Talking Points: Comprehensive Smoking Prevention Programs

Transcription

1 Talking Points: Comprehensive Smoking Prevention Programs R R R What Are the Effects of Smoking? Smoking results in an estimated 438,000 deaths a year from diseases such as cancer, heart disease and stroke. For every person who dies, there are 20 more who live with a smoking related disease. The U.S. annually spends $75 billion on smoking related health care and experiences $92 billion in lost productivity. Each year, the effects of secondhand smoke cost an estimated $10 billion in excess medical care, premature death and disease costs the economy would not be forced to bear if secondhand smoke were eliminated. An estimated 3,000 nonsmokers die each year from lung cancer and tens of thousands die from heart disease. What Are the Benefits of Tobacco Prevention and Control Programs? The states with the best funded and most sustained tobacco prevention programs during the 1990s reduced cigarette sales more than twice as much as the country as a whole. States could prevent nearly 2 million of today's youth from becoming smokers and save more than 600,000 of them from premature, smoking caused deaths by funding tobacco prevention programs at the minimum levels recommended by the Centers for Disease Control and Prevention (CDC). Lifetime health care costs for smokers total at least $16,000 more than nonsmokers, on average. For every 1,000 youth averted from smoking, future health care costs would decline by roughly $16 million, and for every 1,000 adults prompted to quit, future health care costs drop by roughly $8.5 million. Why Should State Legislators Be Concerned? After years of decline, youth smoking rates appear to have stalled and may be increasing. There was no observed change in adult smoking rates between 2004 and Tobacco companies marketing spending increased by 123 percent from 1998 to State tobacco prevention and control funding is down from a peak of $749 million in 2002 to $595.4 million in CDC recommends minimum state spending of $1.6 billion on tobacco prevention. Current spending for states as a whole in FY 2007 is only 37 percent of that.

2 R R What Disparities Are Associated with Smoking? Smoking levels vary widely among different ethnicities, with American Indians/Alaska Natives having the highest prevalence (32 percent are smokers, compared to 20.9 percent for the nation as a whole). Cigarette smoking is more common among adults who live below the poverty level than those living at or above it. Smoking is also more common among men than women. Smoking is a primary factor in the three leading causes of death among minorities (heart disease, cancer and stroke). Minorities often have less access to primary health care providers who would encourage smoking cessation. Tobacco companies target minorities, especially the African American and Hispanic communities, in their marketing efforts. Kids are more susceptible to cigarette advertising and marketing than adults. Four out of five smokers age 12 to 17 prefer Marlboro, Camel and Newport three of the most heavily advertised brands of cigarettes. Only 54 percent of those over age 26 prefer these brands. Nearly 90 percent of people who smoke begin at or before age 18. What Can State Legislators Do? Demonstrate leadership. Support adequate funding for evidence based, effective, comprehensive tobacco control programs. Prevent tobacco use among young people. Vote to increase cigarette taxes. Price increases are an effective deterrent to youth smoking. Increasing the unit price of tobacco also decreases consumption and increases cessation among adults and youth. Legislators can also support statewide media campaigns to prevent smoking. And they can support and seek to strengthen community enforcement of youth tobacco sales restrictions. Promote smoking cessation. Expand the services available through statewide quit lines to include behavioral counseling and nicotine replacement therapy and make them available for free or at a reduced cost. Eliminate exposure to secondhand smoke. Ban smoking in public places and workplaces to protect nonsmokers from secondhand smoke and encourage cessation among smokers. Identify and eliminate health disparities related to tobacco use. Support efforts to prevent the tobacco industry from using cigarette marketing campaigns that target specific groups. Legislators can also ensure that anti tobacco programs have sufficient capacity to serve all populations. For more detail, see the Legislator Policy Brief, Comprehensive Smoking Prevention Programs, by visiting: If you would like more information, references, or to explore this topic in greater depth, please: send your inquiry to (keyword: inquiry) or call the CSG Health Policy Group at (859) This Healthy States publication is funded by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, under Cooperative Agreement U38/CCU Points of view in this document are those of the author and do not necessarily represent the official position or policies of the U.S. government.

3 Comprehensive Smoking Prevention Programs Legislator Policy Brief

4 The Healthy States Initiative A partnership to promote public health The Healthy States Initiative helps state leaders access the information they need to make informed decisions on public health issues. The initiative brings together state legislators, Centers for Disease Control and Prevention (CDC) officials, state health department officials and public health experts to share information and to identify innovative solutions. The Council of State Governments partners in the initiative are the National Black Caucus of State Legislators (NBCSL) and the National Hispanic Caucus of State Legislators (NHCSL). These organizations enhance information-sharing with state legislators and policymakers on critical public health issues. Funding for this publication is provided by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, under Cooperative Agreement U38/CCU Points of view in this document are those of the author and do not necessarily represent the official position or policies of the U.S. government. Why public health? State legislators play a vital role in determining the structure and resources available to state and local agencies dedicated to protecting the public s health. Public health agencies educate the public and offer interventions across a wide spectrum of public health issues including: Ensuring that children and at-risk adults are immunized against deadly diseases; Assisting victims of chronic conditions such as cancer, heart disease and asthma; Preventing disease and disability resulting from interactions between people and the environment; Researching how HIV/AIDS infections and other sexually transmitted diseases can be prevented; Promoting the health and well-being of people with disabilities; and Working with schools to prevent risky behavior among children, adolescents and young adults. Information resources for state policymakers New information resources produced under this initiative include: Healthy States Web site. This unique Web site offers information and resources on many public health issues. Visit to get information, sign up for publications and view other information on the initiative. Health Policy Highlights and Healthy States e-weekly. Each week, this free weekly electronic newsletter brings the latest public health news, resources, reports and upcoming events straight to your inbox. Healthy States Quarterly. CSG publishes a free quarterly newsletter covering public health legislative and policy trends, innovative best practices from the executive and legislative branches, current research and information on Healthy States activities. Forums and Web Conferences. Web conferences are offered to allow public health experts, legislators and legislative staff to interact on priority public health issues. Forums include educational sessions on public health issues, new legislator training and roundtable discussions with peers and public health experts. Healthy States Publications. New resources will assist state legislators interested in public health topics, including obesity and chronic disease prevention, HIV/AIDS and sexually transmitted disease prevention, vaccines, health disparities and school health. For more information If you are interested in the learning opportunities available through the Healthy States Initiative, visit or

5 Comprehensive Smoking Prevention Programs Overview As the leading preventable cause of death in the United States, smoking results in an estimated 438,000 deaths and $92 billion in lost productivity each year. For every person who dies, there are 20 more living with a smoking-related disease. With an additional $75 billion spent on health care, smoking costs more than $167 billion annually. 1 This issue brief provides state policymakers with key background information about smoking and identifies proven and cost-effective prevention strategies for states. What Do Legislators Need To Know About Smoking? Smoking harms nearly every organ in the body, but its effects on the lungs and heart are particularly devastating: the three leading causes of smoking-attributable deaths are lung cancer, chronic obstructive pulmonary disease (COPD) and coronary heart disease. The Centers for Disease Control and Prevention (CDC) reports that between 1997 and 2001, smoking-related illnesses resulted in 438,000 premature deaths and 5.5 million years of potential life lost, a measure of premature mortality. 1 An estimated 20.9 percent of all adults (45.1 million people) smoke cigarettes in the United States. 2 Youth smoking rates began declining steadily in 1997, but from 2002 to 2005 this decline appears to have stalled. 3, 4 Reasons for the stall may include reductions in funds for tobacco prevention, increases in tobacco industry advertising and promotion from $6 billion in 1997 to more than $15 billion in 2003, and the glamorization of smoking in films, which influences youth initiation. 5 Likewise, there was no observed change in adult smoking rates between 2004 and Smoking levels vary widely among different ethnicities, with American Indians/Alaska Natives having the highest prevalence (32 percent are smokers), followed by whites (21.9 percent), African-Americans (21.5 percent), Hispanics (16.2 percent) and Asians (13.3 percent). 3 Cigarette smoking is more common among adults who live below the poverty level (29.9 percent) than those living at or above it (20.6 percent). It is also more common among men (23.9 percent) than women (18.1 percent). 3 There is sound evidence that comprehensive tobacco control programs are effective in reducing the human and financial costs of smoking. In order to decrease the impact of smoking-related disease and death on public health and the economy, every state should implement comprehensive tobacco-control programs. Successful state policy initiatives have incorporated such elements as smokefree indoor air policies, tobacco product price increases, youth tobacco sales restrictions, anti-tobacco media campaigns and community-based support services such as telephone quit lines. What Can State Legislators Do To Help Prevent Smoking? State legislators play a crucial role in protecting the public s health and decreasing health care costs by supporting comprehensive tobacco control programs, which reduce disease, disability and death related to tobacco use. The five goals of a comprehensive program are: To prevent youth and young adults from beginning to use tobacco. To promote retailer compliance with youth tobacco sales restrictions combined with other interventions to decrease minors ability to buy tobacco. To promote tobacco cessation. To eliminate exposure to secondhand smoke. To identify and eliminate in the use and impact of tobacco disparities. Legislator Policy Brief Comprehensive Smoking Prevention Programs 1

