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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Lung Cancer, Spiral CT and Tobacco Industry Funding

An interesting article was published in the New York Times yesterday, revealing that one of the studies reporting the most positive effects on the potential of spiral CT in detecting early stage lung cancer, was funded by the tobacco industry. The article raises questions about the motivations from the tobacco industry to fund such a study, and the reasons for lung cancer researchers accepting research funding to investigate lung cancer screening from the tobacco industry.

In fact, the story is a little more complicated. The study was part funded by an organization called, “Foundation for Lung Cancer: Early Detection, Prevention & Treatment”. The New York Times examined tax records and discovered that this foundation is mainly funded via a grant from Ligett Group, which makes a number of brand-name cigarettes. The article suggests the possibility that the foundation may have been set up to hide the original source of the funding, and numerous senior cancer researchers and journal editors stated that they were shocked to find out that the research had been funded by a tobacco company.

Within the medical research community there is wide acceptance of pharmaceutical company funding for research and educational purposes. While we are all aware of cases of unethical behavior by pharmaceutical companies, their overall mission is to improve health and is entirely consistent with that of academic medical researchers. The tobacco industry, on the other hand, has a long history of trying to misuse research to sell more cigarettes: virtually the only legal consumer product that is lethal to the user when used as intended. So many academic institutions (including my own, the School of Public Health at the University of Medicine and Dentistry of New Jersey) have an explicit policy of not seeking or accepting funding from the tobacco industry, other than that resulting from a law suit against the industry. The other issue brought up by the NY Times article is that of disclosure of funding sources. There is a sense that while we all may have a right to earn a living as we see fit, when it comes to medical research and informing the public about health matters, we should try to be up front in disclosing the sources of our funding.

Sometimes this is more difficult than you might expect. For example, for some time now I have taken to sending a rather long statement about my own funding to journals when I submit a paper for publication. But the journal editors make the decision as to what is most relevant to print as a statement of funding or potential conflict of interest. I happen to feel this is an important issue and so I’m attaching my own funding statement to the bottom of this article.

Funding statement. This statement provides a brief summary of the sources of funding for Jonathan Foulds PhD

Jonathan Foulds is primarily funded by a grant from New Jersey Department of Health and Senior Services. His other recent research funding (also as P.I.) is from the Cancer Institute of New Jersey, the Rutgers Community Health Foundation and the Robert Wood Johnson Foundation. He has worked as a consultant, as a promotional speaker and received honoraria from pharmaceutical companies involved in production of tobacco dependence treatment medications (e.g. Pfizer, Novartis, GSK, Celtic Pharma) as well as a variety of agencies involved in promoting health (e.g. W.H.O., N.I.H., etc). Some of these agencies have provided sponsorship funds for educational events conducted by the program he directs. The program he directs (Tobacco Dependence Program at UMDNJ-School of Public Health) conducts trainings and charges health professionals and their organizations for providing these. He has also worked as an expert witness in litigation, including for plaintiffs in law suits against tobacco companies. He has not received any funding from the tobacco industry other than deposition fees from defendants attorneys in litigation against the tobacco industry (i.e. while acting as a witness for the plaintiffs). He is paid for writing a regular column on a health website: http://www.healthline.com/blogs/smoking_cessation/ .

Labels: cigarette smoking, funding, jonathan foulds, lung cancer, spral CT, tobacco industry

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