Tobacco control is a prime example of a government program with the noblest of intentions. Tobacco is unhealthy; and its impact on public health makes it easy to convince people that government should fund programs that reduce smoking. The Centers for Disease Control and Prevention is now recommending large increases in spending on anti-smoking programs — to more than double the annual spending of over $717 million.
But how effective are these programs? Not very — so why is the CDC recommending pouring millions of dollars more into programs that are unlikely to have any significant impact on public health? Early tobacco control policy efforts that largely consisted of raising taxes were quite successful in reducing smoking. The effect of more recent tobacco-control policies is much more ambiguous.
Bans on tobacco use in various places have been implemented widely. Bans have been imposed on restaurants and bars in 27 states and Washington. Four other states have imposed bans in restaurants, but exempt bars. Several more states have passed bans that take effect in the near future. Proponents argue that bans lower smoking, although evidence on this is mixed.
"Anti-tobacco" programs are the latest measure used by governments to control tobacco use. These programs fund anti-smoking ads that run in newspapers, magazines and on TV, school programs to educate children about the hazards of smoking, cessation interventions (intensive counseling services and cessation medications) and grants for researchers to demonstrate effectiveness of tobacco-control programs. These programs hire many people and are very expensive.
The CDC provides recommendations for how much money states should spend on anti-tobacco programs. According to the CDC, careful research shows that its recommendations would prevent hundreds of thousands of premature tobacco-related deaths. But the data do not back the CDC's claims.
The CDC recommends that states should spend $15 to $20 per resident each year on anti-smoking programs. Only two states — Maine and Mississippi — have consistently met or exceeded that goal over the years 2000–2007. In contrast, three states — Michigan, Missouri and Tennessee — have spent nothing on anti-smoking programs. Georgia spent just over $2 million in 2008, barely 5 percent of what the CDC now recommends. Nationwide, states have spent a total of $5.3 billion (in inflation-adjusted 2005 dollars) over those years, an average of $18 per person. But all that money has failed to significantly reduce smoking. Nor have the states that spent more seen a more dramatic reduction in smoking than states that have spent less.
Statistical analysis that I've conducted shows that there is a very tenuous link between cigarette sales and state anti-tobacco spending. At best, spending large amounts of money on anti-tobacco programs seems to produce a trivial drop in cigarette sales — less than a pack a year per capita. States would be better advised to put these resources toward other public health policies that produce larger results.
What was the basis of the CDC spending recommendations? Was the agency truly trying to identify anti-smoking policies that work well and use public funds effectively, or did the CDC simply assume that, "If you spend it, they will quit smoking"? If it was the latter, then it is unfortunate for both taxpayers and public health.
The CDC is now arguing that state anti-tobacco programs are underfunded. Tobacco-control advocates — many of whom receive money through these programs — repeat the CDC under-funding claims when pleading their cases for spending increases. It will be truly unfortunate if states simply accept these claims and increase funding without investigating the programs' effectiveness. However difficult it is to look beyond noble intentions, appraisal of a program's effectiveness is vital — particularly in these tight fiscal times — if we truly want to improve public health effectively.