Unwise to cut tobacco control funding in tough times

The U.S. and many other economies across the globe are going through tough financial times just now. In these tough times, legislators and policy makers have to make tough choices about how to spend limited budgets. In recent times in the United States, one of the targets for cuts has been tobacco control funding.

Using my home state as an example, I’d like to summarize some of the reasons why cutting tobacco control funding is not a wise policy, even in tough financial times.

Here in New Jersey, our Comprehensive Tobacco Control Program (CTCP) started in 2000, with funding of $32.5 million via the Master Settlement Agreement. At that time the Centers for Disease Control (CDC) recommended a minimum of $45 million annual expenditure on tobacco control. The program was set up to follow CDC guidelines to have components for media, evaluation, community activities, youth prevention, and smoking cessation. With the post 9/11 recession causing severe budget problems for the state, funding was drastically cut by 66% to $11 million in 2004 and has remained at that level. The state brings in approximately $1 billion per year from tobacco sources (MSA plus tobacco taxes) and so is currently spending around 1% of tobacco revenues on tobacco control. In 2007 the CDC updated its funding recommendations for New Jersey to $120 million ($13.75 per person per year, and 12% of total tobacco-related revenue to the state).

Despite being drastically underfunded, the New Jersey CTCP has had many noteable achievements. Just a few of these are:

- Over the years 2000 to 2007, cigarette taxes were increased from 80 cents per pack to $2.575 per pack (highest state tax in the country).
- Legislation was passed to ban smoking in all workplaces and indoor public places, and implemented in 2006, adding casinos in 2008.
- The number of cigarettes being smoked by New Jersey youth was cut by 50% from 1999 to 2006.
- Adults cigarette smoking fell from 21% during the mid 1990s to 17.1% in 2007, the lowest level recorded.

Some may ask for early signs of a health impact. One early response to reduced smoking is a reduced rate of heart attacks. The number of acute myocardial infarctions causing reported inpatient hospitalizations in New Jersey was above 22,000 every year from 1995 to 2003 (24278 in 2000), but dipped below 22,000 in 2004 and has continued to fall to below 20,000 in 2006. This reduction from the year 2000 to 2006 was evident for every age group over age 15. Clearly all of this reduction cannot be entirely attributed to the CTCP, but it is highly likely that many heart attacks were prevented by the reduced smoking in the state. In tough financial times, one has to consider the cost savings to the healthcare system from reduced hospital admissions for MIs, lung cancer, premature babies, respiratory disease and all the other diseases caused by smoking.

Some point to the successes in reducing smoking and seem to be under the misguided impression that smoking is so rare nowadays that there is no longer a need for robust tobacco control programs. The reality is that according to our latest data (2006), New Jersey’s 7th through 12th graders smoke 90 million cigarettes a year. This does not include the significant proportions smoking cigars and bidis, or chewing tobacco.

Per capita cigarette consumption is currently 43 packs per year (down from 69 packs in 1999), and lower than the average for the country (69 packs).

To put New Jersey’s investment in tobacco control into perspective, on an annual basis it is less than the amount of revenue the state receives in excise taxes from illegal cigarette sales to kids ($11.5 million)!

Yet in that scenario of incredible success despite serious underfunding, New Jersey’s Comprehensive Tobacco Control Program is currently threatened with further cuts. I don’t think we can really say that with New Jersey’s youth smoking 90 million cigarettes per year, and with 43 packs being consumed annually for every person in the state, that the work for tobacco control is done. We are only beginning to see the return on investment in terms of reduced health effects from tobacco. To cut the program now would result in a reversal of the progress, and directly cause more heart attacks, more cases of lung cancer and emphysema, and more premature babies.

Tobacco control spending provides an excellent return on investment, and it is for this reason that CDC recommends that New Jersey should spend $120 million, rather than be considering cutting from $11m. Even in tough financial times, a dollar spent on tobacco control is a dollar well spent on improving health and reducing healthcare costs.

So when times are tough, and money is needed for other important causes (like healthcare for uninsured smokers), a far better way to fund these is to increase the excise tax on cigarettes. http://www.tobaccofreekids.org/reports/prices/



Full details and evaluation of New Jersey’s Comprehensive Tobacco Control Program can be found at: http://www.nj.gov/health/as/ctcp/research.htm

For more details on the toll of tobacco in New Jersey, click on:
http://www.tobaccofreekids.org/reports/settlements/toll.php?StateID=NJ

For the CDC’s best practices for Comprehensive Tobacco Control (2007), click on:
http://www.cdc.gov/tobacco/tobacco_control_programs/stateandcommunity/best_practices/

Labels: cigarette tax, comprehensive tobacco control, funding, jonathan foulds, New Jersey

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Which kids in the US are most likely to use tobacco?

The tobacco industry has a problem. Its products kill the consumers when used as intended. Given the high rate of people ceasing tobacco use due to premature death or success in beating the addiction, the industry has its work cut out in replacing these consumers with new users. Each company is aware that smokers quickly develop brand loyalty, and so the race is on to hook kids before other companies can get their hands on them. Youth are also a major target for tobacco companies because the younger they get them, the more years of tobacco sales will be achieved before the consumer dies.

