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Ms. Phinney & Mr. King,

 

 I read with interest the Seattle Post-Intelligencer’s August 31, 2006 article, “State cuts sharply number of adults who smoke.”  http://seattlepi.nwsource.com/local/283250_smoking31.html   Ms. Phinney’s article stated, in part:

“The number of adult smokers in Washington declined by 21 percent since 2000, meaning there are 205,000 fewer smokers in the state, according to the state Department of Health. The state now has the fifth-lowest smoking rate in the nation, compared with the 20th-lowest in 2000, Health Secretary Mary Selecky said at a news conference Thursday. That still leaves us with about 790,000 adult smokers. Add the 73,000 under-18year-olds who weren't included in the statistics, and smoking may be down, but not out, in this corner of the Pacific Northwest.” (Underlines added.)

 

I also read with interest the Seattle Time’s August 31, 2006 article, “State's smoking rate way down even before new ban took effect.”  http://seattletimes.nwsource.com/html/localnews/2003237031_smoking31m.html   Mr. King’s article stated, in part:

 

“Smoking has taken a major nose dive in Washington state — even without factoring in the statewide indoor-smoking ban that took effect last December. Based on surveys taken through the end of last year, 17.8 percent of the state's adults smoked as of the end of 2005, compared with 22.4 percent in 1999, just before a well-funded statewide anti-tobacco campaign began, state health officials announced Wednesday. That's a 20.5 percent drop and represents 205,000 fewer smokers.” (Underlines added.)

 

The Tacoma News Tribune published a short article by the Associated Press, which quoted several items from Governor Gregoire’s August 30, 2006 press release. The Governor’s press release is attached as “Washington Smoking Gregoire Press Release 08-30-06.”

 

I make a few observations concerning the above-referenced news reports and Governor Gregoire’s press release:

 

1. Survey bias that is acknowledged by Washington Tobacco Prevention and Control, and has injected discrepancies as high as 25.1% into previous smoking rate estimates by the State of Washington, presents important questions as to the accuracy of Governor Gregoire’s statements and press release headline. See “Solutions for Survey Discrepancies in Washington State Smoking Prevalence” attached.

 

2. U.S. Census bureau population estimates, when applied to Washington adult populations and reported smoking prevalence, plainly say that a 205,000 reduction in Washington Current Smoker populations cannot have occurred. U.S. Census Bureau population statistics show the decline in adult Current Smokers is, at best, about one-half of that claimed, and that number necessarily assumes zero bias or prevalence estimate error. See below analysis and “Washington 18-Plus Populations 1999 2005” attached.

 

3. A statistical error or variance in the adult smoking prevalence estimate of merely 2.1 percent would produce zero decline in Washington Current Smoker populations since 1999. 

 

4. The “cherry picked” time period of 1999 to 2005 masks and hides the fact that, at best, adult Current Smoker populations have remained highly stable since the beginning of tobacco control’s Project ASSIST in the early 1990s, and may have in fact modesty increased. That remarkable stability of Current Smoker populations has occurred despite the fact that Washington has the 3^rd highest cigarette tax and the strictest smoking ban in the nation. See “WACIGTAX Populations Consumption Table 1.” attached.

 

5. The period described in Governor Gregoire’s (1999 to 2005) press release includes 2001 I-773 cigarette tax increase of 60 cents per pack, 2005 cigarette tax increases by the legislature, and passing the strictest smoking ban in the nation through I-901 in 2005. The period also includes the cumulative impact of a 45 cents per pack increase in cigarettes to fund the 1998 tobacco Master Settlement Agreement (MSA), which Governor Gregoire championed and personally negotiated. The results described by Governor Gregoire therefore represent results for one of the most aggressive and punitive public policy interventions by tobacco control in the nation. So what has truly been accomplished?

 

We the people do understand that this is an election year and that the primaries draw nigh. Under such conditions campaign rhetoric often tends to exceed the bounds of statistical certainty and historical reality. But the fact remains that consumers, taxpayers and legislators -- as well as state agencies that rely on Department of Health statistics to make policy decisions -- can find themselves contending with the real world consequences of agenda-driven Social Marketing rhetoric long after campaign ardor has run its course. Preserving the credibility of our governing institutions and state fiscal responsibility mandate a careful look at election-eve rhetoric about tobacco control versus documented fact. Preserving the credibility of our governing institutions and state fiscal responsibility also require critical and earnest review by media of politician’s electioneering claims.

