Enacting tobacco taxes by direct popular vote in the United States: lessons from 20 years of experience

Background: Tobacco tax increases reduce tobacco use, can provide funds for tobacco prevention and enjoy broad public support. Because of tobacco industry influence in legislatures, US public health advocates have shifted the venue for tobacco tax policymaking to direct popular vote 22 times since 1988. Methods: We combined case studies of individual state campaigns with tobacco industry documents to identify strategies related to outcome. Results: The tobacco industry developed a voter segmentation model to determine which tobacco tax increases it could defeat. Two industry arguments arising from this model often were raised in losing campaigns the tax increase did not dedicate enough to tobacco control and hospitals and health maintenance organisations would profit. The industry effectively influenced early voters. Success was associated with building a strong base of public support before the campaign, dedicating sufficient funds to tobacco control, avoiding proposals largely devoted to financing hospitals and other medical service providers, effectively engaging grassroots and framing the campaign with clear justifications for cigarette tax increases. Conclusions: Tobacco tax ballot measures commonly allocated substantial funds to medical services; tobacco companies are becoming more successful in making this use of funds an issue. Proponents' campaigns should be timed to account for the trend to voting well before election day. Ballot measures to increase tobacco taxes with a substantial fraction of the money devoted to tobacco control activities will probably fare better than ones that give priority to funding medical services.