6 Actions for State Legislators Demonstrate Leadership Support legislation for evidence-based interventions such as cigarette tax increases, smokefree indoor air policies and funding for comprehensive tobacco control programs. Create or serve on a statewide tobacco control task force. Actively and publicly support efforts to prevent youth tobacco use and provide assistance to adults who want to quit. Prevent Initial Tobacco Use Among Young People Increase the price of tobacco products. There is strong evidence to indicate that increasing the price of tobacco is an effective deterrent to youth smoking. 7 Support statewide media campaigns to prevent smoking. Increasing mass media campaigns and other strategies are effective ways to decrease youth tobacco use. 8 Target young people in smoking prevention efforts 90 percent of smokers start before the age of 21 and 65 percent start before the age of School programs can reduce smoking among children by 25 to 60 percent. 10 Support school-based programs in conjunction with community enforcement of youth tobacco sales restrictions or other interventions such as stronger local laws directed at retailers, active enforcement of retailer sales laws and retailer education with reinforcement to decrease minors access to tobacco. Promote Cessation Among Young People and Adults Expand the services available through statewide quit lines to assist in smoking cessation. When combined with educational approaches and/or medical therapies, telephone quit lines can effectively help smokers quit. 11 Cut costs or offer free nicotine replacement therapies and encourage health care providers to screen for and treat tobacco use at every visit, which can improve outcomes for underserved and uninsured populations. 12 Encourage clinicians to screen for tobacco use and offer cessation counseling, which is highly cost-effective. All the service costs can be recovered through long-term health care cost savings Comprehensive Smoking Prevention Programs Legislator Policy Brief

7 Eliminate Exposure To Secondhand Smoke Protect the health of nonsmokers. Each year, the effects of secondhand smoke cost an estimated $10 billion. 14 An estimated 3,000 nonsmokers die from lung cancer and tens of thousands die from heart disease. 15 Protect restaurant and bar workers from secondhand smoke. Studies have found that they are less likely than other workers to be protected by smokefree workplace policies and more likely to be exposed to high levels of secondhand smoke on the job. 16 Smokefree policies and regulations do not have an adverse economic impact on the hospitality industry, multiple studies have shown. 17 Ban smoking in public places and workplaces. Smoking bans not only protect nonsmokers from secondhand smoke, they also reduce current smokers tobacco use and encourage cessation. 18 Identify and Eliminate Health Disparities Related To Tobacco Use Review Behavioral Risk Factor Surveillance System (BRFSS) data in your state related to specific population groups. Smoking rates are not evenly distributed higher smoking rates, for example, are associated with fewer years of education and lower incomes. 19 Provide smoking cessation services, including telephone quit lines and medications, free or at reduced cost to increase use, thus reducing the financial burden of smoking-related illnesses on state health insurance programs. Establish and fund multicultural organizations and networks to collect data and implement culturally appropriate interventions to increase the capacity of minority communities to plan and address tobacco as a priority issue. 20 Support efforts to prevent the tobacco industry from using cigarette marketing campaigns that target specific groups. Ensure that anti-tobacco programs are tailored to serve all populations, taking into account varying cultural characteristics. Support faith-based cessation programs that offer one-on-one counseling, culturally appropriate self-help materials and communitywide activities. Legislator Policy Brief Comprehensive Smoking Prevention Programs 3

8 State Policy Examples Clearing the Air in California As the longest running large tobacco control program, California is reaping the benefits of cleaner indoor air and reductions in youth and adult smoking rates. The California Tobacco Control Program was associated with 33,000 fewer deaths from heart disease 21 and an estimated $8 billion in savings from 1989 through California s program features the combined efforts of local health departments and community-based organizations, a statewide media campaign, quit lines, restrictions on where smoking is allowed and restrictions on the marketing of tobacco products. It is also associated with lung and bronchus cancer rates that declined three times faster than the rest of the nation from Making the Grade in Maine When the American Lung Association released its annual State Tobacco Control report card in January 2006, Maine became the first state ever to receive an A in each of the four categories: tobacco prevention spending, cigarette tax, smokefree air and youth access. 23 Maine, which in 2005 had the highest funded prevention program in the nation in relation to the CDC s Best Practices minimum recommended funding, reduced smoking rates among middle school students by 64 percent and by 59 percent among high school students between 1997 and Maine s tobacco prevention program, which is entirely funded with tobacco settlement money, consists of a statewide counter-marketing media campaign; cessation services, which include a quit line and medication program, as well as training for health professionals; funding for community-based organizations; enforcement activities related to youth access and clean indoor air; training for retailers to assist in complying with youth access laws; and local youth advocacy programs. 4 Comprehensive Smoking Prevention Programs Legislator Policy Brief

9 Saving Lives and Money in New York In 2003, both New York City and the state implemented comprehensive smoke-free workplace laws that included restaurants and bars. While these have been highly successful in improving air quality and reducing secondhand smoke exposure, they are only one part of New York s comprehensive tobacco control program. In addition to clean indoor air laws, New Yorkers benefit from state policies that: fund community-based organizations to fight tobacco use at the local level; maintain high excise taxes on tobacco products; produce aggressive, emotionally powerful media campaigns to motivate smokers to quit and discourage others from starting; and offer cessation assistance, such as quit lines, reduced-cost nicotine replacement products and tobacco use screening by physicians. Rigorous evaluation standards included in the law that created New York s tobacco prevention program are providing strong evidence that tobacco control saves lives and money. Decreasing Youth Smoking in West Virginia Long in the top six states with highest adult and youth smoking rates, West Virginia s comprehensive tobacco prevention program significantly reduced the youth smoking prevalence from 42.2 percent in 1999 to 28.5 percent in 2003 and there is evidence that rates continue to decrease. In addition to efforts to control youth smoking, West Virginia s Division of Tobacco Prevention (DTP) funds prevention activities related to clean indoor air and cessation. All but one of 55 counties in West Virginia are covered by clean indoor air regulations and cessation services such as quit lines, nicotine replacement therapy and counseling sessions are provided at no charge to all uninsured West Virginia residents and at a reduced cost to those with insurance. West Virginia also requires evaluation of DTP s tobacco prevention efforts to ensure that they are sciencebased, responsive to communities and accountable to state policymakers. Legislator Policy Brief Comprehensive Smoking Prevention Programs 5

10 Advice from a State Legislator Want to Fight Smoking in Your State? Pete Grannis New York State Assembly Assemblymember Pete Grannis, a veteran anti-smoking champion and legislator since 1974, represents part of Manhattan in New York s State Assembly. Grannis serves on the Assembly s Health Committee and was a co-author of the state s clean indoor air and cigarette fire safety acts. His Advice To State Legislators: Start with data for particular groups. Identify how smoking impacts different constituent or interest groups and share that data with the group. For example, finding out how secondhand smoke affects people suffering from asthma can be a powerful motivation for that group to help out with anti-smoking efforts. Build effective coalitions. For the efforts in New York, we relied heavily on the cancer, heart and lung associations, on local government, public health officials and even the New York state restaurant association, said Grannis, describing the coalition behind a successful effort in 2003 to expand the state s clean indoor air act to include restaurants and bars. Generate favorable editorial and news coverage. According to Grannis, getting strong support from newspaper editorials and favorable news coverage helped to build a large, effective coalition in New York. Relevant, timely information is key. While our opponents warned of the catastrophic impacts [of a smoking ban for restaurants and bars], we went ahead with our efforts, said Grannis. Proponents of the ban pushed forward because they were armed with solid information about financial impacts from previous efforts in California and Boston. Source: Healthy States September 2005 Web Conference, No Ifs, Ands or Butts: Proven Anti-Smoking Strategies for States. Archive and issue brief available at Want to Know More? We ll help you find experts to talk to about this topic If you would like to explore this topic in greater depth, contact us at the Healthy States Initiative and we ll help you connect with an expert on this issue from the CDC. fellow state legislators who have worked on this issue. other public health champions or officials who are respected authorities on this issue. Send your inquiry to (keyword: inquiry) or call the health policy group at (859) and let us help you find the advice and resources you need. 6 Comprehensive Smoking Prevention Programs Legislator Policy Brief

11 Advice from a Public Health Official What Works in Tobacco Control? Dr. Ursula Bauer Director, New York s Tobacco Control Program Dr. Ursula Bauer, a chronic disease epidemiologist by training, has been working in the field of tobacco control, surveillance and education since Bauer has been the director of the Tobacco Control Program for the State Health Department in New York since Her Advice To State Legislators: Make tobacco use difficult. Keep the price high, keep the product out of view or inaccessible and restrict where and how tobacco may be used or sold. Protect nonsmokers. Nearly 80 percent of New Yorkers favor our clean indoor air law, including almost half of smokers. We know that restaurant and bar workers have less exposure to secondhand smoke, and that the nonsmoking public in general and youth in particular are reporting less exposure to secondhand smoke since our clean indoor air laws went into effect. Fund community-based organizations. These organizations, Bauer said, take tobacco control action locally. They challenge and counter tobacco advertising and promotion in our stores and on our streets, even in our schools, businesses, homes and health care institutions. They educate community members and decision makers about the health and economic impact of tobacco use and mobilize citizens to demand protection from tobacco smoke. Mandate evaluation of your tobacco control program. As a result of the evaluation requirement in the law that created New York s tobacco control program, we re accumulating evidence about the effectiveness of our own tobacco control efforts even as researchers across the country and around the world continue to add to the overwhelming evidence that investment in tobacco control saves lives and money. Source: Healthy States September 2005 Web Conference, No Ifs, Ands or Butts: Proven Anti-Smoking Strategies for States. Archive and issue brief available at Legislator Policy Brief Comprehensive Smoking Prevention Programs 7

