By Kim Krisberg
Public health vs. tobacco. It's a David and Goliath kind of story. The kind in which the good guys win and everyone sleeps a little sounder knowing that the bigger, richer guys don't hold all the power.
Of course, the story isn't so cut and dry. While public health has been slowly and steadfastly winning the battle against smoking in the United States (though progress has slowed and disparities still exist), the opposition hasn't gone away -- in fact, it's still bigger, much richer and working harder than ever to hook new users and undermine successful anti-tobacco efforts. In other words, it's no time to back down. Unfortunately, public health workers are finding their toolboxes increasingly lighter.
"It used to be we could go to an elementary school and ask fifth-graders what they knew about tobacco and they would already know our (anti-tobacco) slogans," said Tim Church, director of communications at the Washington State Department of Health. "Now, if we went out and talked to a fourth- or fifth-grader, they probably wouldn't even remember seeing an anti-tobacco campaign."
Up until a few years ago, Washington's tobacco prevention program had a strong foundation to stand on. At one point, Church said, the efforts were supported with about $26 million in state funds as well as a couple million more in federal dollars. In fact, in the summer of 2010, the health department announced that the state's adult smoking rate had dropped to a new low of just below 15 percent, making Washington home to the third-lowest smoking rate in the nation. Since Washington launched its Tobacco Prevention and Control Program in 2000, the state's smoking rate had declined by about a third, according to the health department.
Today, Washington's tobacco prevention program is "essentially no longer operating," Church told me. As a result of state budget cuts, the program now has a very small amount of funding that it uses to enforce laws against selling tobacco to minors and to help develop smoke-free policy. But there's no longer any media campaigns targeting young people and adults nor any funding for school-based efforts, and the state's quitline, which in 2010 was getting an average of 1,900 calls a month, is no longer supported with state funds and now only serves those who can pay.
"It is absolutely frustrating," he said. "But, we made a huge impact on thousands and thousands of lives over the last 10 years and that means a lot."
Short-sighted funding decisions
Washington state is far from alone. According to a report released Nov. 30. by a coalition of public health organizations, states have cut funding for tobacco prevention by 12 percent in the past year and by 36 percent over the past four years. The funding levels come despite the billions in revenue states continue to receive via the 1998 tobacco master settlement agreement, which was the result of a multi-state lawsuit brought against major tobacco companies to recoup tobacco-related medical costs and fund tobacco prevention efforts.
The Nov. 30 report finds that in fiscal year 2012, states will collect more than $25 billion in master settlement funds, but will only spend 1.8 percent of it on efforts to prevent kids from smoking and to help current smokers quit. According to the Centers for Disease Control and Prevention, tobacco use is still the leading cause of preventable death in the United States and results in billions of dollars in health care costs and lost productivity. In 2010, almost one in five adults were current smokers.
"We're missing out on a tremendous opportunity," said Danny McGoldrick, vice president for research at the Campaign for Tobacco-Free Kids, one of the organizations that released the funding report. "When states cut money for tobacco prevention, the only winners are tobacco companies and the losers are our kids, our health and our pocketbooks."
McGoldrick said it would only take about 15 percent of 2012's master settlement payout to fund state tobacco programs at levels recommended by CDC, noting that for every $1 spent to get people to stop smoking, the tobacco companies spend $23 to get people to start. According to a recent CDC study, "States that invest more fully in comprehensive tobacco control programs have seen larger declines in cigarette sales than the United States as a whole, and smoking prevalence among adults and youths has declined faster as spending for tobacco control programs has increased."
"When the spending goes up, tobacco use goes down...it's been well established in the science," McGoldrick told me. "We know the problem and we know the solution, we have the money and we know the voters want us to do it. It's a no-brainer, but the people making the funding decisions aren't using their brains."