In the United States, tobacco use by high school kids is defined as either current use (any use in past 30 days) or frequent use (use on 20 out of the last 30 days). The proportion of high school kids who were current (frequent) cigarette smokers in the US increased from 1991 when it was 27.5% (12.5%) to peak in 1997 at 36.4% (16.7%), before falling to 23% (9.7%) in 2005. It is unlikely to be a coincidence that the increase in youth cigarette smoking throughout the 1990s was reversed from the same year the Master Settlement Agreement was signed (law suit in which states sued tobacco companies for tobacco-caused Medicaid costs). The MSA triggered significant publicity about the harmfulness of tobacco, resulted in a marked increase in tobacco control funding, and also resulted in price increases (which was how the companies easily recouped the money they paid in the settlement).

In 2005 white (non-Hispanic) girls had the highest current cigarette use (27%), followed by white boys (24.9%) and Hispanic boys (24.8%). These rates are much higher than among African American high school kids, of whom only 11.8% of girls and 14% of boys were cigarette smokers.

African American youth have consistently had much lower smoking rates than white youth over the past 25 years, although in the early 1970 their smoking rates were similar to whites. No-one knows what caused such a marked decline in African American youth smoking from the early 70s through to the 1980s and beyond. If you have any idea I’d like to hear it (and note that African American youth were also less likely to use alcohol or illicit drugs than white youth during that same time period).

You can read a full report on the latest data on youth cigarette smoking in the US at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5526a2.htm

Labels: cigarette smoking, jonathan foulds, USA, youth

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Become an Ex

On previous posts I’ve talked about good websites for helping smokers quit:

Can smoking cessation internet sites help you to quit? 4/21/07
http://www.healthline.com/blogs/smoking_cessation/2007/04/can-smoking-cessation-internet-sites.html

There are quite a few good ones, and so far my favorite is at www.quitnet.com .

But I recently checked out a fairly new one and was very impressed. Its at www.becomeanex.org . It has been funded by a coalition on public health agencies, and appears to have been really well put together and is really easy to use. One of its main selling points is its emphasis on quitting smoking as a process, and its recognition that it is not all over in a month. So this site presents quitting as a process, provides loads of useful tips and advice, and is particularly good at helping you link with networks of other smokers for added support. The site makes good use of new technologies to make it easy to register, easy to communicate with other smokers trying to quit, and fairly easy to ask a question not just of others trying to quit, but also of recognized experts, like Dr Richard Hurt of the Mayo Clinic.

I found it very simple to register. You can set up your own profile, add your photo and details if you want (or not if you don’t), and there are plenty of subgroups you can join, made up of people with a particular thing in common (e.g. living in Texas, or using Chantix). The only slight problem I had was that when I clicked on some of the video components they didn’t all run smoothly. That may have just been a problem with my PC as I’m a bit technologically challenged. I believe this site is fairly new, (launched March, 2008) but I think it looks like it could be very helpful to tobacco users thinking about quitting.

Check it out and let me know what you think.
www.becomeanex.org

Labels: becomeanex, cessation, cigarette smoking, jonathan foulds, website

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Tobacco Harm Reduction

There are a bunch of policy options designed to reduce the harm to health caused by tobacco.

Right now, those option focus on reducing exposure to second-hand tobacco smoke pollution, reducing initiation of smoking among young people, and encouraging existing smokers to quit. In many developed countries these policies have had some success, with significant reductions in the proportion of the population who smoke. In some other countries there has been little progress or smoking has actually increased. At the end of the 20th century almost half of all men on the planet were smokers. Perhaps the main hope for improving this situation is via implementation of the World Health organization’s Framework Convention on Tobacco Control (FCTC). Details on the FCTC can be found at;
http://www.who.int/tobacco/framework/en/

There have also been moves to reduce the harm to health via increased regulation of the tobacco industry and the products it sells. For example, in the European Union, there are fairly tight regulations governing the advertising of tobacco, the emissions from cigarettes, the warnings on packs and also an almost complete ban on oral snuff tobacco.

In the United States, there is currently a piece of legislation that has cleared a number of initial hurdles, (but with a few more to be crossed) that would, for the first time, give the US Food and Drug Administration (FDA) the right to regulate tobacco products. Though most people agree that it is only right that the tobacco industry should be more tightly regulated, there are differences of opinion as to the way to do it that would be most likely to lead to reduced harm to health.

One model (on which the current FDA legislation appears to be based), involves reducing the potential nicotine delivery from tobacco products gradually down to the level at which they would no longer be addictive. The existing smokers would hopefully gradually switch over to nicotine replacement products or give up nicotine altogether.

Another model involves gradually reducing the permissible toxins levels that can be emitted by tobacco products, while keeping the nicotine delivery at a level that users can still be addicted. In the end this policy might end up at a similar place to the previous one, with users using clean nicotine products, without any tobacco.

