Public Health Feature - November 2006
By Erin Prather
Don't be surprised if your patients are having an increasingly harder time giving up tobacco. A Massachusetts Department of Public Health (DPH) report says tobacco companies have steadily increased the nicotine dosage in all classes of cigarettes, even those branded as "light," since 1998. That, coupled with the paltry amounts the State of Texas spends on getting people to stop smoking compared with the fortune the tobacco companies pay to entice people to start or to continue, means you're going to need a persuasive argument against cigarettes.
Data were collected from reports submitted to DPH from 1998 to 2004 by companies selling cigarettes in Massachusetts (one of only three states that require tobacco companies to submit this information annually).
Besides upping nicotine dosages, the tobacco industry is spending an estimated $15.4 billion annually on marketing nationwide. The Campaign for Tobacco-Free Kids reports that $966.5 million is spent each year in Texas. By comparison, the state spent only $7 million on tobacco prevention programs in 2005.
State epidemiologist Vince Fonseca, MD, MPH, believes funding for antismoking programs must increase. He says 24,000 Texans die from smoking-related illnesses each year; for every Texan who dies, 20 more suffer from at least one serious illness attributable to smoking.
"Tobacco is the single most preventable cause of death and disease in Texas. The state allocates only 39 cents per Texan for tobacco prevention, and each year 60,000 Texas children become daily smokers."
As one of four states to settle with the tobacco industry separate from the November 1998 multistate settlement of a lawsuit against Big Tobacco, Texas agreed to launch a tobacco prevention pilot program. The tobacco industry agreed to pay the state $15 billion over 25 years and to pay $2.3 billion to Texas counties and hospital districts for caring for indigent patients. The settlement also directed $200 million to a Tobacco Education Enforcement Trust Fund.
Up to 7.5 percent of the annual interest generated from the trust is available to fund a tobacco prevention and cessation program. Only interest earned from each of the endowments is available to spend and must be appropriated by the Texas Legislature. No future payments go into the trust.
The initial payment went into permanent endowments earmarked for various purposes, including higher education, individual endowments for medical schools, children and public health, emergency medical services and trauma care, and community hospital capital improvement.
The state has the numbers to back up the impact money has on antismoking campaigns (see "An Antismoking Campaign by the Numbers").
The Texas Department of State Health Services (DSHS) began the Texas Tobacco Prevention Pilot Initiative in 2000 to study the effectiveness of a tobacco control program in Houston and Southeast Texas. The initiative supported youth prevention and adult cessation efforts with a media campaign, school and community education programs, and enforcement efforts. Three dollars per capita were spent on tobacco prevention.
An evaluation of the program by the Kaiser Permanente Center for Health Research found that between 1999 and 2002, adult smoking rates fell 5.1 percent in the pilot population, compared with 2.5 percent in the general public. An evaluation in 2004 showed that trend continuing. Smoking among high school students fell from 34 percent in 2000 to 18.8 percent in 2003 and to 18.3 percent in 2005.
Kaiser also calculated 29,643 fewer adult smokers as a result of one year's implementation of the program, and assumed there would be 163,622 fewer adult smokers if the program had been executed statewide.
"The reduction in youth and adult smokers is twice the reduction seen in the rest of the state where there was no initiative," Dr. Fonseca said. "Remember, the overwhelming majority of replacement smokers are youths. If they get past the teenage years and early adulthood without smoking, chances are they'll never pick it up."
Regarding costs, Kaiser estimates that spending $2.71 per capita in 2003 on the study's population generated a five-year savings of more than $252 million, or about $57 per capita. That's a $21 return for every $1 invested. If the antismoking initiative is implemented statewide at $3 per capita, Kaiser predicts a net return of $1.4 billion to the state in five years.
Kaiser also estimates that if the program had included physician counseling for patients to stop smoking, the number of new quitters would have increased by 7.7 percent. (See " A Clinical Toolkit for Treating Tobacco Dependence .")
Dr. Fonseca also points to a recent DSHS analysis showing a 50-percent decline of heart attack deaths in the study's population, compared with a 17-percent drop statewide, since the program began.
"It's no secret there's a connection between heart disease and smoking. It's not surprising to see a decrease of heart attacks in the pilot initiative area; it shows that these programs can drop the death rate. Not only does the Kaiser Center show these types of programs help economically, our data show they benefit the everyday health of Texans. That's why the Texas Tobacco Prevention Pilot Initiative should be implemented statewide," he said.
Eduardo Sanchez, MD, former state health commissioner and now director of the Institute for Health Policy at The University of Texas School of Public Health at Houston, says the Kaiser data that DSHS will give the legislature next year is "compelling" information.
