Tobacco prevention spending: Will progress go up in smoke?

States have increased funding for tobacco prevention and cessation programs by 20% to $717.2 million for fiscal year 2008, but that's still less than half of the expenditure recommended by the Centers for Disease Control and Prevention (CDC).

An analysis of the resources committed to the programs was released at year's end by a coalition of public health organizations that warned that with smoking rates at a standstill after nearly a decade of decline, the nation's progress in reducing smoking is at risk unless states significantly increase funding for programs to prevent children from smoking and help smokers quit.

The report, "A Broken Promise to Our Children: The 1998 State Tobacco Settlement Nine Years Later," was released by the Campaign for Tobacco-Free Kids, American Heart Association, American Lung Association, and American Cancer Society Cancer Action Network.

The report found that only Maine, Delaware, and Colorado currently fund tobacco prevention programs at CDC minimum levels. Meanwhile, only 17 other states fund programs at even half the CDC recommended level, and 30 states and the District of Columbia are spending less than half the CDC minimum, while Connecticut is alone in not appropriating any funding for tobacco prevention this year (see chart).

One key reason for the increase in funding is that Florida went from $1 million last year to $58 million this year as a result of a state constitutional amendment initiated by public health organizations that requires the state to spend 15% of its annual tobacco settlement revenue on tobacco prevention. The report says the amendment restores funding for what had been one of the nation's most effective and innovative tobacco prevention programs and gives Florida the opportunity to again be a national leader if it properly implements its program.

Other states that increased funding for tobacco prevention programs include Indiana, Iowa, Oklahoma, South Dakota, Tennessee, and Wisconsin, although most remain below CDC's recommendations.

The groups say total state funding for tobacco prevention amounts to less than 3% of the record $24.9 billion the states will collect this year from the tobacco settlement and tobacco taxes. And just 6.4% of this tobacco revenue would fund prevention programs in every state at CDC minimums.

"The states' funding of tobacco prevention pales compared to the $13.4 billion a year spent on tobacco marketing and the nearly $100 billion spent each year on health care bills due to tobacco use," the report says.

The report was issued as recent surveys have found that the nation's progress in reducing smoking has stalled among both youth and adults. CDC has reported that 20.8% of adults smoked in 2006, about the same as the 20.9% in 2004 and 2005. That followed a steady decline between 1997 and 2004. High school smoking rates have similarly stalled after declining from a high of 36.4% in 1997, and 23% of high schoolers still smoke, according to CDC data. CDC attributed the stall to several factors, including cuts in tobacco prevention funding, increases in tobacco marketing, and stagnant cigarette prices due to industry discounting.

"The states' failure to do more to prevent and reduce tobacco use is especially troubling in light of recent national surveys indicating that the remarkable progress the United States has made in reducing smoking has stalled among both young and adults," the report declares. "If the nation is to continue reducing smoking and other tobacco use, Congress and the states must resist complacency and redouble efforts to implement proven tobacco control measures. These include fully funded tobacco prevention programs, higher tobacco taxes and smoke-free workplace laws at the state level, and U.S. Food and Drug Administration regulation of tobacco products, higher tobacco taxes, and a national public education campaign at the federal level."

The public health groups also say there is more evidence than ever that tobacco prevention and cessation programs work to reduce smoking, save lives, and save money. In 2007, the Institute of Medicine, the President's Cancer Panel, and the CDC all issued landmark reports concluding that there is overwhelming evidence that comprehensive state tobacco control programs substantially reduce tobacco use. The groups all said because of their effectiveness, every state should fund such programs at CDC-recommended levels.

Beginning in 2008, the groups say, states will have a critical second chance to adequately fund tobacco prevention programs because of a provision in the 1998 multistate tobacco settlement that calls for the 46 states, the District of Columbia, and the U.S. territories that are parties to the settlement to receive "bonus" payments totaling nearly $1 billion per year. "By allocating these new windfall funds to tobacco prevention and cessation programs, states can finally keep the promise of the tobacco settlement to confront the tobacco problem," the report says.

According to the coalition, states have no credible excuses for their failure to adequately fund programs to prevent kids from smoking and help smokers quit. The report notes that when the public health problems posed by tobacco are compared to other health problems, "it is clear that the amount the states are spending on tobacco prevention pales in comparison to the enormity of the problem." Tobacco use is the No. 1 cause of preventable death in the United States, claiming more lives each year (more than 400,000) than AIDS, alcohol, car accidents, murders, suicides, illegal drugs, and fires combined. Tobacco use, the report says, costs the nation nearly $100 billion a year in health care bills. And every day, more than 1,000 kids become new smokers and another 1,200 Americans die because of tobacco use.

Not having enough money available isn't the problem, the report says. States this year will collect a record $24.9 billion from the tobacco settlement and tobacco taxes, and just 6.4% of that total would fund prevention programs at CDC-recommended levels.

After quoting from reports issued by the Institute of Medicine and CDC demonstrating the value of prevention programs, the public health groups say the strongest evidence that tobacco prevention programs work comes from the states themselves. Maine, which has ranked first in funding tobacco prevention programs for six years in a row, has reduced smoking by 64% among middle school students and by 59% among high school students since 1997. And Washington State, which also has a well-funded prevention program, has cut smoking by 60% among sixth graders, 58% among eighth graders, 40% among 10th graders, and 43% among high school seniors.

Maine's Department of Health estimates the state's smoking declines have prevented more than 26,000 youth from becoming smokers, saving more than 14,000 of them from premature smoking-caused deaths, and already have saved more than $416 million in future health care costs. The savings estimates are based on research showing that smokers, on average, have $16,000 more in long-term health care costs than nonsmokers. Likewise, the Washington State Department of Health estimates that the state's smoking decline translates into 65,000 fewer youth smokers, 230,000 fewer adult smokers, and $2.1 billion in long-term health care cost savings.

California studies have demonstrated, according to the report, that the state's long-running tobacco prevention and cessation program has saved tens of thousands of lives by reducing smoking-caused birth complications, heart disease, stroke, and lung cancer. Lung cancer incidence has been declining four times faster in California than in the rest of the nation. And other studies have shown that California and Massachusetts, which started their tobacco prevention programs in 1990 and 1993, respectively, were saving as much as $3 in smoking-caused health care costs for every dollar spent on tobacco prevention when their programs were adequately funded.

The National Conference of State Legislatures told State Health Watch its policy is not to comment on reports issued by other organizations and their implications for state action. The National Governors Association did not respond to a request for comment on the report and state actions.

"Our nation has made significant progress in reducing tobacco use with a comprehensive approach that includes well-funded tobacco prevention and cessation programs, tobacco tax increases, and smoke-free workplace laws," the report concludes. "Continued progress will not occur, however, unless states use more of the billions of dollars they receive from the tobacco settlement and tobacco taxes to fund comprehensive tobacco prevention and cessation programs based on the recommendations of the CDC.

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