 

Background Information

 

The smoking prevalence and population data reported by The Times and The PI is on point with information included in two reports that I provided to the Washington Department of Revenue and Washington Office of the Attorney General August 3, 2006. Those reports were sent on August 3^rd as follow-up to communications with the state that date to June 2006. A third report was sent to the revenue department and attorney general’s office on August 13, 2006. The three reports provided to state offices are listed below. According to E-Mail communications subsequently received from the Department of Revenue my reports were forwarded to the Washington Department of Health on or about August 14, 2006.

 

            1. August 3, 2006: “Current Smoker Populations & Cigarette Consumption” (Pages 1-4 text, 5-25 exhibits): Analyzes current smoker populations and average cigarette consumption for the USA overall and the State of Washington, in light of tobacco company, Nicotine Replacement Therapy distributor, and tribal indirect subsidies created by Parity Pricing.

 

            2. August 3, 2006: “Nicotine Replacement Therapy: Efficacy & Revenue Yields” (Pages 1-2 text, 3-11 exhibits): Analyzes effect of Nicotine Replacement Therapy 7 percent efficacy (93 percent ineffective) on state and federal excise receipts. As NRT efficacy rises above 10 percent state tax revenues and product distributor income precipitously decline. This occurs because the higher efficacy rises the faster the source consumer base of persons who smoke declines.

 

            3. August 13, 2006: “Nicotine Replacement Therapy: Parity Pricing” (Pages 1-5 text, 6-17 exhibits): Presents data table and receipts proof that Nicotine Replacement Therapy product costs to consumers are increased at parity with which the cost of cigarettes is increased through higher taxes promoted by tobacco control advocates. For example, in Washington the cost of cigarettes increased by $12.00 per carton through new taxes June 200 to January 2006. The corresponding increase in a box of Nicorette on a per unit basis was $12.06 for the same period. Issues of a “Natural Floor” for Nicotine Replacement Therapy product pricing, sovereign acts of states, public interest, and intent are also addressed.

 

The above reports were provided in advance of publication for review and comment by appropriate state offices. At the time initial copy was drafted Washington smoking prevalence data for 2005 was not available. Accordingly, I carried forward previous year prevalence data to 2005. Attached is a copy of Table 1. from the first report, which I discuss below. We now have 2005 prevalence information and spread sheets have been updated to reflect the most recent 17.8 percent prevalence. I await FY 2005 to 2006 Cigarette Tax Stamps Sold data from the Department of Revenue before proceeding to final publication.

 

Seattle Times and Seattle Post-Intelligencer August 31, 2006 Reports

 

I invite attention to the attached January 2006 document, “Solutions for Survey Discrepancies in Washington State Smoking Prevalence,” as published in the Centers for Disease Control and Prevention’s (CDC) Preventing Chronic Disease, Volume 3 No. 1. Please note that the document’s authors include two members of Washington’s Tobacco Prevention and Control Program, as well as a Behavioral Risk Factor Surveillance System Coordinator. That document describes significant and material underreporting of Washington smoking prevalence for the years 2000 to 2002. The underreporting appears to be due to the wording of the Adult Tobacco Survey (ATS) introductions used by Washington, as compared to language applied by the CDC in its Behavioral Risk Factor Surveillance System (BRFSS). That document says, in part:

 

“Consistent with the findings of Ramsey et al (1), we found that the Washington State smoking prevalence data from the Adult Tobacco Survey (ATS) were lower than the prevalence data from the Behavioral Risk Factor Surveillance System (BRFSS). . . . Although the BRFSS is conducted in Washington to collect data on health behaviors, including tobacco-related health behaviors (2), the Washington Tobacco Prevention and Control Program also conducted the ATS from 2000 through 2002 to obtain extensive information on tobacco-related knowledge, attitudes, and behaviors. . . . However, the ATS contained strong, tobacco-specific introductory language, and the BRFSS contained general, health survey introductory language. For each year from 2000 through 2002, the ATS found a lower smoking prevalence in Washington State than did the BRFSS, and this difference became statistically significant in 2001 and 2002 (Table). . . . Therefore, our results support the conclusion of a California study by Cowling et al that the tobacco-specific survey introduction is associated with underreported tobacco use by some smokers (3). Cowling et al state: "The specificity of the introduction may cue respondents to adjust their responses (i.e., deny tobacco use) in order to shorten the length of the interview experience" and "provide a socially desirable response." . . . In 2003, Washington began incorporating ATS questions into the BRFSS, partly to prevent this apparent underreporting in the ATS. . . . Respondents answer the core demographics and health questionnaire of the BRFSS and then either a module of state-specific questions or a module of tobacco-specific questions, many of which are from the ATS. Smoking prevalence based on the expanded BRFSS data for 2003 (N = 18,644) was 19.8% (95% confidence interval [CI], 19.2%–20.6%), which was more similar to previous BRFSS prevalence estimates than previous ATS estimates (Table).” (Underline added.)

