This section describes environmental manipulations based on the application of economic incentives. Economic incentives serve to reduce consumption of tobacco products by increasing, either directly or indirectly, the costs of using these products. In this section, three economic incentive policies are examined: (1) higher excise taxes on cigarettes, (2) preferential hiring and promotion of nonsmokers, and (3) insurance premium differentials for smokers and nonsmokers. An attempt is made here to present some of the conceptual linkages between economic incentives and smoking and to describe the development and current status of each of the three strategies.

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Excise Taxes on Tobacco Products Past and Current Status

The excise tax is an administratively simple mechanism through which public policy can influence the price of tobacco products. The chief purpose of excise taxes has always been generation of revenues, although recently these taxes are receiving increased interest and support as a public health measure.

A Federal excise tax on cigarettes has existed since 1864 and was an especially important source of Federal revenues before the enactment of the Federal income tax in 1913. Since 1951, the tax rate has been raised twice. In 1982, it was doubled from 8 cents to 16 cents per pack; and in 1990, it was raised 8 cents to be implemented in two stages.

In 1921, Iowa became the first state to implement an excise tax on cigarettes. By 1960, all but four states had enacted cigarette excise tax policies, and in 1969 North Carolina was the last state in the Nation to do so. Currently, 396 city and county governments also impose an excise tax on cigarettes. These local governments are largely concentrated in just a few states, and in 1988 they were responsible for 2 percent of all excise taxes collected on cigarettes (Tobacco Institute, 1990).

One of the largest single-year increases even in a state excise tax on cigarettes occurred recently in California. In January 1989, Proposition 99 raised the tax from 10 to 35 cents per pack, boosting the California tax to one of the highest in the Nation. there is now substantial variability in the excise tax rate among states.

an important historical perspective on cigarette excise taxes is gained by considering the relative contribution of the tax to the overall price of cigarettes. Table 3 shows the percentage of the average price of cigarettes accounted for by Federal and state taxes from 1954 to 1988. This table shows that the Federal tax is declining as a proportion of the total cost of cigarettes. Even with the 8-cent increase in 1983, the relative impact is quickly being eroded by inflation toward the pre-1983 level. The overall relative decline in Federal revenues also holds when compared with either the consumer price index or gross national product. As a percentage of the total Federal tax base, revenues from cigarette excise taxes have declined from 3 percent in 1950 to 0.6 percent in 1987. since the early 1970's, state revenues as a percentage of the total price of cigarettes have also declined appreciably. Without constant readjustment of the rate, real revenues from excise taxes will continue to decline as long as a unit rate is used. Annual adjustments to the Federal tax based on a cost-of-living index have been proposed. Alternatively, an ad valorem tax would index the tax rate to the price of cigarettes. As of 1988, Hawaii was the only state to use this methods.

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Anticipated Effects Of a Tax Increase

How much reduction in smoking might we expect in response to increasing the price of cigarettes? The quantitative relationship between price and demand is described by economists as price elasticity, which is defined as the change in demand for a product relative to the change in price. For example, a price elasticity of -0.5 implies that a 10 percent increase in the price of a product will result in a 5 percent decrease in the quantity demanded. Note that a given tax increase must first be translated into the percentage increase in the retail price before its effect can be estimated.

Studies on the price elasticity for cigarettes in the United States were summarized in the 1989 Surgeon General's Report (US DHHS, 1989a). Thirteen studies conducted since 180 were identified. Overall price elasticity estimates varied from 0.14 to -1.23. However, there was a clustering of short-term elasticity estimates in the -0.4 to 0.5 range, and the mean estimate was -0.43. These estimates are similar to those obtained in European studies, as summarized by Pekurinen and Valtonen (1987) and Godfrey and Maynard (1988). Considering the differences in cultural attitudes toward smoking varying levels of government involvement in antismoking health education, and substantial variations in the real price of cigarettes, the overall level of agreement between the American and European studies adds a degree of confidence to the general findings of these studies.

Overall price elasticities convey no information regarding which groups and types of smokers are more sensitive to price changes. However, by analyzing survey-based data rather than aggregate consumption data, Lewit and colleagues have attempted to answer several critical questions about differential impacts. Using a sample of nearly 20,000 adults surveyed in the 1976 National Health Interview Survey, Lewit and Coate (1982) found that the consumption response to a price increase occurs primarily through reduction of smoking prevalence, rather than reduction of the average number of cigarettes smoked per smoker. The elasticity for participation, that is, the number of smokers, was found to be -0.26. the elasticity for the number of cigarettes per smoker was only -0.10. This, it would appear that the primary impact of an increase in the cigarette excise tax would be to encourage some smokers to quit, but the majority of smokers would continue to smoke about the same amount.

