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States Accused of Misspending Tobacco Settlement

Study finds funds diverted away from antismoking programs

WEDNESDAY, Oct. 2, 2002 (HealthDayNews) -- States with the worst tobacco habits and those that grow the plant spend the least on programs to reduce smoking, says a new study that shows most of the billions pried from Big Tobacco in 1998 aren't being spent as intended.

In the 1998 Master Settlement Agreement, tobacco companies agreed to pay states $206 billion over 25 years. Much, though not most, of that money was implicitly earmarked to support antismoking campaigns. However, as many skeptics predicted, states have been using those dollars to pay for everything but that purpose. Some have even "securitized" the money, receiving lump sums up front to patch holes in their budgets.

"As of now, from a public health perspective, the [agreement] seems to be in critical condition," says Dr. Cary Gross, a Yale University physician and lead author of the study. "When states are not investing their tobacco settlement funds in their tobacco control programs, the program funding suffers."

Previous studies have pointed out the failure of states to apply their share of the settlement to tobacco control. Gross and his colleagues showed that tobacco control programs aren't drawing much from other sources of funding either. Their findings appear in tomorrow's issue of The New England Journal of Medicine.

Forty-six states and the District of Columbia signed the settlement, while the rest made separate arrangements. In 2001, states took in an average of $28.35 per resident from the agreement. Yet, they spent only 6 percent of that money on tobacco control programs.

Including other funds, states spent an average of $3.49 per capita on anti-tobacco initiatives, well less than the range of $5 to $15 per head recommended by the U.S. Centers for Disease Control and Prevention (CDC). That figure depends on the state's smoking rate and its age distribution, and on average works out to about $7 per person.

Pennsylvania was the nation's anti-tobacco laggard in 2001, spending just a dime per resident on tobacco control. That has since changed, and the state is now putting about $50 million toward such programs. Maine spent the most, nearly $15.50 per inhabitant.

Tobacco-growing states, such as North Carolina, Kentucky and Tennessee, spent an average of $1.20 per head on tobacco control programs, less than a third of the average among non-growing states. Similarly, states with more smokers spent less on such programs, likely because their pro-smoking culture discouraged efforts to promote quitting, Gross says. State spending on health care linked to smoking was unrelated to how much money they devoted to tobacco control.

"It's sad, because it shows that the states with the greatest public health need are really doing the least to address that need," Gross adds.

The new study relies on data from 2001. However, the situation has only deteriorated since then, experts say. A report issued this summer found that states, struggling with budget shortfalls, have slashed this year's tobacco control programs by more than $102 million, or about 13 percent, from fiscal 2002 levels.

The report, from the American Lung Association, the American Cancer Society, the American Heart Association and the Campaign for Tobacco-Free Kids, showed that Missouri, Michigan, Tennessee and Washington, D.C. have allocated no money this fiscal year for tobacco control. Michigan has allocated a chunk of its share to lure biotechnology firms.

"In each case, the dollars are being used for other programs. They simply have failed to address very serious problems associated with tobacco," says William V. Corr, executive vice president of the Campaign for Tobacco-Free Kids.

Corr says states this year will spend close to 4 percent of their settlement funding on tobacco control. "There's no question that states have failed to keep their promise, they have failed to seize a golden opportunity to reduce tobacco use with proven methods that have now been used in many states around the country," he says.

Still, while 15 states cut their tobacco control programs this year, 18 are spending more money than they did in 2001, Corr says. "That's a very important indicator that there is some leadership being exerted, and some recognition of the importance of these programs."

As a second study in the journal shows, telephone "quitlines" recommended by the U.S. Public Health Service can help people trying to quit stay off tobacco for extended periods of time.

A research team led by Shu-Hong Zhu of the University of California at San Diego evaluated California's Smoker's Hotline. The service, established in 1992, has been the model for scores of quitlines in other states. How well these programs work hasn't been clear.

Zhu's group found that callers who received counseling were nearly twice as likely as those who didn't to stay off cigarettes throughout the year. By 12 months, the number not smoking was low, about 8 percent, compared with about 4 percent of those who called into the line for self-help materials but didn't do more. The one-year abstinence rate was highest -- 12 percent -- for people who called in and received counseling on the spot.

Zhu says the counseling is "very tailored" to individual smokers, helping them understand what needs the habit satisfies and what quitting strategies are most likely to succeed. The initial, lengthiest session is followed up by at least two shorter calls, he says.

"Quitlines really do work in the real world," says Dr. Steven Schroeder, president and chief executive officer of the Robert Wood Johnson Foundation in Princeton, N.J., and author of an editorial accompanying the journal articles. "There are very few public health interventions that can save as many lives."

Applying the California model nationally could encourage 900,000 smokers a year to quit and over the long run save 300,000 lives annually, he says. The CDC estimates that 440,000 Americans die each year from smoking-related illnesses such as lung cancer and heart disease.

What To Do

To find out more about smoking cessation, try the American Legacy Foundation or the Campaign for Tobacco-Free Kids.

SOURCES: Cary Gross, M.D., assistant professor, medicine, Yale School of Medicine, New Haven, Conn.; William V. Corr, executive vice president, Campaign for Tobacco-Free Kids, Washington, D.C.; Shu-Hong Zhu, Ph.D., associate professor, family and preventive medicine, University of California, San Diego; Steven Schroeder, M.D., president and chief executive officer, Robert Wood Johnson Foundation, Princeton, N.J.; Oct. 3, 2002, The New England Journal of Medicine
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