledto bitter disputes between health officials andlegislative decision makers.10 –12
This review of the literature suggests that thereis a division between the will of the public and thepolicy decisions of government officials.13 Specifi-cally, the present study seeks to describe theopinions of Long Beach residents regarding the useof MSA funds, and to identify predictors of their willto use these funds for tobacco control and otherhealth programmes.
Methods
Setting
Long Beach, California’s fifth largest city, has anethnically diverse population that can serve as
Public opinion analysis regarding the uses of master settlement agreement (MSA) funds 191
a representative microcosm of urban America; LongBeach presents most of the complexities andchallenges that will present in other metropolitanareas. While two-thirds of its 450 000 population arebetween the ages of 18 and 64 years, significantproportions (25 and 11%, respectively) are agedunder 18 years or 65 years and older. The populationis comprised of 50% Caucasians, 24% Latinos, 13%African Americans, 13% Asian and Pacific Islanders,including the largest settlement of Cambodians inthe USA, and less than 1% Native Americans andothers. More than half of the population has somelevel of college education. Although the medianfamily income is more than $36 000, approximately17% of the population lives below the poverty level.Located within Los Angeles County, the city isgoverned by a mayor and nine district councilmembers. The city’s Department of Health andHuman Services is one of only three city-operatedindependent health jurisdictions in the state.14
Sample and instrument
During late 2000, a random digit dialled survey wasconducted in Long Beach as part of a survey of theattitudes of residents on the implementation of the1998 Californian law that banned smoking in bars,lounges and casinos. One section of the telephonesurvey contained questions regarding the use of MSAfunds. The telephone interviews included 11 demo-graphic items, 28 questions regarding smokingstatus and history, two questions about the use ofMSA funds, 31 lifestyle descriptors, 10 questionssoliciting opinions about smoking, 30 items regard-ing opinions and experience with drinking alcohol,12 items related to the smoke-free-bars initiative,and four queries about tobacco taxes and otherrestrictions on tobacco use.
The survey included two specific questionsregarding the uses of the MSA funds. The firstquestion was: “As you may know, the State ofCalifornia will be receiving money from the tobaccocompanies as part of what is known as the ‘MasterSettlement Agreement’… tell me which one of thefollowing uses you most agree with:
(1) The money should be used for public debtreduction;
(2) The money should be used by the general fund;(3) The money should be used for improvement of
public safety;(4) The money should be used for improvement
of healthcare services”
The second question continued, “If the statedetermines that the ‘Master Settlement Agreement’
money will be spent on health-related services,which one of the following health-related issueswould you most agree with?
(1) The money should be used for senior transpor-tation to medical services;
(2) The money should be used for keeping hospitalemergency rooms open;
(3) The money should be used for anti-smokingeducation for youth;
(4) The money should be used for increasing accessto clinical services;
(5) The money should be used for generaltobacco-education and smoking-cessationservices.”
Completed survey responses were obtained froma sample that generally represented the adultpopulation of Long Beach. Among the surveyrespondents, there was a slightly higher percentageof African Americans (survey 14.7% vs population13%), Latinos (survey 30.1% vs population 24%) andNative Americans (survey 1.7% vs population 1%)than in the population. Under-represented groupsincluded Asians (survey 5.9% vs population 13%) andWhites (survey 39.6% vs population 50%). Regardingethnicity, it is noteworthy that more than 8% of therespondents chose ‘other’, ‘do not know’ or refusedto answer the question. This result is significantlydifferent from Long Beach census data, whichindicates less than 1% ‘other’. As the survey wasonly conducted in English or Spanish, languagebarriers may explain some of the differencesbetween the sample and the population.
Data analysis methods
The statistical analyses used in the present researchincluded univariate frequency distributions, cross-tabulations and the statistical method known asclassification and regression trees (CART) devel-oped in 1984.15 –17 The CART procedure is a methodof multivariate analysis that forms trees of vari-ables by using rules to split sets of variables intointer-related branches. CART uses a type of step-wise method to determine rules for splitting thevariables into nodes. However, unlike typicalstatistical regression procedures, CART does notrequire advance selection of variables. Parentnodes are always split into two nodes; the splittingprocess is repeated as each child node is treated asthe next parent node that can be split into two morenodes until it reaches a terminal node. In CART, therules for splitting nodes involve looking first at allpossible splits for all variables included in theanalysis. Next, CART ranks each splitting rule based
R.H. Friis et al.192
on how well the split separates the classescontained in the parent node. Once the best splitis found, CART continues the same process for eachchild node, until no further splitting is possible (onlyone case left) or stopped (too few cases accordingto criteria set by the user).18 An example of childnodes is splitting the variable age into those aged 40years and younger and those aged over 40 years.