Studies that have examined age-specific responses to the price of cigarettes are of particular interest to public health professionals because they assess the potential impact of price policy on teenage smoking. It is well known that most adult smokers started before the age of 20, and thus a high priority for smoking control efforts is the reduction of teenage smoking

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Table 4

Age-specific estimates of the price elasticity of demand for cigarettes

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Elasticities

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Overall Participation Quantity per Smoker

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Age Group

12-17 yr -1.40 -1.20 -0.25

25 -0.89 -0.74 -0.20

26-35 -0.47 -0.44 -0.04

36-74 -0.45 -0.15 -0.15

All Adults -0.42 -0.26 -0.10

All Ages -0.47 -0.31 -0.11

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Adapted from US DHHS (1989a, p. 537), and US GA) (1989, p.30).

rates (DiFranza et al., 1987). The first study (Lewit et al., 198a) found the price elasticity for youths aged 12 to 17 to be -1.40, a substantially higher figure than for adults. Similar to adults. adolescents also respond to price primarily through participation, rather than the quantity smoked per smoker. The price elasticity estimates for participation and quantity smoked were -1.20 and -0.25, respectively A second study, by Grossman and colleagues (1983), used data from four smaller, more recent samples provided by the National Surveys on Drug Abuse. The estimated price elasticities for participation were all less than the figure obtained in the earlier study. To obtain their summary estimate of -0.76 for these studies, the authors excluded the highest and lowest figures and averaged the remaining two. The authors of a General Accounting Office report on teenage smoking suggest relying on this lower elasticity estimate, rather than the -1.20 figure, because of the recency of the data used in the second study (US GA), 1989). A summary of the elasticity estimates provided by these studies is shown in Table 4.

The participation elasticity estimates provided in Table 4 may be used to project the decrease in smoking prevalence related to a given tax rate change. The current price of cigarettes is needed to convert the tax increase into the percentage change in the retail price of cigarettes. Also necessary are estimates of current prevalence of smoking. For example, Warner (1986b) projected the reduction in prevalence in adult cigarette smoking for three specific values of possible tax rate changes. In 1986, a 16-cent-per-pack increase in the excise tax would have raised prices 15.1 percent. Based on 1982 prevalence date, this would be expected to reduce the number of adult smokers by over 2.5 million (3.9 percent). More recently,

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Cummings and Sciandra (1989) have used similar methods to estimate the response in overall smoking prevalence in New York State to a scheduled 12-cent increase in the state excise tax.

The US GAO report (1989) employed analogous procedures to estimate the effect of a tax increase on teenage smoking. Using the more conservative estimate for participation elasticity of -0.76 and the more recently available prevalence estimates, the GAO predicted that a 21-cent tax increase would result in a reduction of more than on-half million teenage smokers. Because deterrence in the teen years may result in lifelong abstinence from smoking, the health impact on this group is especially significant.

Projected responses to excise tax increases are subject to a number of potentially distorting influences, and estimates should be interpreted with caution. The level of uncertainty increases as we seek to generalize the results of previous studies to changing social and normative environments, varying levels of tax increases, and long-term impact on smoking. Recent empirical data on cigarette consumption trends may be helpful in validating short-term price response estimates. Several conceptual issues regarding the use of results from elasticity studies in forecasting price response are also summarized below.

Significant increases in the cigarette excise tax have occurred recently in the United States, Canada, and the State of California. From 1981 through 1984, the real price of cigarettes in the United increased 27 percent, while per capita consumption declined 10 percent (Harris, 1987). In Canada, the real price of cigarettes rose 66 percent from 1982 to 1988, with an attendant 24 percent drop in per capita consumption (Canadian council on Smoking and Health, 1990). Finally, preliminary data from California suggest that overall sales in California in the third quarter of 1989 dropped 10.5 percent from that in the third quarter of 1988 (James Howard, personal communication, 1990). The 25-cent-per-pack state tax increase implemented in January 1989 raised the price of cigarettes in California about 20 percent.

These declines in cigarette consumption reflect a substantially accelerated decline over the rate for previous years and are consistent with a price elasticity in the range of -0.36 to -0.50. However, the extent to which the declines may be attributed purely to the price increases cannot be precisely determined. The Canadian Council on Smoking and Health attributes only about half of the decline in consumption to the effect of the increase in cigarette prices.

