In summary Anti-smoking crusade dating back decades has resulted in fewer deaths, more savings. Fresh data reveals new cigarette tax reducing smoking.

California’s low rate of lung cancer deaths saved nearly 5,000 lives in 2014—and saved Californians at least $500 million just in that year, according to a CALmatters analysis in consultation with public health researchers. Those savings will likely grow into the billions of dollars in the decades ahead, experts say.

Earlier this month, a study from the UC San Diego School of Medicine found California’s rate of lung cancer mortality was 28 percent lower than the rest of the country in 2014, the most recent year of available data. The study’s authors attributed California’s low number of lung cancer deaths to the state’s early and aggressive anti-smoking initiatives.

If California had the same rate of lung cancer deaths as the rest of the country, on average, roughly 4,700 more Californians would have died in 2014. Those terminal patients would have cost an estimated $546 million in hospitalization expenses alone that year, according to a CALmatters analysis vetted by public health experts at UC San Francisco and UC San Diego. That does not include other expensive components of cancer treatment that don’t require hospitalization, or savings from non-terminal lung cancer cases.

The savings are even larger when factoring in the lost economic productivity from premature lung cancer deaths. When the continued earnings and other economic contributions of saved lives are considered, savings top $1.5 billion for 2014 alone.

With nearly one-third of Californians on Medi-Cal, the state’s health insurance program for low-income residents, it’s likely lots of those savings are going directly into state coffers. The Department of Health Care Services, which administers Medi-Cal, said it could not provide reliable cost savings estimates.

But 2014’s savings are by no means an outlier, and experts project savings from California’s low lung cancer mortality rates will only grow in the years ahead.

“You’ve seen a huge difference between California and the rest of the country in people starting smoking under [age] 35,” said John Pierce, a professor of cancer research at UCSD and a co-author on the study. “Lung cancer’s peak years are 65 to 80, so there’s going to be huge affects decades from now.”

In 1974, 45 percent of Californians age 18 to 34 had ever started smoking, compared to 48 percent of younger Americans in the rest of the country. By 2013, only 19% of younger Californians had ever started smoking, compared to 31 percent in the rest of the U.S.

Research indicates that preventing young people from smoking greatly reduces the chance of heavy smoking later in life. Smoking causes the vast majority of lung cancer cases.

Pierce credits California’s low smoking rates with two related initiatives: California consistently raising excise taxes on cigarettes between the 1960’s and 1990’s, and the launch of a first-in-the nation tobacco control program in 1988.

Aided by state laws restricting tobacco advertising and smoking in public places, the program’s anti-smoking media campaigns helped tilt California into a state that culturally frowns on smoking.

“Unless it starts going up all the time, you can adjust to a tax,” said Pierce. “What you don’t adjust to is the social norms.”

Cigarette consumption slowing after tax, but experts worry about e-cigs

In 2016, California voters overwhelmingly approved the biggest hike in cigarette taxes since the state began taxing tobacco in 1959. Anti-smoking advocates hoped the new $2 per pack tax would induce smokers to quit and prevent new smokers from starting while reinvigorating the tobacco control program with new revenue.

The results look promising since the tax went into effect in April of last year. Cigarette pack “distributions”—tax lingo for a pack of cigarettes typically sold from a distributor to a retailer, and a good proxy for consumption—are down 20 percent from two years ago, according to data obtained from the California Department of Tax and Fee Administration.

About 80,000 fewer packs were sold in the first three months of 2018 than the first three months of 2017, which preceded the tax.

While the sustained decline in cigarette purchases is good news for California lungs and pocketbooks, experts worry that a rise in e-cigarette smoking may temper the gains the state has made over the past few decades in reducing tobacco consumption.

The new cigarette tax approved in 2016 included a tax on e-cigs, making California one of just a handful of states to tax so-called “vaping” devices containing nicotine.

The big worry among California public health experts is not so much the health risks of e-cigarette use on its own, but whether e-cigarette use will lure younger consumers into conventional cigarettes.

“Just when we thought we really had this under control, the whole world changed,” said Wendy Max, a professor of health economics at UC San Francisco. “Cigarette smoking is down but electronic cigarette usage is back.”

State health agencies have been retooling their anti-tobacco messaging to deter e-cigarette use.