"We can say, 'Here are the numbers, you decide. You have many tough choices to make, but here is one that will result in not only better health for your constituents, but also overall savings for the state. In fact, the savings will exceed the investments made,'" he said.
In May, the Texas Medical Association House of Delegates passed a resolution recommending the legislature appropriate adequate funds for reducing tobacco use. It also suggested that smoke-free public places for dining and drinking should be a priority for the 2007 legislative session.
Erin Prathercan be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email at Erin Prather .
An Antismoking Campaign by the Numbers
The Texas Tobacco Prevention Pilot Initiative, an experiment by the Texas Department of State Health Services to test the impact of an antismoking campaign in Southeast Texas, produced some dramatic results.
$3 per capita Amount spent on tobacco prevention
5.1 percent Smoking decline in pilot population
2.5 percent Smoking decline in general population
34 percent High school students who smoked in 2000
18.8 percent High school students who smoked in 2003
18.3 percent High school students who smoked in 2005
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Amarillo Clears the Way
Five years ago, the Amarillo Hospital District applied to use state tobacco settlement funds for a comprehensive tobacco control program. It was the first hospital district to do so. The program, called Tobacco Free Amarillo, focuses on preventing youths from using tobacco and encouraging adults to quit. It consists of five community outreach components: school programs, community programs, media, cessation programs, and program evaluation.
Mary Coyne, who is in charge of media, says she wishes more hospital districts would consider using their settlement funds for similar programs.
"Prevention and control programs are major components of the tobacco settlement, and it's frustrating that there are dollars not going in that direction. Before our program began, studies showed 42 percent of 12th graders smoked sometime in the past 30 days. That dropped to 25 percent in 2005, an overall 42-percent decrease," she said.
Examples of Tobacco Free Amarillo's efforts include a tobacco prevention presentation to sixth-graders, education through the Women, Infants, and Children program about tobacco dangers, and school-based preventative curriculum.
A Clinical Toolkit for Treating Tobacco Dependence
A physician's advice can have tremendous influence on a patient's tobacco use. Current data show that in less than three minutes of counseling, a physician can help double a patient's chance of success.
DSHS offers an online toolkit to support tobacco intervention efforts. Available at www.dshs.state.tx.us/tobacco/toolkit.shtm , the toolkit offers flexibility to meet the needs of different office practices and different patients and seeks to accommodate the busiest practitioner.
Additionally, patients who participate in counseling and are referred to the DSHS Quitline at (877) 937-7848 by their physician receive a free two-month supply of nicotine replacement patches. The offer is available only while supplies last.
Other materials to help physicians help their patients stop smoking are available from TMA's Physician Oncology Education Program (POEP). Contact POEP at (800) 880-1300, ext. 1672, or (512) 370-1672; or e-mail POEP .
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Smoke-Free Ordinances Increasing; Database Now Available
The release of a recent U.S. Surgeon General's report concluding that there is no risk-free level of exposure to secondhand smoke has spurred a continuing increase in questions about smoking ordinances across Texas. The report concludes that secondhand smoke causes lung cancer, heart disease, sudden infant death syndrome, low birth weight, asthma, bronchitis, and other serious illnesses, and is responsible for tens of thousands of deaths each year in the United States.
Currently, 240 Texas cities have antismoking ordinances. Earlier this year, the Beaumont City Council banned smoking in all enclosed public places, including bars. It joined Laredo, El Paso, Lubbock, and Austin in passing such ordinances.
Despite efforts by opponents to overturn the decision, the Beaumont ban went into effect Aug. 1. Texas physicians and medical students have been instrumental in getting the bans passed in each city.
Larger cities, like Dallas and Houston, continue to have more lenient restrictions, despite attempts by supporters to pass stricter ordinances. Although both cities have banned smoking in most public places, residents can continue to light up in stand-alone bars.
In Austin, bar owners have complained of decreasing clientele and difficulty in interpreting that city's law. Austin allows establishments to use their own "rules" to enforce the smoking ban, just as they do for public intoxication. Last summer, U.S. District Judge Sam Sparks ruled that the ban was too vague on enforcement and asked the city council to define how bars can implement the ordinance. The council had not acted at press time.
A 2005 indoor-air quality study by The University of Texas College of Engineering and the Texas Department of State Health Services (DSHS) found Austin indoor-air quality greatly improved after the ban started. Measurements were made for 30- or 60-minute periods during the month before the ordinance was passed and again on the same day of the week and time of day in the month after the ordinance went into effect. A statistically significant decrease in particulate matter and carbon monoxide was seen in all bars after the ban, except for one venue that was exempt from the ordinance. Researchers found no significant change in the overall number of patrons.