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recent consumption trends, and how they have been interpreted, point to several of the difficulties involved in accurately measuring and predicting responses to price increases. There are many influences on smoking behavior that operate concurrently with changing levels of price, making it difficult to isolate specific effects. It is possible that more of the recent decline in smoking than is generally recognized is due to general societal trends. On the other hand, Harris (1987) suggests that the decline in smoking prevalence, particularly among lower income groups, might have been substantially greater if the real price of cigarettes had not declined during the 1970's

Recent experience suggests that tax increases are not simply passed directly to consumers but may be accompanied by an additional percentage increase by the manufacturers, thus "multiplying" the impact of the tax increase (Harris, 1987). There has also been increased marketing and sales of low-cost generic and discount brand cigarettes (Adler and Freedman, 1990), a trend that may serve to partially offset the influence of a tax increase. The long-term impact of tax increases on consumption is less clear than the short-term response. It is also uncertain whether large increases in price have the proportionately equivalent effect of small increases.

Preferential Hiring and Promotion Relationship to Other Policies

A range of worksite policies and programs may potentially influence smoking behaviors. Rigotti (1989) outlines a continuum of worksite smoking policies that includes (1) no explicit policy, (2) environmental alterations, (3) designated smoking and nonsmoking areas, (4) total smoking bans, and (5) preferential or exclusive hiring of nonsmokers. This section considers only the fifth and most restrictive category. This does not imply that less restrictive policies do not also generate economic incentives for reducing cigarette consumption. Job opportunities may be constrained for those who resist applying for positions where restrictions are imposed. Among the costs of noncompliance with established worksite smoking policies is the threat of losing one's job-certainly an economic incentive. Some worksites have also developed financial incentive programs as part of their overall effort to facilitate smoking cessation among employees. These incentives typically involve small monetary rewards to employees who successfully maintain abstinence from smoking (Orleans and Shipley, 1982). Variations of this approach include the use of contests, prizes, and lotteries to increase the program's visibility and appeal. A number of programmatic approaches to worksite incentives are described in a workbook published by the National Cancer Institutes (US DHHS, 1989c).

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Walsh and McDougall (1988) identify several motivational concerns that underlie company smoking policies. The reasons for preferential hiring and promotion of nonsmokers appear somewhat different and more situation-specific than those given for on-site restrictions. Protection of the health and rights of nonsmokers in the workplace is a key component of worksite restrictions (Rigotti, 1989). However, the extension of policies to personal behaviors away from the worksite may be motivated more by economic considerations (Walsh and McDougall, 1988). Employers defend the practice of preferentially hiring nonsmokers because smokers incur higher costs to both the business and society (Action on Smoking and Health, 1989). Some occupations involve environmental exposures where employees who smoke are at a much greater health risk and this not hired for this reason. Hiring restrictions have been imposed also for jobs that require high levels of physical fitness, such as for firefighters and police officers. Additionally, for occupations where respiratory functional decline caused tobacco use can be confused with compensable occupational injury, employers have hired only nonsmokers to limit disability costs.

Prevalence and Current Trends

Recent surveys of employers suggest that the practice of hiring only nonsmokers is uncommon, occurring in only 1 to 2 percent of the businesses surveyed (Bureau of National Affairs, 1987; Peterson and Massengill, 1986; Swart, 1988). The Bureau of National Affairs report found little evidence that exclusive hiring practices are becoming more prevalent, despite growing implementation and acceptance of worksite restrictions. However, a more recent report (Action on Smoking and Health, 1989) cited evidence to suggest that the frequency of these practices is increasing Hiring preferences, as opposed to absolute hiring restrictions, are more common. The Bureau of National Affairs survey found that 5 percent of the organizations surveyed gave companywide preference to nonsmoking applicants, and another 10 percent allowed individual supervisors to preferentially hire nonsmokers. It is possible that informal preferential hiring practices are substantially more widespread than the policy survey suggests. A poll by a New York recruiting firm found that 46 percent of the executives of large firms would choose a nonsmoker over an equally qualified smoker (Bureau of National Affairs, 1987).

Such informal preferences may also apply to promotion and firing decisions. although Peterson and Massengill (1986) found that none of the companies surveyed indicated that they preferentially promoted nonsmokers, anecdotal evidence suggests such practices exist, although discreetly (Freedman, 1987). A similar situation may exists with regard to demoting or firing employees who smoke, even though companies that

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hire only nonsmokers do not as a rule dismiss smokers employed prior to implementation of the hiring policy (Action on Smoking and Health, 1989).

