America Won the Battle against Smoking but Risks Losing the War

States have reduced smoking to an all-time low. But future efforts suddenly seem hazy.
by | December 2014
David Kidd/Shutterstock

In America’s public health battle against smoking, no place has staked more capital on eradicating the habit than New York City. Under former Mayor Michael Bloomberg, the city led the nation in efforts to ban smoking in bars and restaurants before such measures swept the states. In the early 2000s, New York launched major counter-marketing campaigns, established the highest cigarette taxes in the country and pushed restrictions on outdoor smoking. Nationwide smoking rates plunged over the next decade. New York’s fell even faster.

MORE: Read the rest of the December issue.

That’s why the news this September came as a surprise. The city’s adult smoking rate, which had reached an all-time low of 14 percent in 2010, climbed to 16 percent. City officials blamed the rising rate on a steady slide in antismoking spending -- cutbacks of about 50 percent over the past five years. But New York City is hardly an outlier in the shrinking of tobacco prevention funding. Overall state spending, fueled by the 1998 tobacco settlement case, is currently at 60 percent of its 2002 peak.

The cut in funding comes at a cost. While the national smoking rate continues to move downward, the decline has slowed among some key demographics, particularly 25- to 44-year-olds, a cohort that is driving New York City’s rate of increase. The number of people over 18 who report initiating smoking is also higher today than it was in 2002 before the smoking ban was in full swing.

All of which suggests that the U.S. government’s goal of reaching an adult smoking rate of 12 percent by 2020 may be hard to achieve. Adult smoking currently stands at 18 percent, and the surgeon general reported this year that as much as 15 percent of the public could still be smoking in 2050.

More than a decade after the public health crusade to reduce smoking got under way, there are signs that states have lost focus. At the very least, public health experts warn, states can’t expect to continue making gains against tobacco use without getting serious once again about the public health issue. “The thing that makes tobacco different from other public health epidemics,” says Dave Dobbins, chief operating officer of the American Legacy Foundation, “is that if you suddenly decide the problem is solved and you’re going to walk away from it, unlike polio, there’s an extremely powerful industry spending billions of dollars [that’s] going to fill that void very quickly.”

It takes a three-pronged approach to drive down the rate of smoking: funding of antismoking programs, regular tax increases on cigarettes and restrictions on where people can light up. In the first seven years following the major 1998 tobacco settlement between the states and tobacco companies -- a settlement that provided states with billions of dollars of additional resources to reduce tobacco use -- habitual smoking declined 11.4 percent as states ramped up on all fronts. But then spending began to backslide and declines in smoking rates tapered for the next several years. In 2009, the federal government stepped in to pick up some of the slack. Congress put in place the largest federal cigarette tax increase ever, and the Centers for Disease Control and Prevention (CDC) has been spending $50 million a year in a counter-marketing program. But public health experts warn that the effects of the federal tax increase will wane with each passing year, and the CDC can’t fund marketing indefinitely.

SOURCE: The Campaign for Tobacco-Free Kids

Right now, there’s not much happening to fill the void at the state level. Between tobacco settlement money that’s distributed to states annually and revenue from their own tobacco taxes, states pulled in about $25 billion last year. But they are not required to spend their $7 billion in settlement money on tobacco cessation -- a sore spot among some of the attorneys general who negotiated the deal. As a percentage of overall tobacco revenue, states spent only about 2 percent of it fighting tobacco use. The money instead went to a variety of other needs, from state literacy programs in Colorado to a teacher retirement fund in West Virginia to shoring up Medicaid in others.

In 14 states and the District of Columbia, at least a quarter of tobacco settlement money is going to pay off debt on tobacco bonds that gave those states money upfront in exchange for a portion of the annual proceeds from the settlement, according to data compiled by ProPublica. In eight of those states, 100 percent of annual proceeds are going to debt service. Ohio is one of them.

Under former Gov. Ted Strickland, Ohio sold tobacco bonds in 2007 to finance new schools and tax cuts. Shortly thereafter, as the recession applied budgetary pressure, spending on tobacco prevention began to fall steadily from a $60 million a year high in the early 2000s to almost nothing today. “The general public thinks that’s what [settlement money] goes to, but it does not here in Ohio,” says Jeff Stephens, a lobbyist for the American Cancer Action Network.

In Ohio, the link between funding and smoking rates is clear. Under the state’s well-respected tobacco use and prevention foundation, established with tobacco settlement money in the early 2000s, smoking rates fell 27 percent to a low of 1 in 5. But after settlement money stopped flowing and the foundation languished, the state’s smoking rate edged up to 1 in 4.  Last year, the state put up $1.5 million for an antismoking campaign, its first appropriation since 2011. Gov. John Kasich has made the issue a priority, pledging another $35 million over the next five years from a separate tobacco settlement.

But Ohio is in rare company. It’s one of a few states that have decided to make more antismoking money available. In New York City, where the decline in funding smoking cessation efforts mirrored the state’s spending reductions, the goal is maintaining current funding levels. “I’m an eternal optimist,” says Blair Horner, a longtime consumer advocate with the Public Interest Research Group, “but it’s more a fight trying to protect what we’ve got.”

The fight Horner is referring to involves the near record-level lobbying from companies like Altria, the parent company of Philip Morris. Altria spent a reported $1.2 million last year in the state lobbying for its products.