By using this decision tree procedure, analystsare able to uncover and present extremely complexrelationships in large data sets. CART does not use a‘black box’ method to determine classification, asdo some other classification techniques such asartificial neural networks. The important variablesthat make up the model are shown along with thetree and other aspects of the classification. TheCART tree diagram output is easier to comprehendthan the other classification techniques, such aslogistic regression. In addition, the results of CARTare very accurate relative to logistic regression, theanalytic method widely used in public healthresearch. CART models are, on average, at leastas good as logistic regression, and are usually moreaccurate.18
CART has several other advantages. One of themis the avoidance of parametric assumptions, whichare common in traditional statistical techniques. Inaddition, CART automatically determines whichvariables are important in the model and informsthe user of the relative importance of eachvariable. Third, unusual observations, or outliers,have marginal to no effect on CART.19 Fourth, CARTis very flexible for an analysis of categorical orcontinuous variables.
The essential output of CART is a decision treethat has a root node at the top. At each node thereis a split, either left or right (yes or no), based onone variable. The path that the tree takes below thecurrent node (the parent node) is to one of two(child) nodes below. The nodes continue to split,parent to child, until the tree hits a terminal or endnode. The path from root node to terminal nodedescribes a profile that best fits one of thedependent variable categories. Consequently,using the decision tree, a researcher can use a listof values of a particular observation to follow thetree path to the most likely dependent variablevalue.
Regarding the uses of the MSA funds, the responseto the question that gave the four options: (1) publicdebt reduction; (2) general fund; (3) improvementof public safety; or (4) improvement of healthcareservices, was the dependent variable for the firstCART analysis. For this analysis, the responses werecollapsed into two categories: improvement ofhealthcare services and expenditures for non-health
areas. The second CART analysis investigated theresponse to the five options of health-relatedspending: (1) senior transportation to medicalservices; (2) hospital emergency rooms; (3) anti-smoking education for youth; (4) access to clinicalservices; or (5) general tobacco-education andsmoking-cessation services. In this second analysis,the responses were collapsed into tobacco-relatedspending and non-tobacco-related spending.
Results
Most Long Beach residents who responded to thetelephone survey clearly shared the opinion thatthe MSA funds should be spent on health pro-grammes. A total of 80% ðn ¼ 1200Þ stated thatthe funds should be used for the improvement ofhealthcare services. A minority of respondentsbelieved that the funds should be spent onimprovement of public safety (11%, n ¼ 158Þ;public debt reduction (5%, n ¼ 74Þ or in a generalfund (4%, n ¼ 54Þ: Cross-tabulations and bivariateanalyses using Chi-squared statistics are found inTable 1.
When asked to assume that funds were allocatedto health, 36% chose funding for hospital emergencyrooms, 23% chose anti-smoking programmes foryouth, 15% chose increasing access to clinicalservices, 14% chose general tobacco-educationand smoking-cessation services, and 11% choseusing the funds for transportation of seniors tomedical services. A total of 62% would prefer not toallocate the MSA funds to health-related pro-grammes that are directly linked to prevention orcessation of tobacco use. Cross-tabulations andbivariate analyses using Chi-squared statistics arefound in Table 2.
The bivariate analysis demonstrates that thereare significant differences between those whochose improvement of health services and thosewho chose general funds, debt reduction or publicsafety as their preferred use of MSA funds. Thereare significant differences among ethnic groups,with Asians more likely to choose non-health-related spending. Those who chose to spend theMSA funds on health included women and currentsmokers. Those who chose spending on health weremore likely than respondents who favoured non-health spending to agree that providing help tosmokers is important, and that preventing youthfrom smoking is important.