Any increase in the prevalence of nonsmoker hiring policies is expected to be gradual. When businesses were asked to project whether they would have such a policy in place in the future, 3.8 percent predicted they would by 1990, and 6.6 percent by 1995 (Swart, 1988). There are several reasons for reluctance on the part of employers to implement preferential hiring polices. There is a perception that less restrictive measures are working well and that hiring restrictions are intrusive and go beyond normal employment practices. Businesses may not want to restrict their pool of available employees. Also, verification of smoking status of current and potential employees and decisions on how to respond to infractions are problematic and potentially costly. Guidelines by Action on Smoking and Health (1989) suggest that employers clearly state their policy to all applicants and that consequences of infractions be stipulated. Some employers have implemented biochemical or physiological testing to verify smoking status.

Influence of Hiring and Promotion Preferences

although several formal evaluations of the effect of worksite smoking policies on smoking have been conducted, none have specifically examined the impact of preferential or exclusive hiring practices. Clearly, one potentially important contribution that such policies make is the message they convey about the changing social acceptability of smoking. Formal policies against hiring smokers are still relatively uncommon but may be highly visible and attract considerable media attention. The more direct impact of such policies is expected to occur through the economic incentive to quit smoking provided by the policy. If employment is contingent on quitting smoking, some potential applicants might be motivated to quit smoking rather than settle for some other job Whether or not this happens depends on a number of considerations, including the availability of other employment opportunities and the strength of the individual's propensity to smoke.

Legal Issues

The legal right of employers to preferentially or exclusively hire nonsmokers is generally recognized. Federal and state statutes prohibit discrimination on the basis of race, religion, national origin, and, in most circumstances, age and sex. In some situations, it is also unlawful to discriminate on the basis of sexual orientation, political affiliation, marital status, citizenship, and physical or mental handicap (Myers, 1990). Aside from these attributes, employers in most situations have the right to make hiring decisions on whatever basis they choose, including smoking status.

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On the forefront of occupations experiencing establishment of nonsmoker hiring polices are emergency services. A firefighter in Oklahoma who was dismissed from his job when observed smoking off duty challenged his dismissal, but the employment policy of the fire department was upheld in Federal court in 1987. Another challenge to a nonsmokers-only hiring policy occurred when the application of a New York woman for employment in a jewelry store was rejected. In this case, the applicant claimed that she was discriminated against on the basis of a handicap, namely an addiction to smoking Although New York state law classifies addicts of certain drugs as handicapped, no mention is made of tobacco. Even so, the case is proceeding after it was determined by a state board that there was probable cause to suspect that unlawful discrimination had occurred.

Additional legal challenges to preferential hiring polices are probable. The American Civil Liberties Union opposes such practices except where the smoking status of applicants or employees can be shown on a case-by-case basis to interfere with job performance. However, no actions by the American Civil Liberties Union to date have been initiated against employers who refuse to hire smokers. Additional challenges to non-smoker hiring practices may be brought on the basis that they are discriminatory to blacks, because of a higher smoking prevalence among blacks. One other potential focus of legal debate on preferential hiring practices is the invasion of privacy issue, although this aspect of such policies has so far gone unchallenged.

Two additional caveats may apply to employment policies that favor nonsmokers. The first applies to any workplaces that are covered by collective bargaining agreements with labor unions. Most cases in which unions have confronted management on smoking policies have focused on workplace restrictions. However, collective bargaining agreements may also pertain to restrictions on eligibility for employment. Efforts by the Manville Corporation, a Texas asbestos manufacturer, to hire only nonsmokers and ban workplace smoking have been stymied by litigation instigated by the International Machinists Union. Although in some cases management has successfully defended its nonsmoker-hiring policies, the general recommendation for employers is to develop and impose hiring policies and smoking restrictions in consultation with the unions involved and in accordance with current collective bargaining agreements (Action on Smoking and Health, 1989).

The second situation limitation on the legal right of employers to hire only nonsmokers occurs when state or local laws prohibit such practices. In 1`989 legislation was passed in Virginia that prohibits state agencies from requiring employees

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to be nonsmokers. Private employers are not affected by the legislation, nor are agencies prevented from implementing workplace smoking restrictions. A similar bill in the State of Maryland, applicable to both public and private employers, was defeated in 1989.