12 Key Facts and Terms Health and Economic Impact Cigarette smoking is the leading cause of preventable disease and death in the United States, resulting in approximately 438,000 deaths annually and 5.5 million years of potential life lost. For every person who dies, there are 20 more living with a smoking-related disease. 1 An estimated 35,000 Americans die of heart disease and another 3,000 die from lung cancer each year as a result of exposure to secondhand smoke. 15 Eliminating smoking during pregnancy may lead to a 10 percent reduction in all infant deaths. 25 Each year an estimated 150,000 to 300,000 children younger than 18 months of age have lower respiratory tract infections from exposure to secondhand smoke. 26 Smoking-related illnesses are responsible for $75 billion in health care costs and $92 billion in lost productivity each year, for a combined $167 billion. 1 About 14 percent of all Medicaid expenditures are for smoking-related illnesses. 27 An estimated 45.1 million people smoke cigarettes in the United States. Approximately 20 billion packs of cigarettes were sold in the U.S. in Each pack cost the nation an estimated $8.61 in medical care costs and lost productivity. 28 Health Disparities Higher smoking rates are associated with fewer years of education and lower incomes, which in turn are associated with decreased access to health care. 19 In 2005, cigarette smoking was highest among American Indians/Alaska Natives (32 percent), followed by whites (21.9 percent), African-Americans (21.5 percent), Hispanics (16.2 percent) and Asians (13.3 percent). It is more common among men (23.9 percent) than women (18.1 percent). 2 The three leading causes of death among minorities (heart disease, cancer and stroke) are results of smoking and tobacco usage. 29 Within minority communities, barriers to smoking cessation are financial, lingual and logistical. Minorities often have less access to primary health care providers who would encourage smoking cessation. 30 Organizations such as the National Black Leadership Initiative on Cancer and the National Hispanic Leadership Initiative on Cancer seek to reduce barriers that limit the access of minorities to services. 31 Tobacco companies target minorities, especially the African-American and Hispanic communities, in their marketing efforts by sponsoring athletic, cultural and entertainment events and advertising on billboards and in magazines. 32 Involvement of community-based organizations is an effective means to increase the capacity of minority communities to plan and make tobacco control a priority Comprehensive Smoking Prevention Programs Legislator Policy Brief

13 What Works Studies have consistently concluded that when properly funded and implemented, comprehensive smoking prevention and cessation programs reduce smoking among both youth and adults. Specific programs that have been proven effective are described below. The first seven of the following interventions are recommended in the CDC s "Guide to Community Preventive Services: Tobacco Use Prevention and Control", and the first three are proven to be the most effective strategies. Price Increases. Increasing the price of tobacco products has been shown to decrease tobacco use initiation and increase cessation. Young people, African-Americans and low-income adults are particularly sensitive to price increases. Mass Media. Sustained public education campaigns using advertising and mass media in combination with culturally appropriate community-based services, quit lines and other interventions have been proven effective in decreasing initiation and increasing cessation. Smoking Bans and Restrictions. As of January 2007, smokefree laws that include restaurants and bars are in force in 13 states California, Colorado, Connecticut, Delaware, Hawaii, Maine, Massachusetts, New Jersey, New York, Ohio, Rhode Island, Vermont and Washington plus the District of Columbia and Puerto Rico. Five other states Arkansas, Florida, Idaho, Louisiana and Nevada have smokefree laws that exempt stand-alone bars. 34 Studies have shown that smoking bans in workplaces lead to an average reduction in secondhand smoke exposure of 72 percent. 35 Arkansas and Louisiana also passed laws to prohibit smoking in cars with young children. Vermont and Washington have prohibited foster parents from smoking in the presence of children in the home and car. 36 Telephone-Supported Cessation. Quit lines have been shown to be effective tools for assisting smokers to quit. When paired with other interventions such as patient education, provider-delivered counseling and nicotine replacement therapy, cessation rates increase. Community Mobilization Efforts. Assessing tobacco retailer compliance with youth sales restriction laws and disseminating the findings, combined with additional interventions such as stronger local laws directed at the retail distribution of tobacco, active enforcement of retailer state laws and retailer education with reinforcement are recommended as effective in reducing tobacco use among youth. Provider Reminders and Education. Effective efforts to increase the number of patients who quit and the number who are advised to quit by their providers include: Reminders to providers to screen for tobacco use among their patients and discuss the risks and dangers of tobacco use with them; Education programs for providers on methods for helping their patients quit; and Physician-provided, culturally-appropriate patient education materials. 37 Reducing Patient Costs. Programs that reduce out-of-pocket costs for smoking cessation products are effective in increasing both the number of patients who use cessation therapies and the number of patients who successfully quit. These programs are 100 percent cost-effective considering potential savings from avoided inpatient, outpatient, laboratory, radiology and pharmacy services. Faith-Based Programs. In religious communities, church-based cessation programs have proven effective. These programs should offer one-on-one counseling, culturally appropriate self-help materials and community-wide activities, 38, 39 which seek to communicate effective cessation guidelines. More information about these interventions is available in the "Guide to Community Preventive Services": thecommunityguide.org/tobacco. Legislator Policy Brief Comprehensive Smoking Prevention Programs 9

14 References 1 Centers for Disease Control & Prevention. Annual smoking-attributable mortality, years of potential life lost, and productivity losses United States, MMWR 2005; 54(25): Accessed from March 21, CDC. Tobacco Use Among Adults United States MMWR 2006;55(42): Accessed from mm5542a1.htm March 21, CDC. Tobacco use, access, and exposure to tobacco in media among middle and high school students United States, MMWR 2005;54(12): Accessed from March 21, CDC. Youth risk behavior surveillance United States, MMWR Surveillance Summary 2006;55(SS05): Accessed from mmwr/preview/mmwrhtml/ss5505a1.htm March 21, Campaign for Tobacco Free Kids. A Broken Promise to Our Children: The 1998 State Tobacco Settlement Eight Years Later. Accessed from tobaccofreekids.org/reports/settlements/2007/fullreport.pdf March 21, CDC. State-Specific Prevalence of Current Cigarette Smoking Among Adults and Secondhand Smoke Rules and Policies in Homes and Workplaces --- United States, MMWR 2006; 55(42): Accessed from March 21, Task Force on Community Preventive Services. Increasing the Unit Price for Tobacco Products is Effective in Reducing Initiation of Tobacco Products and in Increasing Cessation. The Guide to Community Preventive Services. January Accessed from March 21, Task Force on Community Preventive Services. Effectiveness of Mass Media Campaigns to Reduce Initiation of Tobacco Use and Increase Cessation. The Guide to Community Preventive Services. January Accessed from March 21, Mowery PD, Brick PD, Farrelly MC. Legacy First Look Report 3. Pathways to established smoking: Results from the 1999 National Youth Tobacco Survey. Washington DC: American Legacy Foundation. October Accessed from March 21, CDC. Best Practices for Comprehensive Tobacco Control Programs August Accessed from stateandcommunity/best_practices/bestprac-dwnld.htm March 21, Task Force on Community Preventive Services. Effectiveness of Telephone Counseling and Support to Help More Tobacco Users Quit. The Guide to Community Preventive Services. January Accessed from March 21, Task Force on Community Preventive Services. Effectiveness of reducing out-of-pocket patient costs for effective therapies to stop using tobacco. The Guide to Community Preventive Services. January Accessed from March 21, Partnership for Prevention. Tobacco Cessation Counseling Tables Accessed from &id=82 March 21, Behan DF, Eriksen MP, Lin Y. Economic effects of environmental tobacco smoke. March 31, Society of Actuaries. Accessed from org/ccm/content/areas-of-practice/life-insurance/research/economic-effects-of-environmental-tobacco-smoke-soa March 21, California Environmental Protection Agency. Proposed Identification of Environmental Tobacco Smoke as a Toxic Air Contaminant. Part B: Health Effects Accessed from March 21, Wortley PM, Caraballo RS, Pederson LL, et al. Exposure to secondhand smoke in the workplace: serum cotinine by occupation. J Occup Environ Med 2002; 44: Dept. of Health & Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Accessed from March 21, CDC. Strategies for reducing environmental tobacco smoke, increasing tobacco-use cessation, and reducing initiation in communities and health care systems. MMWR 2000;49(RR12): Accessed from March 21, CDC. Cigarette smoking among adults United States, MMWR 2004; 54(44): Accessed from mmwrhtml/mm5444a2.htm March 21, Comprehensive Smoking Prevention Programs Legislator Policy Brief