In addition, the bivariate analysis shows signifi-cant differences between those who would chooseto spend the MSA funds on tobacco-related health
Public opinion analysis regarding the uses of master settlement agreement (MSA) funds 193
programmes and those who would choose otherhealth programmes. Those who chose spending ontobacco-related health programmes were morelikely to agree that providing help to smokers isimportant, to agree that preventing youth
from smoking is important, and to agree withthe 50-cent/pack cigarette tax. There are alsosignificant differences among ethnic groups, withthose identified as ‘other’ more likely to favourspending on tobacco-related health programmes.
Table 1 Cross-tabulations of uses of the master settlement agreement funds and selected independent variables ðn ¼ 1506Þ:
Improvement of healthcareservices n (row %)
General funds, debtreduction or publicsafety n(row%)
Providing help to smokers is veryimportantAgree 1051 (82%) 224 (18%)Disagree 139 (70%) 60 (30%) x2 ¼ 17:5; df ¼ 1; P ¼ 0:000
Preventing young people from starting tosmoke is very importantAgree 1101 (82%) 249 (18%)Disagree 94 (78%) 37 (28%) x2 ¼ 7:4; df ¼ 1; P ¼ 0:007
People who are more bothered by environmentaltobacco smoke (ETS) and who have finished highschool are also more likely to choose tobacco-related spending.
The next phases of the investigation utilized theCART analysis. These results are divided into twoparts. Part 1 related to the item about the use ofMSA funds for health-related vs non-health-related
Table 2 Cross-tabulations of health-related uses of the master settlement agreement funds and selected independent variablesðn ¼ 1506Þ:
Primary and secondaryprevention of tobacco use n(row%)
Other health-relatedprogrammes n(row%)
Providing help to smokers is very importantAgree 494 (39%) 774 (61%)Disagree 56 (28%) 143 (72%) x2 ¼ 8:6; df ¼ 1; P ¼ 0:003
Preventing young people fromstarting to smoke is very importantAgree 508 (43%) 837 (57%)Disagree 42 (32%) 88 (68%) x2 ¼ 1:5;df ¼ 1; P ¼ 0:219
Public opinion analysis regarding the uses of master settlement agreement (MSA) funds 195
areas. Part 2 concerned specific health-related usesfor the MSA funds.
Part 1
The first CART analysis related to the questionabout what the State of California should do withthe money received from the MSA. One responsewas that the money should be used for improve-ment of healthcare services. The alternateresponses were non-health-related. The indepen-dent variables used to predict what type of personwould choose health- or non-health-related use ofthe MSA money are listed by importance in Fig. 1.
Four survey questions were clearly more import-ant than the others in determining if the respondentwanted to use the MSA money for health-relatedreasons. The question about providing help tosmokers who want to quit was by far the mostimportant independent variable. The second mostimportant variable was the age of the respondent.This variable was 42% as important as the questionregarding providing help to smokers. The third mostimportant variable, 22% as important as the leadingpredictor, involved how the respondent felt aboutpreventing young people from starting to smoke.The final important variable in predicting theresponse was how strongly he/she agreed with the50 cent/pack tax. The latter variable was 13% as
important as the most important predictor vari-able. Fig. 2 shows the CART decision tree; theprofiles are shown in Table 3.
Part 2
The second CART analysis used a question thatassumed the MSA money would be spent on health-related services. The question asked whether thehealth-related money should be spent on issuesrelating to smoking-prevention/education issues.The independent variables used to predict whattype of person would use the MSA money fortobacco-related issues, assuming that the moneywas spent on health-related issues, are shown inFig. 3; the profiles are shown in Table 4.
There were five questions on the survey thatwere clearly more important than the others indetermining whether the respondent wanted touse the MSA money for tobacco-related healthprogrammes. The question about providing help tosmokers who want to quit was by far the mostimportant variable. The second most importantvariable, 61% as important as the leading pre-dictor, involved how the respondent felt aboutpreventing young people from starting tosmoke. The third most important variable inpredicting the response was how strongly he/sheagreed with the 50 cent/pack tax; this variablewas 40% as important as the most importantpredictor variable. The final two most impor-tant variables, 18% and 15% as important as themost important variable, respectively, werethe degree to which the person was bothered bysecond-hand smoke, and the person’s ethnicity.The CART decision tree is shown in Fig. 3.