Differential Insurance Premiums Current Status

Substantial evidence that smoking is firmly associated with reduced longevity, health care costs, and damage to property has accumulated over the past 45 years. This evidence has elicited varying degrees of response from the corresponding major components of the insurance industry-life, health, and property. Before the release of the 1964 Surgeon General's Report, no major insurer of any type offered premium reductions to nonsmokers. Now almost all life insurance companies provide nonsmoker discounts, whereas only a small but growing number of health and property insurers do so. This section examines the development and current status of differential premium rates for smokers and nonsmokers for each of the three major arms of the insurance industry. to the extent that these differentials are visibly passed on to individual consumers, they may provide an economic incentive not to smoke. Premium differentials could be labeled as either nonsmoker discounts or smoker surcharges; the net premium costs to smokers and nonsmokers would be the same. However, for both historical reasons and marketing purposes, the term "nonsmoker discount" is generally used.

although life insurance companies began to introduce nonsmoker discounts as early as 1965, adoption proceeded slowly until 1`979. In that year, a definitive actuarial study by State Mutual Life Assurance revealed a substantial and statistically significant mortality difference between smokers and nonsmokers. Collaborative evidence provided by other companies soon followed. By 1984, the National Association of Insurance Commissioners had developed formal guidelines for setting differential premium rates for smokers and nonsmokers, which were subsequently incorporated into practice in most states. Currently, the vast majority of companies provide nonsmoker discounts on individual policies. The size of the discounts varies across ages and gender; average discounts are in the range of 12 to 22 percent (US DHHS, 1989a).

The situation for health insurance, where providers have been slower to adopt nonsmoker discounts, is considerable more complicated. Most health insurance is purchased as group coverage, where the health status and risk factors of individuals typically are not considered. Furthermore, actuarial data on the health care cost differentials of smokers and nonsmokers have not been as complete and readily available as for mortality differentials (US DHHS, 1989a). Administrative costs and the problem of verifying the smoking status of individuals covered

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by group policies may also contribute to the reluctance of the industry to provide discounts. Despite a National Association of Insurance Commissioners resolution (1985) supporting premium differentials in both group and individual polices and an Action on Smoking and Health (1987) special report that questioned the legality of not differentiating, only about 15 percent of individual polices offer nonsmoker discounts. Even fewer group plans do. Individual polices carry discounts that range from 3 to 15 percent. Group plan differentials are usually provided no he basis of percentage of nonsmokers in the group and offer discounts of a few percentage points to groups below a specified smoking prevalence level.

Nonsmoker discounts in property and casualty insurance are also relatively uncommon. This situation exists despite solid evidence that smoking materials are responsible for a significant percentage of house fire property damage and fir-related deaths and that smokers have more vehicular accidents than nonsmokers (US DHHS, 1989a). The farmer's Insurance Group was the first company to offer nonsmoker discounts and as of 1987 was still the only major insurer to offer them on both homeowner and automobile polices. Discounts on homeowner polices range from 3 to 7 percent and on automobile polices from 10 to 25 percent. Recently the Hanover Insurance Company increased its nonsmoker discount for automobile polices from 5 to 10 percent. The difficulty of verifying smoking status, as well as prohibitory regulations in certain states, have deterred more companies from adopting discount policies.

State insurance commissions and legislatures have prohibited certain practices that offer premium differentials because the were deemed discriminatory. However, the National Association of Insurance Commissioners has actively sought to encourage state governments to remove legal barriers to nonsmoker discounts and has facilitated the collection of actuarial data to help justify the practice. In the future, a willingness on the part of state legislatures and insurance commissions to require the availability of differentially priced policies may result from these efforts.

One additional insurance industry practice that indirectly offers a financial incentive to quite smoking is the coverage of costs for smoking cessation programs. This coverage is currently uncommon, and the future growth of such policies is uncertain. Only 11 percent of carriers surveyed in 1985 provided benefits for smoking cessation programs (US DHHS, 1989a). Employers have absorbed some of the burden for providing cessation resources, and more may be expected to do so if discounts for group health insurance polices continue to become more widely available.

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Effects of Premium Differentials

Similar to the situation regarding preferential hiring, no empirical studies have assessed the impact of differential insurance premiums on smoking. Until such studies are conducted, expectations must remain speculative. Premium differentials may reduce smoking by providing both economic incentives and social or educational influences. For several reasons, premium differentials will probably provide less economic incentive for not smoking than direct increases in the price of cigarettes. Their impact is acute only at the time the policies are paid, and even then it may not be made clear to consumers that smokers are paying more. In many circumstances, smokers will have the option of simply switching to another policy or provider that does not differentiate. Health insurance premiums are often paid entirely by employers, although increasing efforts by employers to reduce their health insurance costs may result in more smokers have to pay extra for health insurance.