15 20 CDC. State Programs in Action. Exemplary Work to Prevent Chronic Disease and Promote Health Accessed from publications/exemplary/pdfs/tobacco.pdf March 21, Fichtenberg CM, Glantz SA. Association of the California Tobacco Control Program with declines in cigarette consumption and mortality from heart disease. New England Journal of Medicine 2000; 343(24): Abstract accessed from March 21, Tobacco Control Section, California Department of Health Services. California tobacco control update, August Accessed from ca.gov/tobacco March 21, American Lung Association. American Lung Association challenges states to go smoke-free by January 10, Accessed from lungusa.org/site/apps/nl/content3.asp?c=dvluk9o0e&b=40408&ct= March 21, Campaign for Tobacco-Free Kids. A Broken Promise to Our Children: The 1998 State Tobacco Settlement Six Years Later. November Accessed from March 21, U.S. Department of Health and Human Services. Women and Smoking A Report of the Surgeon General Accessed from March 21, U.S. Environmental Protection Agency. Respiratory Effects of Smoking: Lung Cancer and Other Disorders Washington, DC: U.S. Environmental Protection Agency. 27 CDC. Annual smoking-attributable mortality, years of potential life lost, and economic costs United States, MMWR. 2002;51(14): Accessed from March 21, CDC. Sustaining state programs for tobacco control: Data highlights Accessed from March 21, CDC. National Center for Health Statistics. Deaths Leading Causes. Accessed from March 21, Daza P, et al. Racial and ethnic differences in predictors of smoking cessation. Substance Use & Misuse 2006;41 (3): National Cancer Institute. Division of Cancer Prevention and Control. Cancer in Minorities and Underserved. Accessed from gov/public/factbk93/sdcpc.html March 21, U.S. Department of Health and Human Services. Tobacco Use Among U.S. Racial/Ethnic Minority Groups African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report of the Surgeon General, Accessed from March 21, Campaign for Tobacco Free Kids. Community-Based Programs Reduce Tobacco Use. Accessed from pdf/0053.pdf March 21, Campaign for Tobacco-Free Kids. Smoke free laws protecting our right to clean air. Accessed from March 21, Task Force on Community Preventive Services. Effectiveness of Smoking Bans and Restrictions to Reduce Exposure to Environmental Tobacco Smoke (ETS). The Guide to Community Preventive Services. January Accessed from March 21, Emily Bazar. Laws prohibit smoking around children. USA Today (November 28, 2006) Accessed from March 21, Diefenbach, MA, et al. Targeted Smoking-Cessation Programs for Underserved Populations, Primary Care & Cancer June 2000:20(6) Accessed from March 21, Pederson L, et al., Smoking cessation among African Americans: what we know and do not know about the interventions and self quitting, Preventive Medicine, 2000 July, 31(1): Schorling J, et al., A trial of church-based smoking cessation interventions for rural African Americans, Preventive Medicine, 1997 January-February, 26(1): Legislator Policy Brief Comprehensive Smoking Prevention Programs 11

16 Resources CDC s Tobacco Information and Prevention Source CDC s Sustaining State Funding for Tobacco Control Web site CDC s Best Practices for Comprehensive Tobacco Control Programs CDC s State Tobacco Activities and Tracking Evaluation System (STATE System) CDC s Surgeon General s Reports on Smoking Healthy States Initiative s Smoking and Health Web Page Healthy States Initiative s Smoking and Health Web Conference Archive and Issue Brief Healthy States Initiative s State Official s Guide to Wellness Healthy States Initiative s TrendsAlert: Costs of Chronic Diseases: What Are States Facing? Healthy States Initiative's TrendsAlert: Using Sound Science to Prevent Chronic Disease: State Policy Implications American Cancer Society s Tobacco and Cancer Web Page American Heart Association American Legacy Foundation American Lung Association Campaign for Tobacco Free Kids 12 Comprehensive Smoking Prevention Programs Legislator Policy Brief

17 Preventing Diseases: Policies that work based on the research evidence 1) Promote healthy eating. Policies that give kids healthier food choices at school can help curb rising rates of youth obesity. Ensuring that every neighborhood has access to healthy foods will improve the nutrition of many Americans. 2) Get people moving. Policies that encourage more physical activity among kids and adults have been proven to reduce rates of obesity and to help prevent other chronic diseases. 3) Discourage smoking. Policies that support comprehensive tobacco control programs those which combine school-based, communitybased and media interventions are extremely effective at curbing smoking and reducing the incidence of cancer and heart disease. 4) Encourage prevention coverage. Policies that encourage health insurers to cover the costs of recommended preventive screenings, tests and vaccinations are proven to increase the rates of people taking preventive action. 5) Promote health screenings. Policies that promote through worksite wellness programs and media campaigns the importance of health screenings in primary care settings are proven to help reduce rates of chronic disease. 6) Protect kids smiles. Policies that promote the use of dental sealants for kids in schools and community water fluoridation are proven to dramatically reduce oral diseases. 7) Require childhood immunizations. Requiring immunizations for school and child care settings reduces illness and prevents further transmission of those diseases among children. Scientific, economic and social concerns should be addressed when policies to mandate immunizations are considered. 8) Encourage immunizations for adults. Policies that support and encourage immunizations of adults, including college students and health care workers, reduce illness, hospitalizations and deaths. 9) Make chlamydia screenings routine. Screening and treating chlamydia, the most common sexually transmitted bacterial infection, will help protect sexually active young women against infertility and other complications of pelvic inflammatory disease (PID) that are caused by chlamydia. 10) Promote routine HIV testing. Making HIV testing part of routine medical care for those aged 13 to 64 can foster earlier detection of HIV infection among the quarter of a million Americans who do not know they are infected. Learn more about these and other proven prevention strategies at and

18 The Council of State Governments' (CSG) Healthy States Initiative is designed to help state leaders make informed decisions on public health issues. The enterprise brings together state legislators, officials from the Centers for Disease Control and Prevention, state health department officials, and public health experts to share information, analyze trends, identify innovative responses, and provide expert advice on public health issues. CSG's partners in the initiative are the National Black Caucus of State Legislators and the National Hispanic Caucus of State Legislators. Funding for this publication is provided by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, under Cooperative Agreement U38/ CCU Points of view in this document are those of the author and do not necessarily represent the official position or policies of the U.S. government. Published May 2007

19 New Funding to Discourage Smoking Keeping the Promise of Tobacco Prevention Legislator Policy Brief

20 The Healthy States Initiative A partnership to promote public health The Healthy States Initiative helps state leaders access the information they need to make informed decisions on public health issues. The initiative brings together state legislators, Centers for Disease Control and Prevention (CDC) officials, state health department officials and public health experts to share information and to identify innovative solutions. The Council of State Governments partners in the initiative are the National Black Caucus of State Legislators (NBCSL) and the National Hispanic Caucus of State Legislators (NHCSL). These organizations enhance information sharing with state legislators and policymakers on critical public health issues. Funding for this publication is provided by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, under Cooperative Agreement U38/CCU Points of view in this document are those of the author and do not necessarily represent the official position or policies of the U.S. government. Why Public Health? State legislators play a vital role in determining the structure and resources available to state and local agencies dedicated to protecting the public s health. Public health agencies educate the public and offer interventions across a wide spectrum of public health issues including: Ensuring that children and at risk adults are immunized against deadly diseases; Assisting victims of chronic conditions such as cancer, heart disease and asthma; Preventing disease and disability resulting from interactions between people and the environment; Researching how HIV/AIDS infections and other sexually transmitted diseases can be prevented; Promoting the health and well being of people with disabilities; and Working with schools to prevent risky behavior among children, adolescents and young adults. Information Resources For State Policymakers New information resources produced under this initiative include: Healthy States Web site. This unique Web site offers information and resources on many public health issues. Visit to get information, sign up for publications and view other information on the initiative. Health Policy Highlights and Healthy States e weekly. Each week, this free weekly electronic newsletter brings the latest public health news, resources, reports and upcoming events straight to your inbox. Healthy States Quarterly. CSG publishes a free quarterly newsletter covering public health legislative and policy trends, innovative best practices from the executive and legislative branches, current research and information on Healthy States activities. Forums and Web Conferences. Web conferences are offered to allow public health experts, legislators and legislative staff to interact on priority public health issues. Forums include educational sessions on public health issues, new legislator training and roundtable discussions with peers and public health experts. Healthy States Publications. New resources will assist state legislators interested in public health topics, including obesity and chronic disease prevention, HIV/AIDS and sexually transmitted disease prevention, vaccines, health disparities and school health. For More Information If you are interested in the learning opportunities available through the Healthy States Initiative, visit or Legislator Policy Brief