Discussion
These analyses were conducted to determinedistinguishing characteristics of people whobelieve that MSA funds should be spent onhealth-related issues and those who believe thatMSA funds should be spent on non-health-relatedprogrammes. Next, the analyses sought to com-pare those who would devote the funds totobacco-related programmes and those whowould choose other health programmes. Theimportance of predictor variables and severalprofiles were established for each of the opinionsusing CART techniques. For large urban commu-nities that are similar to Long Beach, theseprofiles can be useful for predicting public opinionsurrounding MSA funds.
Figure 1. Variable importance using classification andregression trees analysis to predict opinion regarding usesof master settlement agreement funds. (A) Funds shouldbe spent on improvement of healthcare services. (B) Oncefunds are designated for health, funds should be spent onprevention of tobacco-related diseases.
R.H. Friis et al.196
Threevariableswere importantpredictorsofbothopinions about whether the MSA funds should bespent on health care and opinions about theparticular health programmes that should be ear-marked. The most important variable for predictingthe two key response variables was the respondent’sview of providing help to smokers who want to quit.Theothertwovariables focusedonthe importanceofpreventing youngpeople from starting to smoke, andan agreement with the current California 50-cen-t/pack tax on cigarettes. Age was a very importantvariable for predicting those who are highly likely towant the MSA funds to be spent on health pro-grammes; however, age was not an importantpredictor variable for the second question.
The profiles show that the younger and olderrespondents who want MSA funds to be used forhealth and who believe that helping smokers isimportant differ in their views of the cigarette taxand providing help to smokers who want to quit.The younger group agrees with the tax and stronglyagrees that providing help to smokers is important.The older group holds opposite views on the tax andon assisting smokers to quit, yet is in favour ofdevoting the funds to health. We believe that thesefindings suggest that the older group may see theuse of MSA funds as a replacement for the currentcigarette tax.
Figure 2. Classification and regression trees analysis. Funds should be spent on improvement of healthcare services.HS ¼ high school.
Table 3 Profiles regarding the alternate uses of mastersettlement agreement (MSA) funds: health or non-health.
Groups who are highly likely to want the MSA funds to bespent on health-related issues:
PROFILE 1-A, 96% (23 of 24)Those who do not strongly agree with providing help tosmokers who want to quitThose who disagree with the current 50-cent/pack tax oncigarettesThose who had more than $10 000 annual personal incomeThose aged 42 years or youngerThose more positive in their belief that preventing youngpeople from starting to smoke is important
PROFILE 1-B, 86% (472 out of 548)Those who strongly agree that providing help to smokers whowant to quit is very importantThose aged 28 years or older
PROFILE 1-C, 86% (57 out of 66)Those who strongly agree that providing help to smokers whowant to quit is very importantThose aged 27 years or youngerThose who strongly agree with a 50-cent/pack tax
Groups highly likely to want the MSA funds to be spent on non-health issues
PROFILE 1-D, 80% (8 out of 10)Those who do not strongly agree that providing help tosmokers who want to quit is importantThose who disagree with the current 50-cent/pack tax oncigarettesThose who had less than $10 000 annual personal income
Public opinion analysis regarding the uses of master settlement agreement (MSA) funds 197
One profile group chose to spend the MSA fundson non-health programmes: improvement of publicsafety, public debt reduction or a general fund. Thisgroup included respondents whose annual incomewas less than $10 000, who disagreed with thecigarette tax and who did not think that helpingsmokers is important. It is possible that the low-income group may believe that spending on non-health programmes will more directly affect them.
Respondents who do not strongly agree thatproviding help to smokers is important also feel thatthe MSA funds should be spent on programmes otherthan control of tobacco use: hospital emergencyrooms, access to clinical services, and transpor-tation of seniors to medical services. Females whocomprise African American or ‘other’ ethnicities,who believe in the importance of helping smokersand who agree with the cigarette tax also feel thatthe MSA funds should be spent on programmes otherthan tobacco control. They may believe that thecurrent tax is sufficient for programmes to helpsmokers. Two profiles that predict opinions that theMSA funds should be earmarked for tobacco-relatedprogrammes include those who have lived with asmoker. They may be more compassionate towardssmokers and their needs.