The role of the insurance industry in providing additional awareness and support for the declining social acceptability of smoking may be just as powerful as any economic incentives it provides. Being asked about one's smoking status when completing insurance forms is yet another reminder of the potential personal health and economic consequences of smoking. Health maintenance organizations may be especially inclined to provide educational reminders and resources for smoking cessation, although adoption of such efforts is also advocated for the larger community of health care providers (S.R. Cummings et al., 1989).

An Overview of Economic Incentives

There are several aspects of the use of economic incentives to discourage smoking that have raised ethical concerns about their fairness and appropriateness. The regressivity issue concerning excise taxes has surfaced repeatedly and is a basis for opposition to proposals to increase taxes on cigarettes. A regressive tax is defined as one were the proportion of individual's income consumed by the tax is inversely related to income level (Fusfeld, 1982). Cigarette taxes appear to be highly regressive (Citizens for Tax Justice, 1988; Toder, 1985), although Harris (1985) suggests that the regressivity issue has been exaggerated. Proponents of increasing excise tax rates, although aware of the regressivity issue, weigh this concern against the expected improvements in health status and longevity resulting from the reduced prevalence of smoking. They also note that the lower income groups, were the burden of smoking-related disease is greatest, are also expected to show the greatest response to a price increase (Townsend, 1987).

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Many other elements have been introduced into the debate over the fairness of economic incentives. Among these are ethical concerns about paternalism, victim blaming, and fair distribution of costs. The current racial and socioeconomic disparities between smokers and nonsmokers has elicited charges the economic incentive policies are racist and elitist. The accuracy of projected effects of a tax increase has been questioned, and little empirical evidence is available on the effects of the other economic incentive strategies. Potential consequences include a lack of employment opportunities and affordable insurance for those whoa re unwilling or unable to stop smoking.

Despite the numerous arguments raised in opposition to economic incentive policies, there is broad support for these approaches. Increases in the cigarette excise tax are advocated by numerous health organizations, including the American Heart Association, American Lung Association, American Cancer Society, American Public Health Association, and American and Canadian Medical Associations. Several proposals have been offered to mitigate at least some of the previously raised ethical concerns. These suggestions merit serious consideration and further reflect the importance of a coordinated, multifaceted approach to smoking and tobacco control For example, Toder (1985) and Warner (1986b) argue that potentially negative effects of excise tax regressivity could be offset by making other aspects of the tax structure more progressive. earmarking of tobacco tax revenues for health care and tobacco cessation and education programs may reduce the perception that smokers are being victimized or exploited. A 1987 American Medical Association poll (Harvey and Shubat, 1987) showed that a majority of smokers support an increase in the cigarette excise tax if the revenues are earmarked for Medicare costs. In California, 75 percent of the estimated $600 million generated in the first year of the Proposition 99 tax increase is designated for health care, drug education, and research. Increased affordability and availability of smoking cessation resources and programs help remove economic and logistical barriers to quitting and also contribute to an atmosphere of positive support and reinforcement for those trying to quit.

the economic incentive strategies examined here focus on methods that increase the cost of smoking for consumers. Another approach is to apply economic inducements and policies to the supply side of the smoking problem, which includes agricultural practices and policies, cigarette manufacturing and distribution, and advertising (Walsh and Gordon, 1986). Initiatives that may reduce smoking by affecting this side of the smoking equation include (1) elimination of the tobacco support program (Warner, 1988), (2) agricultural

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policies that promote and subsidize alternative crops (Milio, 1985), (3) elimination of tax deductions for tobacco advertising (US DHHS, 1989a), (4) further restrictions on advertising (Warner et al., 1986), and (5) tighter controls on the distribution and sale of tobacco products (DiFranza et al., 1987). The political influence of the tobacco industry has undoubtedly impeded the implementation of these initiatives, but the increasing political influence of the antismoking movement enhances the opportunity for a broad spectrum of antismoking legislation. The potential impact of polices to restrict advertising and actively support the agricultural transition to other crops extends beyond their direct impact by complementing and reinforcing other antismoking efforts. For example, economic inducements and education efforts might be even more effective when seen as part of a broader and more congruous Federal policy to reduce smoking and improve health.

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