21 New Funding to Discourage Smoking Overview Cigarette smoking is responsible for an estimated 438,000 deaths per year in the United States, or about one in five deaths overall. 1 An additional 8.6 million Americans suffer from smoking-caused illnesses 2 that result in $167 billion in health care bills and lost productivity each year. 1 When adequately funded, statewide tobacco prevention programs have successfully reduced smoking levels among adults and children, 3 however, no change was observed in recent years in youth smoking rates or adult cigarette smoking rates. 4 Cigarette sales dropped more than twice as much in states that invested heavily in tobacco control programs than in the U.S. as a whole. 5 Moreover, recent research shows that the more states spend on comprehensive tobacco control programs, the greater the reductions in smoking and the longer states invest in such programs, the greater and faster the impact. 6 This issue brief provides state policymakers with information about two potential sources of funding for statewide tobacco control programs. What Legislators Need to Know About Tobacco Prevention Studies show that states could save $23.4 billion in long-term, smoking-related health care costs by spending the minimum amount recommended by the Centers for Disease Control and Prevention (CDC) on tobacco prevention programs. 7 Yet, the vast majority of states fall far short of funding such programs at even these minimum levels. States spend less than 3 percent of the $21.7 billion available to them from tobacco excise taxes and tobacco industry legal settlements on tobacco prevention and control. 8 States only need to spend 7.3 percent of the amount available, or $1.6 billion on tobacco prevention to meet CDC-recommended minimum levels. 8 For each dollar the states currently spend on tobacco prevention, the tobacco companies spend $22 to market their products. 9 Recent declines in funding for smoking prevention and increases in tobacco marketing appear to have contributed to a 10, 11 stall in the progress previously seen in reducing smoking rates among both youth and adults. New Funding: Tobacco Settlement Dollars In April 2008, payments to the states from the 1998 tobacco settlement are scheduled to increase substantially, from $6.1 billion in FY 2007 to $7 billion in FY The states will continue to receive these bonus payments totaling more than $900 million each year thereafter through States could use these additional funds to support tobacco prevention efforts and help to further reduce smoking rates in young people and adults. The additional $900 million, combined with what states already spend for tobacco prevention and control, could bring spending up to CDC recommended minimums. 8 New Funding: Taxes on Tobacco Products States are bringing in millions of dollars a year by raising cigarette taxes and are leveraging longterm health savings of millions more by spending that money on tobacco programs. 12 Every state that has significantly increased its cigarette tax has increased revenue, even while reducing smoking. 13 In addition, every 10 percent increase in the price of cigarettes will reduce youth smoking by about 7 percent and overall cigarette consumption by about 4 percent. 13 New Funding to Discourage Smoking

22 New Funding to Discourage Smoking Background Tobacco Settlement The Master Settlement Agreement (MSA) was negotiated in November 1998 by the four largest tobacco companies with 46 states and six U.S. territories and ended the largest civil suit in U.S. history. 14 Under the MSA, the states and territories were projected to receive $246 billion over 25 years from the cigarette companies. 8 As of July 2006, more than $62 billion had been paid. 15 The four states not participating in the MSA Minnesota, Florida, Texas and Mississippi had previously settled out of court with the cigarette companies and received more than $39 billion. 13 At the time of the MSA, many state officials promised to use a significant portion of the settlement funds for tobacco prevention programs. 16 But competing priorities and tight budgets have prompted some states to use the funds for other purposes. 17 Some tobacco companies required to make annual payments to the states withheld a portion of their April 2006 payments ($813 million of the $5.8 billion expected to go to the states) and may withhold future payments. They claim they were entitled to a downward adjustment because they lost market share in Many MSA states have started legal proceedings to access the withheld funds. 18 What Do State Legislators Need to Know? Many states will be able to allocate new funding for prevention in April 2008 when tobacco settlement payments are scheduled to increase substantially, from $6.1 billion to $7 billion. 19 However, 20 of the 46 states that were a part of the MSA sold at least a portion of their future tobacco settlement payments to investors. Bonus payments to these states will be reduced based on the percentage of their future funds they divested. 20 (See: Table of Smoking Costs and Tobacco Funding by State) By investing in proven efforts to prevent and reduce future tobacco use, states can minimize the ongoing smoking-related health care costs. 21 When adequately funded, comprehensive state tobacco prevention programs quickly and substantially reduce tobacco use, save lives and cut costs related to smoking. 8 The more states spend on comprehensive prevention programs, the greater the reductions in smoking; and the longer states invest, the greater and faster the impact. 8 Cigarette Taxes Since 2002, 43 states, the District of Columbia, Puerto Rico, Guam and the Northern Mariana Islands have all increased cigarette taxes. Twelve of them have passed multiple tax increases. 22 Although a few states now have cigarette tax rates of $2 or more, 8 the average is only slightly more than $1 per pack. 8 In November 2006, South Dakota increased its tax by $1 per pack, 23 and Iowa s legislature did the same in March What Do State Legislators Need to Know? Every state that has significantly increased its cigarette tax has both raised new revenues and reduced smoking levels. 24 Lower income smokers and young smokers are most likely to quit after cigarette taxes are raised. 25 Every pack of cigarettes sold in the United States costs the nation $7.18 in medical costs and lost productivity. 26 Legislator Policy Brief

23 New Funding to Discourage Smoking Actions for State Legislators Educate Yourself on Tobacco Use and Prevention Consult state public health officials and local health departments, and learn about these facts in your state: Costs of tobacco use and the potential of tobacco prevention and cessation programs; CDC-recommended funding level and current spending for these programs; Amount of new tobacco settlement dollars your state will receive in 2008; Current cigarette tax level, how it compares nationally and the benefits an increase could bring; and Impact of cigarette taxes on smoking behavior and state revenues. (See pages 8 9 for state level data) Support Increased Tobacco Program Funding Work with your state s governor and fellow legislators to encourage the use of settlement funds for comprehensive tobacco prevention and cessation programs. Work with your state s leaders to pass increased taxes on cigarettes and other tobacco products, and direct tax revenues to tobacco prevention. Ensure revenue intended or budgeted for tobacco prevention is used for that purpose. Help educate fellow legislators and other state officials about the value of tobacco prevention programs and their potential impact on your state s bottom line specifically reducing tobaccorelated health costs and productivity losses. Work to ban billboard and transit advertising of tobacco products and tobacco brand name sponsorship of athletic, musical, cultural, artistic or social events targeting high risk groups. Support efforts to make cessation treatment available and affordable. Enable state Medicaid programs to cover all U.S. Public Health Service-recommended treatments, cover two courses of treatment per year, eliminate co-payments and promote these benefits to Medicaid recipients. Assure that significant tobacco control funding is targeted to reach your state s high-risk groups. Funding can be used for: Prevention efforts aimed at reversing the stall in the decline of youth and adult smoking rates; Enforcement of laws to prohibit the promotion and sale of tobacco products to minors (particularly in disadvantaged communities); Culturally-specific advertising campaigns to counter tobacco marketing; and Development of a surveillance and evaluation task force to identify problems and observe the progress of programs in targeted communities. Build Community and Media Support for Tobacco Prevention Build broad coalitions to support tobacco control with professional groups, doctors, patients affected by tobacco-related diseases, and health organizations including the American Lung Association, the American Heart Association and the American Cancer Society. Work with community tobacco-control advocates to educate the public on the benefits of cigarette tax increases. Help to publicly promote prevention as a specific use for tax proceeds. Use local community activism techniques to ensure MSA dollars are spent in minority communities. New Funding to Discourage Smoking

24 New Funding to Discourage Smoking State Policy Examples Colorado Ballot Initiative Colorado voters approved a November 2004 ballot initiative that increased the state cigarette tax by 64 cents a pack, with $27 million dedicated to tobacco prevention for The state ranks third in its funding of tobacco prevention and is one of only three states (Delaware and Maine are the others) to meet the CDC-recommended minimum level for FY To date, the excise taxes have been used to fund a new high-risk youth initiative, a youth tobacco prevention media campaign, capacity building for disproportionately affected populations and an expansion of the state s quit line. Since 2004, adult tobacco smoking in Colorado has dropped from 20.1 percent 28 to 17.9 percent. 11 Delaware s Trust Fund Delaware has met the recommended CDC minimum for its tobacco program for the fourth year in a row. Under a 1999 state law, all of Delaware s tobacco settlement payments are placed in the Delaware Health Fund. The legislature must allocate the money through the annual budget process. The FY 2007 budget appropriated $10.3 million to tobacco prevention and cessation. 8 Maine s Partnership Maine is now spending the highest percentage over the CDC-recommended minimum of any state for FY 2007 on tobacco control. Its comprehensive tobacco prevention program is known as the Partnership for a Tobacco-Free Maine. The program originally was funded through a cigarette tax increase in 1997, but is now funded with proceeds from the tobacco settlement. A $500,000 budget increase this year will restore funding to the Tobacco Help Line and support health care provider training and new grants to address disparities. Since 1997, youth smoking in Maine has decreased by 60 percent, saving at least an estimated $416 million in long-term health care costs. 8 Nebraska s Program Restoration Nebraska decreased annual funding for tobacco control to a low of $405,000 in 2003 due to its budget situation. Members of a coalition educated the public and legislators about the costs and health consequences of tobacco use to Nebraska residents. They shared personal stories of smokers and their families and those who had benefited from tobacco control programs. Through personal meetings and mail and telephone campaigns, coalition members expressed concern that years of tobacco control progress could be lost if the low level of funding continued. In 2004, the state legislature increased funding for the comprehensive tobacco control program, Tobacco Free Nebraska, to $2.5 million by using tobacco settlement money. 29 Legislator Policy Brief

