Is Progress in Tobacco Control Going up in Smoke?
As we look back on 2011, proponents of preventive medicine as a key component of healthcare reform continue to worry that tobacco use, the leading cause of death in the U.S., remains largely ignored by those in control of federal and state budgets.
Tobacco use is responsible for more than 443,000 deaths each year; another 8.6 million people live with tobacco-related chronic disease. Yet, a recent report by the Campaign for Tobacco-Free Kids points out that state spending on tobacco use prevention, cessation, and education has dropped to its lowest levels since 1999, when billions first became available from the Master settlement Agreement (MSA) made between state attorneys general and the tobacco industry. A major flaw of the MSA was a lack of accountability requirements, and state governments quickly began using the money for a host of issues unrelated to tobacco.
About $26.5 billion will be this year’s take from the MSA and tobacco excise tax revenues, but only $457 million (1.8%) will be spent on tobacco control issues. Just two states, Alaska and North Dakota, have tobacco control budgets that reach levels recommended by the CDC. Four others – Hawaii, Delaware, Wyoming and Maine – provide about half the proposed levels, with the rest ranging down to a low of $0 in Ohio, Connecticut, New Hampshire, and Nevada.
Although fewer than 20% of U.S. adults smoke, the pace of decline in tobacco use has slowed, and in a couple of states, almost has come to a halt since tobacco control budgets were slashed. A brighter picture emerges for youth smoking, with 8th-, 10th-, and 12th-graders smoking at historically low levels (according to the Monitoring the Future survey, released in December 2011). As with adult smoking, however, the decline is not as steep as in previous years.
A worrisome upswing among youth in the use of smokeless tobacco and “little cigars” shows the impact of novel industry products. Others smokeless products, such as snuff, enticingly flavored tobacco strips and sticks, and flavored cigars escaped the initial ban on flavorings, which the new Food and Drug Administration (FDA) regulations applied to cigarettes only. A related study on this trend appears in the January edition of AJPM.
The good news is that the wave of smokefree indoor air laws continues to grow. Tax increases in a few states in 2009 and 2010 have also helped to curb consumption, as did the 62-cent federal excise tax hike in 2009. In addition, the FDA’s new power over the tobacco industry has produced some restrictions on marketing to youth. The tobacco industry, however, spends more than $10 billion a year on marketing and promotion, giving worldwide impetus to sales of its deadly by exploiting overseas markets..
Our task is clear. We know what works in tobacco control, and we must not let short-term economic excuses deter continued progress.
Many have noted the dividends of comprehensive state-level tobacco control programs, including the authors of a report in the American Journal of Public Health. The study found that from 2000 to 2009, Washington State’s comprehensive tobacco programs prevented nearly 36,000 tobacco-related hospitalizations, with savings of $1.5 billion, or $5 for every $1 invested. Tax increases and clean indoor air laws also helped speed the reductions in tobacco consumption and the related positive health effects.
These human and economic savings are not likely to last, however. Washington State has made some of the largest cuts in tobacco programs in recent years; in 2009, lawmakers diverted to other budgetary categories funds authorized in a 2002 ballot initiative requiring that at least $26.24 million be spent on tobacco control. In 2012, the state will essentially eliminate tobacco control spending, seriously undercutting the benefits of previous efforts.
So what are advocates for public health and tobacco use prevention to do? As always, we must continue our vigilance and efforts to stop bad policymaking at both the state and federal level—speaking out, for example, about current federal legislative attempts to kill the Public Health and Prevention Fund contained within the Affordable Care Act. The core tobacco control initiatives we know to work must be preserved and expanded, including excise tax increases with dedicated funds for tobacco control, smokefree indoor air policies, and comprehensive state programs for tobacco use prevention and cessation. State budgets need re-examination to reverse these sad trends, which threaten public health, and to restore the promises made more than a decade ago to use the MSA to contain this modern epidemic.
— Thomas P. Houston, MD, Clinical Professor of Family Medicine and Public Health, The Ohio State University, Columbus OH, and AJPM Editorial Board member