Last July, DSHS announced creation of an online database containing information about smoking ordinances in Texas cities. The database was developed by the University of Houston and funded by DSHS. Available at http://txshsord.coe.uh.edu/ , the Texas database contains the text of ordinances and can be used to compare policies, provide summaries, and compile customized reports.
Tobacco: Who Is Winning the War?
By Joel S. Dunnington, MD
In 1900, very few people smoked cigarettes. Lung cancer was a very rare disease. In 1950, two large epidemiology studies demonstrated a significant correlation between smoking and lung cancer. In 1953, Ernst Wynder showed that painting tar on the skin of a mouse caused cancer. The industry's own internal research documented carcinogens in cigarette smoke in the early 1950s.
A responsible, ethical corporation would have removed its products from the market or, at the very least, would have researched its products and made them safe. Instead, the tobacco industry met in secret and set up an organized conspiracy of lies, disinformation, public relations manipulation, and scientific fraud that lasted at least until Aug. 17, 2006. On that day, U.S. District Judge Gladys Kessler judged the tobacco industry guilty of fraud, conspiracy, and racketeering. It took 1,653 pages to summarize this industry's acts of racketeering over the past 50 years.
When the suit was filed, the tobacco industry originally faced possible fines and loss of ill-gotten gains of at least $280 billion. However, a U.S Court of Appeals struck down the racketeering provisions. So even though it was found guilty, the tobacco industry does not have to pay any fines or restitution. It must pay only about $140 million in attorney's fees and court costs. It must publish corrective statements about light and ultra-light cigarettes. The companies must also promise to never carry on the racketeering activities they have been engaging in for the past 50 years. Two weeks after the ruling, the tobacco industry came back to the judge and asked if this applied only to the United States or if she meant the entire world. If they have to come clean in the United States, they want to continue their activities around the rest of the world.
On May 21, 2003, the World Health Organization passed the first health treaty in history, the Framework Convention on Tobacco Control. The treaty contains strong tobacco control measures. It has been signed by 168 countries and ratified by 138 countries. But not the United States.
This treaty entered into force on Feb. 27, 2005. It was the fastest enactment of any treaty in history. The problem is President Bush, whose delegation tried to kill or weaken the treaty during the convention and who has refused to send it to the U.S. Senate for ratification. While the rest of the world is moving ahead with smoke-free laws (14 countries) and restrictions on advertising and sales to minors, the U.S. Congress has passed only one significant smoking restriction in the past 50 years, banning smoking on airlines.
In 1986, then-Surgeon General C. Everett Koop, MD, released the first report on secondhand smoke. Twenty years later, Surgeon General Richard Carmona, MD, updated the first report. He said, "The scientific evidence is indisputable: Secondhand smoke is not a mere annoyance. It is a serious health hazard that can lead to disease and premature death in children and nonsmoking adults." He also said, "Smoke free environments are the only approach that protects nonsmokers from the dangers of secondhand smoke."
Texas has received billions of dollars in tobacco settlement money since the tobacco lawsuit was settled. Texas also has collected billions of dollars in tobacco taxes over that time. Texas set up a fund to create a tobacco prevention and control program. The maximum Texas has ever allocated was $12 million per year. It is currently funded for $7 million in 2006. The U.S. Centers for Disease Control and Prevention's recommended funding for a comprehensive tobacco prevention program is $103 million to $284 million.
The tobacco control group at the Texas Department of State Health Services (DSHS) decided to take a portion of the settlement money and, with $3 per capita, target the Beaumont/Port Arthur area with a comprehensive tobacco prevention and control program. The program demonstrated a 32-percent reduction in tobacco use in middle school students and a 41-percent reduction among high school students. The adult smoking prevalence dropped 18.7 percent.
The reward for such a great job of reducing smoking with so little money was to move the program from the Chronic Disease Section of DSHS to the Substance Abuse Section. We'll see if the program continues in the future.
Richard Peto, MD, of Oxford University, says 100 million people died from tobacco in the 20th century. If the current smoking rate continues, 1 billion people will die from tobacco in the 21st century. In the United States, five people have died from anthrax since Sept. 11, 2001; more than 2 million Americans have died from tobacco in the same time. Who are the real purveyors of weapons of mass destruction? Who is really winning the tobacco war?
Dr. Dunnington is an associate professor of radiology at TheUniversity of Texas M.D. Anderson Cancer Center in Houston and a passionate opponent of smoking.
November 2006 Texas Medicine Contents
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