 

NOTE: The CDC Behavioral Risk Factor Surveillance System  (BRFSS) adult smoking prevalence was not 19.8 as stated in the above text (see page 3 of attached “Solutions for Survey Discrepancies in Washington State Smoking Prevalence,” for the accurate figure of 19.5 percent as published by CDC for 2003.)

 

The variances, as reported in the table for the attached document, are large and material. Moreover, since Ms. Phinney’s report cites a 2000 start date for the reported decline, in conflict with Mr. King’s date of 1999, the variances are directly on point with and material to calculating the same alleged decline in Washington smokers of 205,000. I prepared a graphic from a data table in the above-cited source document, which appears below. The variances between Washington and CDC smoking prevalence data for the three years reported are: 2000 -1.8 (8.7%), 2001 -5-5 (24.4%) and 2002 -5.4 (25.1%).

 

 

During the period reported in the attached document the Washington Department of Health discrepancies increased from 8.7% to 25.1%. 2002 Washington adult smoking prevalence data were understated by 25 percent-plus, due to an apparent survey bias created by the Washington Tobacco Control and Prevention’s inclusion of “strong, tobacco-specific introductory language.”

Neither Mr. King’s report in the Seattle Times nor Ms. Phinney’s Seattle Post-Intelligencer report cite interim year data for 2001 to 2004. It will be interesting to compare CDC BRFSS data with current Washington Department of Health reports when CDC releases its reports 2005 in November, as customary. For example, 2003 state-specific prevalence data were published by CDC November 12, 2004 (MMWR 53(44);1035-1037) and 2004 data were published November 11, 2005 (MMWR 54(44);1124-1127). Judging by those publication dates we will, of course, past election day when comparison of Governor Gregoire’s 17.8% prevalence with CDC reports can be made.

 

In the manuscript of the book for which my research is prepared, “Trapped in the Triangle: States at the Precipice”  (ISBN 1-4243-0134-3) I wrote in February of this year:

 

            “The facts about Current Smoker and Former Smoker populations in this work are conservative understatements. CDC adult smoking and “Monitoring the Future Study” youth prevalence data rely on survey self-reporting. Given the extreme risks to employment, reduced access to health care, and other issues that smokers face why would they put themselves on report for social stigma, employment and housing discrimination, added insurance costs, etc. by responding positively to a survey about smoking? The more mandates to coerce “Smoke Free” nicotine brand choices escalate the less likely it is that survey responses truly represent population behaviors.”

 

We now have a report concerning Washington smoking prevalence data published by CDC (see attached) that cites the precise phenomenon discussed in my manuscript. That CDC report cites a 2003 study by Cowling, “Improving the Self-Reporting of Tobacco Use: Results of a Factorial Experiment.”  In that study Cowling, et al say:

 

“Hypothesis 1 suggests that because the CATS introduction cues respondents to the survey topic, some smokers may intentionally deny their habit in an effort to minimise the length of the survey interaction or to provide a socially desirable response. The new introductory statement coincided with the divergent prevalence rates. Our second hypothesis was that the filter question regarding experimentation with cigarettes may screen out smokers who either do not feel they ever "experimented" with cigarettes (but who nonetheless use them) or who misunderstand the question.” (Undelrine added.)