25 New Funding to Discourage Smoking Advice from State Legislators Keeping the Commitment and Promoting the Results Patricia Blevins Delaware Senate Sen. Blevins is a member of the Health and Social Services and the Children, Youth and Families committees. She also serves on the Delaware Health Fund Advisory Committee, which oversees the MSA dollars that come into the state. Her Advice to State Legislators: Pass a law to commit the funding: I think the key to success in being able to get substantial funding for tobacco cessation was when we initially got the settlement money, we enacted a law that required that 100 percent of that funding be used for health purposes. If that hadn t been the case, the money would have been siphoned off for other needs because there are just so many needs. Build support by demonstrating results: I think one of the most important things [policymakers] can do is look at the experience of states that have funded these programs at high levels because the results are tangible. You can actually see the reduction in smoking, the reduction in the number of young people who begin smoking and that pays off big dividends in the long run. Seeking Help from Advocates and Engaging the Provider Community Hannah Pingree Maine House of Representatives Rep. Pingree is the majority leader in the Maine House of Representatives and previously chaired the Health and Human Services Committee. Her Advice to State Legislators: Seek out partners: We ve actually been very lucky to have an incredibly active health community of tobacco partnership groups, of community groups, of hospitals, of health professionals, who in my opinion have created a real level of understanding and urgency around using the tobacco settlement funds for tobacco prevention. I think Maine started off with a very good plan in terms of how to use the tobacco settlement funds and then that plan has been very closely guarded by a big community of advocates. And I think the legislature has had respect for that and obviously it s taken some of us to make sure we stick with where our original goals were. I think it s really important to engage the provider community on these issues. I would give some credit to legislators who have been good on these issues. But I think in Maine we ve been blessed with advocates and those people who have implemented these prevention programs... It s hard to tell other legislators get some great advocates who will hold your feet to the fire, but in a state like Maine, I honestly would give them the majority of the credit for keeping these programs intact and making them so successful. New Funding to Discourage Smoking

26 New Funding to Discourage Smoking Smoking Costs & Tobacco Funding by State FY 2007 CDC- Annual recommended minimum FY 2007 actual FY 2008 projected Cigarette FY 2005 smoking-related funding levels for tobacco program new MSA tax rate total cigarette State/ health costs tobacco programs spending funds available per pack tax revenue territory (millions) (millions) (millions) (millions) (as of July 2007) (millions) Alabama... $1,380 $ 26.7 $ 0.68 $ 8.30 * $0.43 $ Alaska * Arizona... 1, Arkansas * California... 8, * ,024.1 Colorado... 1, * Connecticut... 1, * Delaware District of Columbia * Florida... 5, Not MSA Georgia... 2, * Hawaii Idaho Illinois... 3, Indiana... 1, Iowa * Kansas Kentucky... 1, Louisiana... 1, * Maine Maryland... 1, * Massachusetts... 3, Michigan... 3, ,090.0 Minnesota... 1, Not MSA Mississippi Not MSA Missouri... 1, * Montana Nebraska Nevada New Hampshire New Jersey... 2, * New Mexico New York... 7, * North Carolina... 2, * North Dakota Ohio... 4, Oklahoma... 1, Oregon... 1, * Pennsylvania... 4, ,029.0 Rhode Island * South Carolina... 1, * South Dakota * Tennessee... 1, Texas... 5, Not MSA Utah Legislator Policy Brief

27 FY 2007 CDC- Annual recommended minimum FY 2007 actual FY 2008 projected Cigarette FY 2005 smoking-related funding levels for tobacco program new MSA tax rate total cigarette State/ health costs tobacco programs spending funds available per pack tax revenue territory (millions) (millions) (millions) (millions) (as of July 2007) (millions) Vermont... $ 215 $ 7.9 $ 5.10 $15.40 $1.79 $ 46.1 Virginia... 1, * Washington... 1, * West Virginia Wisconsin... 1, * Wyoming Am. Samoa... N/A N/A N/A 0.02 N/A N/A Guam... N/A N/A N/A N/A No. Mariana Islands... N/A N/A N/A N/A Puerto Rico... N/A N/A N/A N/A U.S. Virgin Islands... N/A N/A N/A 0.02 N/A N/A * States with an asterisk have sold at least a portion of their current and/or future tobacco settlement payments to investors. As a result, the projected new funds may not be fully available to these states, based on the portion of their future payments they have divested. Not MSA These states did not participate in the MSA, having previously settled out of court with the cigarette companies for more than $39 billion. Source: Campaign for Tobacco Free Kids Table created July 2007 Want to Know More? We ll help you find experts to talk to about this topic. If you would like to explore this topic in greater depth, contact us at the Healthy States Initiative and we ll help you connect with: an expert on this issue from the CDC fellow state legislators who have worked on this issue other public health champions or officials who are respected authorities on this issue To send an inquiry, visit Comments+and+Inquiries (keyword: question/comments) or call the health policy group at (859) and let us help you find the advice and resources you need. New Funding to Discourage Smoking

28 New Funding to Discourage Smoking Key Facts Tobacco Prevention Funding Is Down Since 2002 The states allocated $595.4 million for FY 2007, an 8 percent increase from the $551 million allocated in FY 2006, but still substantially less than the peak funding level of $749 million in FY The CDC recommends states spend a minimum of $1.6 billion on tobacco prevention. 8 Funding guidelines on program components are based on published evidence-based practices and the experience of states with effective large-scale and sustained efforts in tobacco control. State Funding for Tobacco Prevention in FY 2007 Source: Campaign for Tobacco Free Kids VT NH CT NJ DE MD MA RI Committed 100 percent of the CDC s minimum funding Committed more than 50 percent of CDC minimum funding Committed percent of CDC minimum funding Committed less than 25 percent of CDC minimum Committed no tobacco settlement or tax revenue for tobacco prevention programs Tobacco Marketing Is Up Since 1998 Tobacco companies marketing spending nearly doubled from 1998 ($6.7 billion) to 2005 ($13.11 billion). 30 In 2004 and 2005, they spent the majority ($10.9 billion and $9.78 billion respectively) on price discounts paid to retailers or wholesalers to reduce the price of cigarettes to consumers, 30 just as numerous states were implementing tobacco tax increases. Legislator Policy Brief

29 Progress in Reducing Youth and Adult Smoking Rates Has Stalled From a high of 36 percent in 1997, youth smoking rates declined significantly to less than 22 percent in Since then, this decline has stalled and may even be increasing. 10 For adults, there was no observed change between 2004 and 2005, after years of progress in reducing rates. 11 States Can See Significant Health Benefits from Increased Funding for Tobacco Prevention The states with the best funded and most sustained tobacco prevention programs during the 1990s Arizona, California, Massachusetts and Oregon reduced cigarette sales more than twice as much as the country as a whole. 6 With funding at CDC-recommended minimum levels, states could prevent nearly 2 million youth from becoming smokers and save more than 600,000 of them from premature, smokingcaused deaths. 7 States Can See Significant Health Cost Reductions from Increased Tobacco Prevention Reducing smoking among pregnant women (including pregnant teens) produces immediate reductions in pregnancy and birth complications and related health care costs. The additional costs linked to each smoking-affected birth averages $1,142 to $1, Massachusetts comprehensive tobacco prevention program, begun in 1993, quickly began paying for itself just through declines in smoking among pregnant women. 32 The lifetime health care costs of smokers total at least $16,000 more than the costs of nonsmokers, on average. 33 So for every 1,000 youth averted from smoking, future health care costs would decline by roughly $16 million, and for every 1,000 adults prompted to quit, future health costs drop by roughly $8.5 million. 31 A 1 percent decline in adult smoking (30,000 adults quitting) translates into lifetime savings of more than $250 million. And maintaining a single 1 percent reduction in youth smoking would keep 16,000 youth alive today from becoming smokers, producing lifetime health savings of an additional quarter of a billion dollars. 8 The Partnership for Prevention ranks tobacco use screening and intervention as one of the three most effective, cost-saving clinical preventive services. 38 The Tobacco Settlement Isn t Reversing the Impact of Tobacco on Minority Populations The bulk of MSA funding in each of the 46 states has not targeted minority communities. 35 Minorities have been specifically targeted by the tobacco industry with multi-million dollar advertising campaigns to influence smoking. 36 New Funding to Discourage Smoking

30 New Funding to Discourage Smoking Resources & References Resources Centers for Disease Control & Prevention (CDC) Best Practices for Comprehensive Tobacco Control Programs State Tobacco Activities & Tracking Evaluation system (STATE) Surgeon General s Reports on Smoking Sustaining State Funding for Tobacco Control Tobacco Information & Prevention Source Healthy States Initiative Legislator Policy Brief: Comprehensive Smoking Prevention Programs State Official s Guide to Wellness Trends Alert: Costs of Chronic Disease: What Are States Facing? Trends Alert: Using Sound Science to Prevent Chronic Disease: State Policy Implications Smoking & Health Web Conference Archive and Issue Brief Agency for Healthcare Research and Quality American Cancer Society American Heart Association American Lung Association Americans for Nonsmokers Rights Campaign for Tobacco Free Kids References 1 Centers for Disease Control & Prevention. Annual smoking-attributable mortality, years of potential life lost, and productivity losses United States, Morbidity and Mortality Weekly Report 2005: 54: Accessed from: July 2, CDC Chronic Disease Prevention Targeting Tobacco Use: The Nation s Leading Cause of Death. Accessed from: July 2, Institute of Medicine & National Research Council. State Programs Can Reduce Tobacco Use. National Academy of Sciences, CDC. Cigarette Use Among High School Students United States, MMWR 2006; 55(26). Accessed from: July 2, CDC. Tobacco Use Among Adults United States, MMWR 2006; 55 (42): Accessed from: July 2, Farrelly, MC, et al., The Impact of Tobacco Control Program Expenditures on Aggregate Cigarette Sales: Journal of Health Economics : Tauras, JA, et al., State Tobacco Control Spending and Youth Smoking, American Journal of Public Health, February, Campaign for Tobacco Free Kids. A Broken Promise to Our Children: The 1998 State Tobacco Settlement Eight Years Later. Accessed from: July 2, Legislator Policy Brief