The results indicated that the majority of LongBeach residents share the opinion that the MSA
funds should be allocated to health programmes.The residents do not, however, feel that thesefunds need to be earmarked solely for smokingprevention or cessation. California is among themany states that are facing serious budget gaps. On14 May 2002, Governor Gray Davis proposed fillingthe $23.6 billion state deficit with additional taxesand reductions in health programmes.20 Statelegislators will need to balance their budgets andmonitor public opinion. Previous studies haveshown that the state legislatures are divertingMSA funds into non-health items. Public healthadvocates need to develop a strategic plan toensure that the states remember the intendedpurpose of MSA. Our findings provide support forcommunity advocates who wish to bring the currentuses of MSA funds to the forefront of public debate.
While the MSA is unique to the United States,many other governments receive funds fromtobacco taxes. A recent review shows thatresearchers in New Zealand, South Africa andAustralia are looking for relationships betweenpublic opinion and the uses of tobacco taxfunds.21 –24 Musk et al.25 found that public opinionregarding smoking control in Western Australia wasstrongly influenced by the tobacco and advertisingindustries until 1983, when co-ordinated publiceducation and information programmes increased
Figure 3. Classification and regression trees analysis. Given that funds are designated for health, they should be spenton prevention of tobacco-related diseases. ETS ¼ environmental tobacco smoke.
R.H. Friis et al.198
the level of community awareness of the adverseeffects of smoking and the need for legislativeaction. In their tobacco tax submission for the 2003budget, health organizations in Great Britain sup-port funding campaigns for reduction of smoking byearmarking a portion of tobacco tax revenues.26
In Germany, a lawsuit similar to those thatpreceded the MSA is currently in court. A chainsmoker is claiming that Reemtsma’s productscaused him to have a heart attack, and the companyfailed to inform him about the dangers of smok-ing.27 In Korea, a man suffering from terminal lungcancer was the first to file a lawsuit against thestate and the state-run Korea Tobacco and Ginseng,Corp. in 1999. Experts expect many similar litiga-tions to follow.28
The limitations of the current research includethe possibility of bias due to the sampling procedureand the survey methodology. We are not certain ofthe reasons for the under-representation of
the Asian community of Long Beach, but speculatethat it may be due to a language barrier as the surveywas conducted only in English and Spanish. BothCalifornia and Long Beach have a strong trackrecord regarding support for restrictions on smok-ing. Smoking is not allowed in any public buildings,including bars and restaurants. The sample closelyresembles other California communities but maynot be representative of communities inother states, especially where smoking restrictionsare not popular. More research is needed inother communities to replicate the preliminaryfindings we have reported, and to determine if theprofiles established here can be used to predictsupport for uses of MSA funds that improvehealthcare services.
Acknowledgements
This research was funded by a grant from theUniversity of California Tobacco-Related DiseaseResearch Program, Number /RT–0185, Robert H.Friis, Principal Investigator. The authors wish tothank Dr. Julia Lee, Lecturer, Department of HealthScience, California State University, Long Beach,for her contributions to the design of the surveymethods and questionnaire used in the presentresearch.
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Table 4 Profiles regarding the uses of master settlementagreement (MSA) funds for specific health purposes.
Groups who are highly likely to want the MSA funds to be usedfor non-tobacco purposes
PROFILE 2-A, 74% (204 out of 277)Those who do not strongly agree that providing help tosmokers who want to quit is important
PROFILE 2-B, 71% (123 out of 173)Those who strongly agree that providing help to smokers whowant to quit is importantThose who generally disagreed with a 50-cent/pack tax
PROFILE 2-C, 79% (52 out of 66)Those who strongly agree that providing help to smokers whowant to quit is importantAfrican American or otherFemalesThose who agree or strongly agree with the 50-cent/pack tax
Groups highly likely to want the MSA funds to be used fortobacco-related purposes
PROFILE 2-D, 69% (24 out of 35)Those who strongly agree that providing help to smokers whowant to quit is importantThose who generally agreed with a 50-cent/pack taxWhite or AsianThose who have lived with a smokerThose who are not bothered by environmental tobacco smokeMales
PROFILE 2-E, 53% (104 out of 195)Those who strongly agree that providing help to smokers whowant to quit is importantThose who generally agree with a 50-cent/pack taxWhite, Latino or AsianThose who have lived with a smokerThose who are bothered a great deal by environmentaltobacco smoke
Public opinion analysis regarding the uses of master settlement agreement (MSA) funds 199
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