 

The bias interjected into self-reporting surveys about tobacco use is not limited to introduction cues and filter questions. Bias is also interjected by the cultural climate in which the survey is taken. Read the below comments by a Washington public health employee and assess the cultural climate in which Washington surveys are responded to:

 

Seattle Weekly, January 18, 2006

 “Big Nanny Is Watching You,” By Philip Dowdy

Quoting Roger Valdez, Director of Tobacco Prevention, Concerning I-901

Seattle-King County Department of Public Health

 

            “Americans think they have a lot of rights they really don’t have. Smoking is one of those things where people think they have a right to smoke, but you don’t. . . . You have no right to smoke. It’s an addiction. It’s something you should see a doctor about. . . . The condo association can ban it, and you have no legal recourse.”

 

Seattle Weekly, February 1, 2006

 

Roger Valdez Letter to the Editor, “Try the Patch”

 

            “We have compassion for smokers battling a powerful addiction . . . Affordable treatment is key: We offer a free nicotine patch program, and we are advocating for important changes in the law to mandate smoking cessation treatment on demand for those with health insurance and offer support for those with no coverage.”

 

So why would no one be surprised to learn that King County reports 13.3 percent smoking prevalence, compared to an overall statewide prevalence of 17.8 percent? With health department employees making legal pronouncements concerning legal rights who would give that person fodder for their “Target Group” cannon? Considering that King County’s “Wellness” program can impose additional insurance costs – and probable career discrimination or unemployment – on county employees who lawfully consume legal tobacco products who would put themselves on report for that?

 

What we have regarded as a public health service has become unfettered aggression against “Target” citizens, consumers, taxpayers and constituents. The Seattle Times and the Seattle Post-Intelligencer may still regard tobacco-related information from state and county health departments as credible, but others understand with uncommon clarity that what is reported can also be electioneering spin to “justify” dogma-driven agendas. Have we traded in statistical reality for bias-by-dogma, to artificially drive down prevalence rates, so health departments and politicians can claim “success” for programs they sponsor and support? When do we get back to merits and constructive results as a way to measure taxpayer-funded state programs? And when does state fiscal responsibility secure at least as much standing in program evaluation as jimmying the data fit a predetermined outcome of “Success” by any statistical means?

 

Hopefully, responsible staff and managers in other state departments or agencies that rely on Department of Health “statistics” will begin to audit important public health information they necessarily rely on when making decisions that affect budgets, taxpayers and consumers.

 

Analysis Previously Submitted to Washington Department of Revenue and Washington Office of the Attorney General

Please see “WACIGTAX Populations Consumption Table 1.” That table includes adult Current Smoker prevalence and populations, as well as cigarettes consumed per year and per day, for USA nationwide and Washington. The source of populations is the U.S. Census Bureau (see, for example, “Washington 18-Plus Populations 1999 2005” attached.) The source for adult smoking prevalence is state-specific data published in Centers for Disease Control and Prevention “Mortality and Morbidity Weekly Review (MMWR) data (see, for example page 3 of “Solutions for Survey Discrepancies in Washington State Smoking Prevalence” attached.) the source for USA cigarettes consumed is a March 8, 2006 press release by the National Association of Attorneys General (NAAG) that included a table of yearly cigarette consumption 1990-2005. The source for Washington cigarette consumption is Cigarette Tax Stamps sold, provided to me by the Washington Department of Revenue June 26, 2006.

 

1. Census bureau 18 and older adult population estimates (not projections) for the State of Washington are 4,270,021 for 1999 and 4,803,394 for 2005. Adult Smoking prevalence of 22.4 in 1999 and 17.8 for 2005 conform and are identical in Table 1. and the governor’s press release. Those data produce current smoker populations of 956,485 for 1999 and 855,004 for 2005. The best case change (assuming no bias error as previously admitted by Washington tobacco control) in Washington adult Current Smoker populations is therefore -101,401, not 205,000 as claimed. The best case change in Washington adult smoker populations is 49.5 percent (less than one-half) of that claimed by Governor Gregoire. We therefore observe apparent election year puffing on “statistics” about tobacco of 100 percent-plus.

 

2. Ms. Phinney reports in The PI that prevalence changes leave us with an adult current smoker population of about 790,000. That figure underestimates 2005 adult current smokers by 65,000 (855,000 – 790,000.) If we have an adult current smoker population of 790,000 for 2005 then a 1999 smoker population of 995,000 is implied by the claimed reduction of 205,000. A 1999 Washington adult smoker population of 995,000 in 1999 overestimates census and prevalence calculated populations by about 39,000. The only apparent way that one can arrive at the claimed 205,000 reduction in current smokers is to overestimate beginning adult smoker populations and the underestimate ending adult smoker populations. Such errors cannot occur by random chance.