31 9 Campaign for Tobacco Free Kids. FTC Reports Show Massive Spending on Tobacco Marketing, Underscoring Need for FDA Authority Over Tobacco and Further State Action. Accessed from: PressRelease.php3?Display=987 July 2, CDC. Youth Risk Behavior Surveillance United States, MMWR 2006; 55(5): 11 Accessed from: cdc.gov/mmwr/pdf/ss/ss5505.pdf July 2, CDC. State-Specific Prevalence of Current Cigarette Smoking Among Adults and Secondhand Smoke Rules and Policies in Homes and Workplaces --- United States, MMWR 2006; 55(42): Accessed from: gov/mmwr/preview/mmwrhtml/mm5542a2.htm July 2, American Lung Association. State of Tobacco Control: 2003 Key Findings Cigarette Taxes. Accessed from: lungaction.org/reports/key303.html July 2, Campaign for Tobacco Free Kids. Higher Cigarette Taxes Reduce Smoking, Save Lives, Save Money. Accessed from: July 2, Master Settlement Agreement. Accessed from: _cigmsa.pdf July 2, Campaign for Tobacco Free Kids. Actual Payments Received by the States From the Tobacco Settlements. Accessed from: July 2, Campaign for Tobacco Free Kids. Using Tobacco Settlement Funds for Tobacco: Supportive Quotes from High-Ranking State Officials. Accessed from: July 2, Vicki Eckenrode. Many uses of tobacco money: States Overall Spending on Smoking Prevention Far Short of CDC Advice. Florida Times-Union. ( July 3, 2005). Accessed from: shtml July 2, Pamela Prah. Tobacco Money Hard Habit for States to Kick. Stateline.org (February 8, 2007). Accessed from: July 2, Campaign for Tobacco Free Kids. Coming Increases to State MSA Payments in April 2008 New Funding for Tobacco Prevention. Accessed from: July 2, Campaign for Tobacco Free Kids. Show Us the Money: A Mid-Year Update on the States Allocation of the Tobacco Settlement Dollars. July 22, 2002 Accessed from: pdf#search= 12%20states%20that%20took%20lump%20sum%20payments%20in%20tobacco%20settlement, July 2, Campaign for Tobacco Free Kids. The MSA Calls for the States to Invest Tobacco Settlement Funds to Prevent & Reduce Tobacco Use. Accessed from: July 2, Campaign for Tobacco Free Kids. Trends in Average State Cigarette Tax Rates. Accessed from: July 2, Campaign for Tobacco Free Kids. Voters Across America Rebuff Big Tobacco, Approve Ballot Measures To Reduce Smoking, Save Lives. Accessed from: July 2, Campaign for Tobacco Free Kids. Raising State Cigarette Taxes Always Increases State Revenues (and Always Reduces Smoking. Accessed from: July 2, CDC. Reducing Tobacco Use: A Report of the Surgeon General Accessed from: sgr/sgr_2000/index.htm. July 2, CDC. Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Economic Costs United States, MMWR 2002; 51(14): Accessed from: July 2, CDC. Sustaining State Funding for Tobacco Control: A Story from Colorado. Accessed from: July 2, CDC. State-specific prevalence of cigarette smoking and quitting among adults United States, MMWR 2005: 54(44): Accessed from: July 2, CDC. Sustaining State Funding for Tobacco Control: Snapshot From Nebraska. Accessed from: tobacco/tobacco_control_programs/stateandcommunity/sustainingstates/nebraska.htm July 2, Federal Trade Commission. Cigarette Report for 2004 and Accessed from: cigarette pdf July 2, Campaign for Tobacco Free Kids. Comprehensive Statewide Tobacco Prevention Programs Save Money. Accessed from: July 2, Connolly, W., Director, Massachusetts Tobacco Control Program, Joint Hearing of the Pennsylvania House of Representatives Committee on Health and Human Services and the Pennsylvania Senate Committee on Public Health and Welfare, June 12, Hodgson, T.A., Cigarette Smoking and Lifetime Medical Expenditures, The Millbank Quarterly 70(1), 1992 See, also, Nusselder, W., et al., Smoking and the Compression of Morbidity, Epidemiology and Community Health, 2000; Warner, K.E., et al., Medical Costs of Smoking in the United States: Estimates, Their Validity, and Their Implications, Tobacco Control 8(3): , Autumn Maciosek, MV, et al., Priorities Among Effective Clinical Preventive Services. American Journal of Preventive Medicine 2006; 31(1): Accessed from: July 2, Reed, William. Tobacco Settlement Monies Went Up in Smoke for Blacks. The Black World Today. June 26, American Heart Association. Tobacco Industry s Targeting of Youth, Minorities, and Women. Accessed from: July 2, 2007 New Funding to Discourage Smoking

32 Preventing Diseases: What Works Policies That Work Based on the Research Evidence 1. Promote healthy eating. Policies that give kids healthier food choices at school can help curb rising rates of youth obesity. Ensuring that every neighborhood has access to healthy foods will improve many Americans nutrition. 2. Get people moving. Policies that encourage more physical activity among kids and adults have reduced rates of obesity and helped prevent other chronic diseases. 3. Help smokers quit and youth never start smoking. Policies that support comprehensive tobacco control programs those which combine schoolbased, community-based and media interventions effectively curb smoking and reduce the incidence of cancer and heart disease. 4. Encourage prevention coverage. Policies that encourage health insurers to cover the costs of recommended preventive screenings, tests and vaccinations are proven to increase the rates of people taking preventive action. 5. Promote health screenings. Policies that promote through worksite wellness programs and media campaigns the importance of health screenings in primary care settings are proven to help reduce rates of chronic disease. 6. Protect kids smiles. Policies that promote the use of dental sealants for kids in schools and community water fluoridation are proven to dramatically reduce oral diseases. 7. Require childhood immunizations. Requiring immunizations for school and child care settings reduces illness and prevents further transmission of those diseases among children. Scientific, economic and social concerns should be addressed when policies to mandate immunizations are considered. 8. Encourage immunizations for adults. Policies that support and encourage immunizations of adults, including college students and health care workers, reduce illness, hospitalizations and deaths. 9. Make chlamydia screenings routine. Screening and treating chlamydia, the most common sexually transmitted bacterial infection, will help protect sexually active young women against infertility and other complications of pelvic inflammatory disease (PID) that are caused by chlamydia. 10. Promote routine HIV testing. Making HIV testing part of routine medical care for those aged 13 to 64 can foster earlier detection of HIV infection among the quarter of a million Americans who do not know they are infected. Learn more about these and other proven prevention strategies at and 12 Legislator Policy Brief

33 The Centers for Disease Control and Prevention (CDC) is part of the United States Department of Health and Human Services, which is the main federal agency for protecting the health and safety of all Americans. Since it was founded in 1946 to help control malaria, CDC has remained at the forefront of public health efforts to prevent and control infectious and chronic diseases, injuries, workplace hazards, disabilities and environmental health threats. Helping state governments enhance their own public health efforts is a key part of CDC s mission. Every year, CDC provides millions in grants to state and local health departments. Some funds are in the form of categorical grants directed at specific statutorily determined health concerns or activities. Other funds are distributed as general purpose block grants, which the CDC has more flexibility in deciding how to direct and distribute. The CDC does not regulate public health in the states. Rather, it provides states with scientific advice in fields ranging from disease prevention to emergency management. It also monitors state and local health experiences in solving public health problems, studies what works, provides scientific assistance with investigations and reports the best practices back to public agencies and health care practitioners. For state legislators who are interested in improving their state s public health, the CDC offers a wealth of resources, including: Recommendations for proven prevention strategies; Examples of effective state programs; Access to top public health experts at the CDC; Meetings specifically aimed at state legislative audiences; Fact sheets on policies that prevent diseases; and State specific statistics on the incidence and costs of disease. This publication from the Healthy States Initiative is also an example of CDC s efforts to help states. The Healthy States Initiative is funded by a cooperative agreement with the CDC. The CDC has developed partnerships with numerous public and private entities among them medical professionals, schools, nonprofit organizations, business groups and international health organizations but its cooperative work with state and local health departments and the legislative and executive branches of state government remains central to its mission. What the CDC Does for States

34 The Council of State Governments (CSG) Healthy States Initiative is designed to help state leaders make informed decisions on public health issues. The enterprise brings together state legislators, officials from the Centers for Disease Control and Prevention, state health department officials, and public health experts to share information, analyze trends, identify innovative responses, and provide expert advice on public health issues. CSG's partners in the initiative are the National Black Caucus of State Legislators and the National Hispanic Caucus of State Legislators. Funding for this publication is provided by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, under Cooperative Agreement U38/CCU Points of view in this document are those of the author and do not necessarily represent the official position or policies of the U.S. government. Published August 2007

