Up in Smoke

July 28, 2008 • Commentary
This article appeared in the Balitmore Sun (Online) on July 28, 2008.

Two recent events underscore big problems with the way society tries to fight tobacco use.

First, a new Harvard study came out alleging that the tobacco industry manipulated menthol levels in cigarettes to hook young smokers in violation of the 1998 Master Settlement Agreement, which bans tobacco companies from targeting youths. And second, billionaires Michael R. Bloomberg and Bill Gates last week threw their support behind a new $500 million worldwide effort to stop smoking.

Whatever the tobacco companies may have done with menthol levels, the bigger scandal is how states have misspent the billions paid to them by the tobacco industry. And however well‐​intentioned, the Gates‐​Bloomberg effort, which involves the Johns Hopkins Bloomberg School of Public Health, is likely to fail because the tobacco control programs that it will fund — featuring such things as higher taxes, smoking bans and advertising restrictions — have failed before. These multiple shortcomings point to the need for a new, more effective approach to handling, and funding, tobacco prevention.

The Master Settlement Agreement resulted in a payment of $206 billion by the tobacco industry to 46 states over 25 years for smoking prevention. The states also receive annual payments in perpetuity based on inflation and cigarette sales.

When the agreement was signed, the state attorneys general pledged that this massive windfall would go toward funding smoking prevention programs. However, from the moment the states got their hands on the tobacco settlement money, this has not been the case. Instead of being spent on smoking prevention, the billions have gone to such things as expanded broadband cable networks, museum development, sewer upgrades, new schools and parks, economic development and general tax rebates.

Maryland’s share of the settlement is $4.4 billion over 25 years. Yet the state falls short of the minimum amount recommended by the U.S. Centers for Disease Control and Prevention for state tobacco prevention spending: $30.3 million per year. According to the Campaign for Tobacco‐​Free Kids, in fiscal year 2007, Maryland spent only $18.7 million from tobacco settlement and tax revenues to prevent and reduce tobacco use.

The CDC recommends that the states invest 20 percent to 25 percent of the money they receive in tobacco control. Only three states ( Maine, Delaware and Colorado) are funding their smoking prevention efforts at the CDC‐​recommended level. According to the Campaign for Tobacco‐​Free Kids, the states will receive $24.9 billion this year from the settlement and tobacco taxes, of which they will spend approximately 3 percent on tobacco control.

Yet the tobacco settlement scandal is greater than the states’ refusal to spend money for tobacco control on tobacco control. That’s because even the meager efforts they do undertake bear little fruit.

For example, an enormous smoking prevention program in 11 communities called COMMIT (Community Intervention Trial for Smoking Cessation) was designed to help smokers, particularly heavy smokers, quit. It was a huge failure. Similarly, the largest attempt to put smoking prevention theory into practice was the American Stop Smoking Intervention Study (ASSIST), an eight‐​year project involving 17 states and run by the National Cancer Institute. This project possessed all of the bells and whistles of traditional smoking prevention: limiting tobacco advertising, restricting public smoking and making it harder for kids to access tobacco. Nevertheless, the project failed to produce a statistically significant reduction in smoking prevalence and consumption.

True, the U.S. smoking rate has declined sharply, but this trend began before the onset of significant government regulation and has continued, in large measure, because our society has continued to grow wealthier. Higher incomes stimulate public interest in, and concern about, matters of personal and public health.

A big part of the problem is that most anti‐​tobacco groups spent the last 25 years operating on the erroneous assumption that if you could prevent the tobacco industry from marketing, you could stop people from smoking. Most tobacco control efforts have failed because they have not been linked to the right predictors of becoming a smoker. These include socioeconomic status, connection and success at school, self‐​esteem, family structure and relations with parents.

Likewise, the $500 million in the Gates‐​Bloomberg plan would be far better spent on advocating for educational, economic and trade policies that would raise living standards and, consequently, dampen public interest in smoking — without the heavy hand of government intervention.

Ten years and $53 billion after the tobacco settlement windfall, there is precious little to show in terms of credible smoking prevention. It’s time for Congress — and perhaps the president — to step in and demand that the states live up to their promise to use the settlement money for effective tobacco prevention. To ensure the settlement money has an impact, it needs to be diverted from projects unrelated to smoking and then placed into interventions that are based on what the best evidence shows are the real reasons kids start using cigarettes.

Until that happens, anti‐​tobacco efforts — whether funded by the states or by well‐​intentioned billionaires — will continue to amount to little more than blowing smoke.

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