 

3. A Washington adult current smoker population of 790,000 in 2005 and a smoking prevalence rate of 17.8 percent produces a Washington 18-plus adult population of 4,438,302, which is 365,000 (-8.2%) less than current census bureau estimates and lower than Washington adult populations reported since 2000. An adult current smoker population of 995,000 and smoking prevalence of 22.4 percent in 1999 produce an adult population in the state of 4,441,964, which is nearly 172,000 (+4.0%) greater than actual population estimates reported. The reported tobacco control “success” of reducing Washington adult current smokers by 205,000 therefore requires use of populations that are inconsistent with U.S. Census Bureau estimates and that are at dramatic variance with time-series trends for the period. 

 

4. The best case reduction in Washington Current Smokers 1999 to 2005 of 101,401 could entirely disappear with a small error of estimate. Reducing that “success” to zero in a 2005 adult population of 4,803,394 requires a swing of 2.1 percent (an 11.8 percent underreporting error in prevalence.) Washington tobacco control prevalence statistics are documented above to have underreporting errors as high as 25.1 percent compared to  CDC prevalence figures. An error of 11.8 percent (less than half of that previously experienced) induced by continued survey bias and the overtly hostile cultural climate toward persons who smoke in Washington is entirely within the realm of statistical probability. The more “toilet-tongue” spread about persons who smoke by the Washington Department of Health and Governor Gregoire the lower the self-reporting on surveys and the greater the “success” that is claimed by tobacco control advocates. Problem is, not only is that a reprehensible way for the state to achieve “success” in any endeavor but – if everything tobacco control claims about the costs of smoking are true -- taxpayers, consumers and other state agencies are also left holding the bag of health care costs for higher numbers of persons who smoke.

 

5. The period that has been “cherry picked” by Governor Gregoire is interesting. If one uses a true measure for success of the results produced by tobacco control since Project ASSIST began in 1991 (Washington Current Smoker population = 852,260) Washington adult smoker populations have increased by 2,744. From 1990 adult smoker populations have decreased by an insignificant 1,738. A mere 10 percent (1.8 prevalence points) error in the estimate, to produce current smoker prevalence of 19.6, would produce current smoker populations in 2005 of 941,465, which would be an increase of 89,205 current smokers since Project ASSIST began. No matter what the color of the estimate lipstick we put on this statistical pig we arrive at the same fundamental conclusion: since Washington tobacco control began in 1991 tobacco consumer populations have remained stable despite record-breaking increases in taxes, the nation’s most stringent smoking bans, and a reprehensible view of “Target” citizen consumers by health department employees (see, for example, the views expressed by Mr. Valdez at King County health above.)

 

6. Finally, please note in Table 1. that as of 2005 Washington cigarette smokers consume 12.3 cigarettes per day versus 22.3 USA nationwide. It is not plausible that Washington “nicotine addicts” have one-half the “cravings” as smokers nationwide. Nor is it plausible that the same consumers of tobacco products would use nearly 50 percent less than those nationwide based solely on geographic location. As illustrated in calculations below the data columns in Table 1. such data indicate a considerable compliance/collections problem that could be as high as $340 million per year for the Washington Department of Revenue. Much of that significant difference in reported versus implied tax revenues is accounted for by tribal and border area sales, in addition to tobacco consumers using Nicotine Replacement Therapy products in “Smoke Free” environments.

 

Washington taxpayers and consumers find themselves confronted with remarkably stable current smoker populations despite record tax increases and strict smoking bans, while millions per year flow out of state coffers in subsidies of tribes and Nicotine Replacement Therapy distributors. Meanwhile Marlboro Man sits tall in the saddle atop Joe Camel, with a stable source consumer base and record profits.

 

By any reasonable standard the Governor’s alleged tobacco control “success” is a dead loser for taxpayers and consumers, as well as the integrity of our governing institutions. 

 

Norman E. Kjono

References

Solutions for Survey Discrepancies in Washington State Smoking Prevalence.pdf

WACIGTAX Populations Consumption Table 1 (08-31-06 Update).pdf

Washington 18-Plus Populations 1999 2005.pdf

Washington Smoking Gregoire Press Release 08-30-06.pdf