35 healthy states brief C S G s p a r t n e r s h i p t o p r o m o t e p u b l i c h e a l t h Vol. 1, No. 5 December 2005 No Ifs, Ands or Butts: Proven Anti-Smoking Strategies for States While cigarette smoking among adults in the United States continues to decline, public health experts warn state legislators that it is too early to declare victory. Some states have used proven prevention strategies to dramatically cut the number of smokers and the burdens of smoking-related chronic diseases. However, stalling rates of youth smoking reduction and the fact that tobacco use remains the leading preventable cause of death show the fight is not over. Smoking Remains a Major Health Threat With high profile events such as the state settlements with the tobacco industry and the many other anti-smoking successes we ve achieved so far some people may conclude that the tobacco problem is solved, but actually our work is far from done, says Dr. Corinne Husten, acting director of the Office on Smoking and Health at the Centers for Disease Control and Prevention (CDC). To show how much work remains to be done, Husten outlines the human and financial toll that tobacco use continues to exact: More than 45 million Americans still smoke. 1 Every year approximately 440,000 Americans die of a smoking-related illness making smoking the leading preventable cause of death. 2 Declines in youth smoking rates have slowed between 2002 and Smoking costs the U.S. economy more than $167 billion a year, including more than $75 billion in medical expenditures and $92 billion in lost productivity. 4 The effects of secondhand smoke exposure cost the economy an estimated $10 billion a year. 5 African-Americans have a higher rate of exposure to secondhand smoke than whites and Hispanics. 6 healthy states brief: smoking and health This issue brief is based on a September 8, 2005 Healthy States Web conference entitled No Ifs, Ands or Butts: Proven Anti-Smoking Strategies for States. To access an archive of this Web conference and other Web conferences in this Healthy States series, visit keyword: web conferences. Why States Must Maintain Anti-Smoking Efforts According to Husten, states should continue to fight smoking not just because it remains a major public health burden, but also because states have developed measurably effective anti-smoking strategies. We have strong evidence that [state] comprehensive tobacco control programs are effective and can dramatically improve health outcomes, she says. For example, Husten says a study recently found that California s program resulted in an estimated 33,000 fewer deaths from heart disease during a 10-year period 7 and in just 8 years saved an estimated $8 billion in health care and lost productivity costs attributable to smoking. 8 After Arizona implemented a comprehensive tobacco control program in 1995, the number of smokers dropped from 23 percent in 1996 to 18 percent in In four states that dedicated significant funding to tobacco control efforts, cigarette sales fell an average of 43 percent between 1990 and 2000 compared with an average of 20 percent for all other states. The four states were Arizona, California, Massachusetts and Oregon. 10 Research shows us that the more states spend on comprehensive tobacco control programs, the greater the reductions in smoking, Husten says. Cigarette sales dropped more than twice as fast in states with comprehensive programs compared to the rest of the country. 11 Another study shows that the more states spend on comprehensive tobacco control programs, the lower the youth smoking rates are and the longer states invest in programs, the greater and faster the impact. 12 The Council of State Governments (CSG) is the premier multibranch organization forecasting policy trends for the community of states, commonwealths and territories on a national and regional basis.

36 Research shows us that the more states spend on comprehensive tobacco control programs, the greater the reductions in smoking. Comprehensive Tobacco Control What does a state comprehensive tobacco control program look like? According to Husten, a CDC-recommended model program includes this combination of policies and interventions: 13 Using excise taxes to increase the price of tobacco products; Sustained media campaigns to discourage smoking; Mobilizing key community and neighborhood organizations and resources to combat smoking; Telephone support quit-lines to connect smokers with resources and counseling to help them quit smoking; Insurance coverage or reduced costs for smoking cessation counseling and drugs; Routine screening and treatment of tobacco use by health care providers; and Smoking bans in public places and work environments A Closer Look: New York s Efforts New York, which has seen its per capita cigarette consumption decline faster than the national average, 14 is an example of a state that has successfully implemented Dr. Corinne Husten, CDC many elements of a comprehensive tobacco control program. According to Dr. Ursula Bauer, director of the state s tobacco control program, New York s comprehensive anti-smoking efforts are built around five major strategies that incorporate most of CDC s recommended policies and interventions. Bauer has identified five key strategies: Funding scores of community-based organizations to help them fight tobacco use at local level and fight tobacco promotion in neighborhood stores, billboards, schools and businesses; Keeping the price of tobacco products high with a $1.50 excise tax per cigarette pack and a 37 percent tax on other tobacco products, and restricting the places where tobacco products can be sold; Minimizing nonsmokers exposure to second-hand smoke through smoking bans in indoor public spaces and workplaces; Running an aggressive, emotionally powerful media campaign to motivate smokers to quit and prevent others from ever starting; and Helping to make it easier for smokers to quit through staffing telephone quitlines, offering counseling and follow-up services, cutting costs for nicotine replacement products and encouraging health care providers to screen for tobacco use. Bauer notes that the first four strategies not only reduce the amount of smoking among adults, but also are effective in preventing children from starting to smoke. Additionally, Bauer says that the law that created New York s comprehensive tobacco program contained a rigorous evaluation requirement. Thanks to the evaluation component, we re accumulating evidence about the effectiveness of our own tobacco control efforts even as researchers across the country and around the world continue to add toward the overwhelming evidence that investment in tobacco control saves lives and money. Community, Legislative Support are Key Bauer says that having the right policies in place is only part of the story of the state s success, however. We know that the public here supports tobacco control, Bauer says. Nearly 80 percent of New Yorkers favor our clean indoor air law, including almost half of smokers and that community-level support, she says, is crucial. Deep and widespread legislative support is another essential element to a successful tobacco control program. Reducing the death and disease caused by smoking is What Works In Tobacco Control? Key Publications About Effective Policies The CDC publishes two useful resources for state legislators seeking to advance evidence-based anti-smoking policy in their states. Best Practices for Comprehensive Tobacco Control Programs is a guidebook to help states plan and establish effective tobacco control programs to prevent and reduce tobacco use. The book identifies and describes the key elements for effective state tobacco control programs, including programs designed for communities, schools and the entire state. The book addresses cessation programs, counter-marketing, enforcement, surveillance and evaluation, and chronic disease programs to reduce the burden of tobacco-related diseases. Program funding models for all 50 states are included. To download a free copy of the guidebook, visit CDC s Guide to Community Preventive Services (commonly known as the Community Guide ), provides policymakers with recommendations about population-based interventions to promote health and to prevent disease, injury, disability, and premature death, appropriate for use by local communities and health care systems. The recommendations come from an independent task force of national experts, which makes its recommendations based on systematic reviews. More information about the Community Guide, the tobacco recommendations and the links to other resources, is available at 2 December 2005 Healthy States Brief: Smoking and Health

37 Key Elements of Effective Comprehensive Tobacco Control Programs Using excise taxes to increase cost of tobacco products Anti-smoking media campaigns Mobilizing neighborhood organizations to combat smoking Phone quit-lines to connect smokers with resources and counseling Insurance coverage for smoking cessation counseling and drugs Routine screening and treatment of tobacco use by health care providers Smoking bans in public places and work environments Source: CDC s Guide to Community Preventive Services certainly not a Democratic or Republican issue it s a core public health issue and [in New York] our coalition is built on that understanding, and that s why we have support for tobacco control across party lines here, says long-time New York Assemblymember Pete Grannis, an author of the state s clean indoor air and cigarette fire safety acts. Funding and Other Challenges Even though the comprehensive tobacco control programs of New York and other states such as California, Massachusetts and Arizona have resulted in proven declines in smoking rates, state level anti-smoking efforts still face daunting challenges. One of the most severe challenges is the stability of funding for tobacco prevention and control. During the last fiscal year, states got $19 billion from tobacco excise taxes and tobacco settlement payments, but spent less than 3 percent of those funds on antismoking efforts. 15 Between the difficult fiscal years of 2002 and 2005, state commitment of settlement funds to prevention and control efforts fell by 28 percent. 16 As state spending on tobacco control programs declined, advertising by the tobacco industry increased. Between 1997 and 2003, the industry increased its promotional spending from nearly $6 billion to over $15 billion a year. 17 The cuts in state anti-smoking efforts have dramatic impacts on program effectiveness. In Massachusetts, after cuts of 92 percent in an anti-youth smoking program, the state saw large increases in illegal cigarette sales to minors. 18 Resources are critical for sustainable tobacco control programs, CDC s Husten notes. Because without these resources, even the most well-designed state program can t be effective. Want to Fight Smoking In Your State? Advice From A Veteran Legislature Assemblymember Pete Grannis is a veteran anti-smoking champion and legislator since 1974, representing part of Manhattan in New York s State Assembly. Grannis serves on the Assembly s Health Committee and was a co-author of the state s clean indoor air and cigarette fire safety acts. He offered this advice to legislators who might want to take action to reduce smoking in their states: Start with data for particular groups. Identify how smoking impacts different constituent or interest groups, and share that data with the group. For example, finding out how secondhand smoke affects people suf fering from asthma can be a powerful motivation for that group to help out with anti-smoking efforts. Build effective coalitions. For the efforts in New York, we relied heavily on the cancer, heart and lung associations, on local government, public health officials and even the New York State restaurant association, says Grannis, describing the coalition behind a successful effort in 2003 to expand the state s clean indoor act to include restaurants and bars. They [the restaurant association] were interested in having a level playing field so that all the establishments would have the same laws apply to them rather than singling out certain establishments that had different rules. Generate favorable editorial and news coverage. According to Grannis, getting strong support from newspaper editorials and favorable news coverage helped to build a large, effective coalition in New York. Relevant, timely information is key. While our opponents warned of the catastrophic impacts [of a smoking ban for restaurants and bars], we went ahead with our efforts, says Grannis. They pushed forward because they were armed with solid information about financial and fiscal impacts from previous efforts in California and Boston. Healthy States Brief: Smoking and Health December