Cathy Callaway, associate director for state and local campaigns at the American Cancer Society's Cancer Action Network, said lawmakers need to take more responsibility for tobacco control efforts in their states. Not only do they need to set aside more master settlement funds, they need to support hikes in tobacco taxes as well as policies proven effective in reducing tobacco use and exposure to secondhand smoke. Adding to the uphill fight against tobacco use is the battle's unlevel playing field: While the tobacco industry can make campaign contributions, "we can't...and if you watch how some lawmakers vote on our issues repeatedly, you'll find a money trail," Callaway told me.
"It seems like every restriction we put in place, the tobacco industry has thought of a way around it," she said. "But as diseases go up, hopefully lawmakers will get it. They'll recognize that past cuts to tobacco programs definitely had a negative impact on our past successes."
Creative shoestring efforts
There's no real silver lining to the current funding situation, but it is forcing some health departments to get creative. Such is the case in Ohio, where as of July state lawmakers stopped allocating funds for tobacco control efforts. For now, Ohio's program can use master settlement funds it was already given for enforcement of existing laws and some prevention work, but legislators mandated that the funds no longer go to supporting Ohio's quitline. The change means the quitline is now entirely dependent on CDC funds that expire in April and that it has gone from serving all residents to only the uninsured, Medicaid beneficiaries and pregnant women, said Mari-jean Siehl, chief of the Tobacco Use Prevention and Cessation Program at the Ohio Department of Health.
"I don't think anyone can look at the number of tobacco users in Ohio and think we don't have a problem," Siehl told me. "But the funding situation is what it is and as a program we do the best we can."
And the best that they can is pretty innovative. Siehl said that back in March 2010, she and her colleagues had a "strong feeling" that the flow of master settlement funds would be in doubt. In response, the health department joined with those in the private sector. The result was the Ohio Tobacco Collaborative, a public-private partnership that offers employers and health plans a baseline cessation package and access to the quitline at a reduced rate. The move will not only help sustain cessation services in Ohio, but push insurers to come into compliance with federal health reform mandates that insurers cover cessation services with no cost-sharing. Still, Siehl hopes new federal funds make it to Ohio so that the quitline can remain accessible for all those who need it.
"It's so important during times of financial challenges that we think outside the box," Siehl said. "We are totally counting on our partners to help us be creative in how we solve this problem. This effort is worth sustaining."
For a copy of the state tobacco funding report, "A Broken Promise to Our Children: The 1998 State Tobacco Settlement 13 Years Later," visit the Campaign for Tobacco-Free Kids.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for almost a decade.
I don't see much sense in taxing the hell out of a product as a deterrent. All (if not most) people these days know the side effect of smoking (if not, read those big letters on the side of your cigarette packs). Whatever happened to personal responsibility? The correlation between high cigarette prices and low consumers only means that those who can afford it will buy them. There should be adequate education concerning the health concerns and effects of smoking, but beyond that people should be able to choose. Since heart diseases outrank lung diseases as deaths in America, should we enable taxes on unhealthy food too along with warning labels? Not necessarily the best example since one is a necessary sustenance and one is not, however I would assume that health complications due to obesity (that isn't based entirely on genetics) account also for 'billions' of medical bills. Why not tax unhealthy fattening food, which main purpose is not to feed but to make people happy, to feed a craving? I'm sure if McDonalds had a 1 dollar tax on every happy meal like cigarettes in CA where a certain amount goes to educational program and the other goes to CDC research, its customer base will surely go down. Heck, just regulate our lives, anything unhealthy just charge extravagant fees for it that way people will stop doing them! Because poor people can't make decisions for themselves. Nope poor people can't read that giant surgeon general warnings, they only understand when they can't afford a product.
Are you familiar with the simple but effective strategy Don McCormick at the Iowa Department of Public Health cooked up to directly influence state policy-makers? He created a story bank to collect high-impact personal stories about smoking cessation so that policy-makers were faced with real-life people and their health issues. I blogged about it here.
It's not that the people making the decisions aren't using their brains. they're just using them for the wrong purpose. Instead of thinking about public health, they are just filling their pockets and giving in to the pressure of Big Tobacco.