In places as varied as Vermont and South Carolina, the debate over more funding gets lost in the overall health budget fight. About five years ago, South Carolina legislators approved $5 million a year for antismoking measures. Since then, smoking rates have declined modestly from 23.1 percent in 2011 to 22 percent in 2013. This past year, state Sen. Thomas Alexander, a Republican who heads the health subcommittee, pushed for another $1 million on top of the $5 million. His fellow lawmakers, however, questioned whether the money they were already spending could be directly linked to the decrease in smoking. “There are folks who just don’t believe in the program, and that’s why evidence-based data is going to be so critical,” he says. “But on top of that, you have so many competing and interrelated demands on the health side.”

Meanwhile, last year the state finished paying off its own tobacco bonds. Most of the $68 million now returning to the state from the settlement has been going to Medicaid. None of it goes toward smoking prevention.

The $5 million that funds South Carolina’s tobacco cessation program comes from a 2009 cigarette tax increase that took about a decade to bring to fruition and required overcoming a gubernatorial veto. But raising cigarette taxes has become more politically perilous nationwide since then, even in more liberal states and despite strong correlations between tax levels and smoking rates. The 10 states with the lowest smoking rates have an average state tax rate of $2.44, about a dollar higher than the national average and about $2 more than tobacco-producing states. A similar correlation shows up among states with low taxes and higher rates of smoking.

Between 2002 and 2004, 45 states raised their cigarette taxes. Another wave of 15 state actions followed in 2009. In the last three years, though, only seven states have increased cigarette taxes. The forces behind the lull could be a combination of tax fatigue among voters, rising alarm over cigarette smuggling and industry lobbying. The “fatigue” argument could be at play in Maryland, the state with the 12th highest cigarette tax in the country. A 2013 effort to raise the tax didn’t make it out of committee. In 2014, the effort got a hearing and no more.

This next year could be different. An influential advocacy organization has sought pledges from incoming Maryland lawmakers, but there’s palpable “weariness” among an electorate that’s seen a host of tax and fee hikes recently, says Marc Kilmer of the Maryland Public Policy Institute, a conservative think tank. In addition, there have been highly publicized reports of cigarette smuggling along a route that goes through Maryland to get to New York, where Gov. Andrew Cuomo has called for a task force to address the problem. New York has suffered a huge loss of tax revenue from an unregulated market that also spurs crime and poses additional health risks when the smuggled good is adulterated. Other states, says Kilmer, “don’t want to be the new New York.”

States have been equally reluctant to tax e-cigarettes, a $1.5 billion industry that barely existed five years ago. E-cigarettes are typically battery-powered cartridges that heat nicotine fluid into a vapor that’s inhaled. While they still contain nicotine, e-cigarettes in general aren’t as carcinogenic, leading many to say they’re far less dangerous than traditional cigarettes. Long-term health effects remain unknown, however, as does whether they’re bringing new smokers into the fold or helping existing smokers quit. But one thing is certain: At the moment, it’s far cheaper to buy the nicotine liquid, which is mostly untaxed, than it is to buy traditional cigarettes.

So far, just two states have imposed e-cigarette taxes. Minnesota set the highest rate by assessing their wholesale value. A similar effort in Washington state, though, failed to get a floor vote in the House, let alone the Senate, which is controlled by Republicans. Lawmakers were worried about a new tax and about taxing an industry they don’t fully understand -- one that could even be helping traditional smokers quit.

Washington state Rep. Reuven Carlyle, the finance committee chairman who proposed the tax, says the conversation will start again next year. “We’re not going to fight the same tobacco fight from the ’50s and ’60s,” he says. It’s incredibly patronizing to science, he continues, to let lobbyists persuade legislators that until there is a detailed analysis of every negative effect of e-cigs relative to a cigarette, nothing should be done.

While states and localities move away from public health spending and cigarette tax hikes, there s been a strong record on the third leg of antismoking efforts: adding new restrictions to the places people can smoke -- and the age at which they can do so. But even there, where public money and new taxes are not involved, there have been obstacles.

Proponents of raising the buying age have a simple argument: 95 percent of smokers started before they were 21. Therefore, making it more difficult to start theoretically means fewer people will ever pick up the habit.

That rationale hasn’t necessarily translated into action. Only individual cities, including New York and a number of municipalities in Massachusetts, have successfully raised the age at which people can buy tobacco to 21. Every state-level effort so far has failed.

During the past decade, about half of the states passed statewide workplace smoking bans that include bars and restaurants. The politics in the holdout states have been difficult. In Kentucky, with its long tradition of tobacco growing and the highest smoking rates in the country, there is surprisingly strong popular support for such a ban and there are yearly attempts to pass one. But the bills -- opposed by deep-pocketed companies like Altria -- keep failing. About a third of Kentuckians are covered under local ordinances, but bringing down smoking rates statewide takes a comprehensive effort, says Ellen Hahn, a professor at the University of Kentucky’s tobacco policy research program.

Nationally there’s also pushback in the area of outdoor bans. Even noted public health experts challenge the health benefits of extending smoking bans outdoors to parks, beaches and other places because the threat of second-hand smoke is diminished. The true benefit to those policies, rather, is what the public health ethicist Ronald Bayer calls “denormalizing” the habit by making it harder to find places to light up. There are now some 2,700 cities, counties and states that have some form of outdoor smoking ban. Add to that the fast-growing number of smoke-free college campuses, which has tripled since 2011, and the movement’s strongest support continues to be environmental restrictions.

“Smoke-free laws aren’t history,” Hahn warns. About half of the nation is covered by comprehensive smoke-free laws, she notes, “and that’s led to inertia. Generally, people think, ‘Oh, that’s over,’ because a lot of people who live in the more populated states, they do have good laws.”