The more money states spend on tobacco control programs, the fewer cigarettes people in those states buy, according to a new study. In fact, between 1990 and 2000, cigarette sales dropped more than twice as much in states with strong anti-smoking programs as they did in the United States overall.

The finding shows that anti-tobacco efforts really work, experts say.

"It's encouraging for those in tobacco control to see that their investments have been worthwhile," said lead researcher Matthew Farrelly, PhD, director of the Public Health Economics and Policy Research Program at the Research Triangle Institute in North Carolina.

Tobacco-related diseases kill about 440,000 Americans each year, and tobacco use is responsible for one-third of all cancer deaths in the United States. Cigarette smoking is the primary cause of lung cancer and a contributing cause of numerous other cancers. Smoking can also cause heart disease and lung disease. About 23% of US adults and 28% of US high school students smoke, according to the US Centers for Disease Control and Prevention (CDC).

"This study provides our clearest evidence to date that tobacco control programs are an excellent investment in public health," said CDC director Julie Gerberding, MD.

Farrelly and colleagues from the CDC and the University of Illinois at Chicago compared cigarette sales in all 50 states with the amount of money each state spent on anti-smoking programs like advertising campaigns or telephone quitlines. Their findings were published in the Journal of Health Economics (Vol. 22, No. 5: 843-859).

States with bigger anti-tobacco budgets had lower cigarette sales. Four states with especially strong programs – Arizona, California, Massachusetts and Oregon – saw cigarette sales drop by 43% from 1990 to 2000. Sales in the US as a whole dropped by only 20% in that same period.

"These new data show that robust tobacco control programs reduce tobacco use," said co-author Terry Pechacek of the CDC.

The researchers weren't able to determine which specific programs were the most successful (whether quitlines work better than television ads, for example). But the four standout states did have something in common, Farrelly noted.

"They all had developed a comprehensive approach to reducing tobacco use," he said. The CDC has recommendations for states on how to develop these comprehensive programs. In general, they include a combination of community-based and school-based programs; counter-marketing through television, print and radio advertising; and cessation programs like telephone quitlines.

Farrelly's study isn't the first to suggest that tobacco control programs work. But it is the first to control for the impact of cigarette taxes on consumption. That's important, Farrelly said, because without that control, it's difficult to separate the effect of the state programs from the effect of higher cigarette prices caused by increased taxes.

His work shows much more conclusively that state anti-tobacco programs also contribute to the drop in smoking, he said.

Unfortunately, most states fall far short when it comes to spending money on tobacco control. The CDC recommends states spend at least $5.98 per person each year on anti-smoking efforts; the average state spends just $1.22 per person, the researchers said.

They determined that if states had spent $6 per person on tobacco control efforts in 1994, cigarette sales would have fallen twice as quickly between 1994 and 2000 as they actually did.

At a time when many states are facing budget crises, the recommended $6 may seem like a lot of money. But Farrelly noted that successful tobacco-control programs get more efficient over time.

"The data seem to reflect that there's a lag between when you invest in tobacco control and when there's an impact," he said. "But what we did find was that expenditures in the past have an impact on current cigarette sales."

One reason may be that there's a natural learning process that goes with any big project; as people running the program gain experience, they become better at it.

Another possible explanation, Farrelly said, is the nature of tobacco addiction. "It takes time to convince smokers to quit and enable them with the tools to quit," he said.