Both of these models have merits. However, there may be problems with the time delay before reaching the point where there is significantly less harm being caused. There may also be challenges for enforcement, as it may be difficult for enforcement authorities to tell if a cigarette is reduced toxin/nicotine or a regular cigarette that has been smuggled in from another country. Another potential problem with both these strategies is that they pretty much put the tobacco industry out of business. Now it’s a fair bet that the tobacco industry would not want to go out of business, and would use its considerable resources and influence to prevent these policies from being implemented to their fullest extent.

This is where a similar but slightly different policy, may have some merit. With this model, the tobacco industry is given notice by regulators that smoked products can no longer be sold in this country 10 years from now. They are told that they should plan for this, by switching their consumers to products that do not involve combustion, i.e. any form of smokeless tobacco.

Now the companies won’t love this idea either. But it at least gives them a way to stay in business and also gets them out of the lung cancer and emphysema business, which has always been a slight PR negative for the tobacco industry. I believe that this policy stands the best chance of being sustainable and acceptable to all stakeholders.

If you would like to view a full slide show and talk I presented to a meeting of tobacco industry representatives that laid out this approach, it can be viewed on the supercourse (a free health teaching website) at: http://www.pitt.edu/~super1/lecture/lec31261/index.htm

Labels: cigarette smoking, FCTC, FDA, harm reduction, jonathan foulds, nicotine addiction, tobacco

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Smoking and suicide

It has long been known that people who smoke are at greater risk of attempting and committing suicide than people who don’t smoke. On the face of it this doesn’t seem particularly surprising as people who sometimes think that they would rather not live would appear to have less reason to quit smoking to improve their health and live longer.

But the recent concern about onset of depression and suicidal thoughts among people quitting smoking (who presumably are in a frame of mind in which they want to live longer when they decide to quit) has led to renewed interest in the relationship between smoking and suicide. A recently published study by Professor Ronald Kessler (Harvard University) and colleagues provided some data and analysis relevant to this issue.

The study involved a survey of a representative sample of the adult American English-speaking population (n=5692). The study found that 2.6% had seriously thought about committing suicide in the previous year, 0.7% had made a plan of how they would do it, and 0.5% had made an attempt. This study, like many prior studies, found that smokers were about two or three times as likely to have thought about or attempted suicide in the past year than non-smokers. Heavy smokers were generally more likely to have thought about suicide than light smokers.

This survey also included a diagnostic interview for recent mental disorders. Like other studies, it found that people with virtually any mental disorder (from specific phobias to bipolar disorder) were more likely to be smokers, with the strongest relationship being for substance use (people with dependence on other substances being around 5 times more likely to be smokers than those not having a substance use disorder). People with a mental disorder were also more likely to have suicidal thoughts or attempts.

The study then examined whether smokers remained at greater risk of suicidal thoughts or attempts, after controlling for mental disorders. Controlling for mental disorders reduced the association between smoking and suicidal behavior to the point that it was no longer statistically significant.

My own interpretation of the data from this and other studies, is that mental disorders or some other factors of which mental disorders are highly correlated (e.g. mental health or general satisfaction with ones life) are a risk factor for both smoking and suicidal behavior. Thus people who as kids are unhappy and have difficulties dealing with their emotion are more likely to take up smoking, and more likely to become addicted to tobacco, and as adults are less able to quit smoking and are also, by virtue of their dissatisfaction with life, more likely to consider and attempt suicide.

Thus the relationship between smoking and suicidality is very unlikely to be causal. It is also worth noting that the size of the association is not very large. About one in 200 non-smokers attempt suicide each year and about one in 100 smokers attempt suicide each year.

None of this provides a direct explanation or helps us understand what may be going on when an individual attempts suicide in close proximity to a time when they had been trying to quit smoking (with or without using Chantix). But it does give us some idea of the frequency of certain events in the population. Around 45 million Americans smoke. At least 15 million of them make a quit attempt each year, and at least 5 million have already tried Chantix. This would imply that in the past year around 450,000 smokers made a suicide attempt, and possibly as many as 150,000 of them in the same year they made a quit attempt. Assuming around 2 million Chantix users in one year, and the same rate of suicide attempts per year as other smokers, this would lead us to expect around 20,000 smokers to make a suicide attempt in the same year they used Chantix, even if a quit attempt or Chantix use had no effect on risk for a suicide attempt. The precise number of events expected by chance will of course vary a bit according to the study one bases ones estimates on. But either way, one would expect a large number of cases by chance.

Now none of this means that making a quit attempt, or taking any particular medication, could or could not affect an individual’s risk for depression or suicide. That is a more complex question. But it does demonstrate that we might expect to hear of a large number of cases of suicide attempts by smokers taking any commonly used medicine, even if that medicine had no causal relationship with the suicide attempt.

The full text of the study by Kessler and colleagues can by accessed via the following link:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17502801

Labels: Chantix, cigarette smoking, jonathan foulds, suicide

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