Up in Smoke: Texas' Smoking Prevention Efforts Not Enough

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Cover Story - December 2007  


By  Crystal Conde
Associate Editor  

Watching patients suffer or die from a preventable disease tends to color a physician's thinking. Meet Joel Dunnington, MD.

A radiologist at The University of Texas M.D. Anderson Cancer Center and consultant for the Texas Medical Association's Council on Public Health, Dr. Dunnington is an outspoken tobacco opponent. His views on the most preventable cause of premature death and disease in the United States may seem radical to some. He openly calls for holding executives, board members, lawyers, and lobbyists associated with the tobacco industry accountable for crimes against humanity for racketeering, conspiracy, and murder. He also speaks with sorrow and outrage about the toll tobacco-related diseases take on the patients he sees.

"I see people who can't swallow, they can't talk, and they have artificial tubes between their airway and esophagus so they can speak," he said. "I see these folks every day. Twenty-five percent of patients who come to M.D. Anderson do so because of smoking."

Many physicians have walked in Dr. Dunnington's shoes and can relate to the harsh consequences of tobacco. Christopher Ruud, MD, president of the Texas Society of Medical Oncology, is among those who have witnessed the ravages of lung cancer. Even with advanced treatments, smokers diagnosed with the disease face a grim reality.

"What's more compelling for smokers is to find out they won't die a sudden death, but that in fact it's going to be a lingering death," said Dr. Ruud, chair of TMA's Committee on Cancer and steering committee member of the Physician Oncology Education Program (POEP).

The Texas numbers are appalling. The Campaign for Tobacco-Free Kids estimates that tobacco kills 24,200 adult Texans every year. Secondhand smoke and smoking during pregnancy account for 2,420 to 4,300 deaths each year. The organization projects that 503,000 children living in Texas today will ultimately die from smoking.

Among Texas high school students, 24 percent smoke, and 12 percent use smokeless tobacco. The campaign reports that 112,100 children younger than 18 try cigarettes for the first time each year in the state.

Numbers like that are a prime reason Dr. Dunnington and other antismoking advocates are furious that Texas' smoking prevention efforts have been mediocre at best, despite receiving a $17.3 billion payout over 25 years, starting in 1998, as the third state to settle a lawsuit against Big Tobacco. Following Texas' settlement that year, 46 states and the District of Columbia settled with the tobacco industry. The lawsuit alleged the tobacco industry violated conspiracy, racketeering, and consumer protection laws, as well as other provisions of state and federal law. Of the $17.3 billion, Texas counties and hospital districts received about $2.3 billion through 2003.

Today, antitobacco advocacy groups and physicians are appealing to state lawmakers to invest tobacco settlement funds fully in comprehensive, statewide approaches toward prevention and cessation. And they're working to shift the entire state in a smoke-free direction. Cuts in funding and restructuring of appropriations, however, have weakened the state's efforts to curtail smoking and are costing tens of thousands of lives each year.

Dr. Dunnington contends the Texas Legislature hasn't done enough to fight tobacco use in Texas.

"Lung cancer, the No. 1 cancer killer in men and women, is almost 100-percent preventable," he said. "We're wasting a lot of money and lives and addicting a lot of kids."

A key state lawmaker says physicians must convince more legislators, including House and Senate leaders, that spending more money on antismoking efforts will pay off.


High Expectations  

The state had good intentions for the $17.3 billion. David R. Smith, MD, president of SUNY Upstate Medical University, was the commissioner from 1992 to 1996 of what was then the Texas Department of Health, now the Texas Department of State Health Services (DSHS).

"The expectations were that we would see a significant investment in the preventive side of tobacco and the effects of firsthand, secondhand smoke, and smokeless tobacco in the state of Texas," he said.

Significantly cutting tobacco use statewide requires a comprehensive approach, a large investment in funding, and a focus on preventing adolescents from taking that first puff. To be effective, the U.S. Centers for Disease Control and Prevention (CDC) recommends that states employ proven strategies (such as tax increases on tobacco products) and programs that keep kids from buying cigarettes and that counter pro-tobacco advertising.

Texas made progress on the tobacco tax front when it hiked the tax by $1, to $1.41 per pack, as of January. According to the Texas Comptroller of Public Accounts' office, from January to September 2006, tobacco taxes in the state generated $370,097,741. During the same period this year, the tax has brought in more revenue, $1,105,996,360. Revenue generated from the tobacco tax increase goes to fund public education.

The comptroller's office doesn't have a way of tracking the number of cigarette packs sold, but does sell tax stamps to cigarette distributors. From January to September 2006, distributors purchased 942,348,000 stamps. This year, during the same time span, fewer stamps, 759,536,700, have been sold.

In addition to increasing tobacco taxes, CDC proposes that a state the size of Texas spend $5 to $16 per capita annually - at least $103 million. Texas, however, has a 2008-09 budget of only about $21.5 million to develop a statewide program to reduce tobacco product usage; that's less than $1 per capita.

For fiscal year 2007, Texas invested about $5.4 million, or 5 percent of the CDC recommendation, ranking it 45th nationally in tobacco prevention spending.

Only three states - Colorado, Delaware, and Maine - fund tobacco prevention initiatives at the CDC's minimum recommendation. In contrast, Michigan, Mississippi, Missouri, New Hampshire, and Tennessee have committed no tobacco settlement revenue to prevention programs. (See " Tobacco Prevention Spending, by State .")

The CDC's 1999 report, "Best Practices for Comprehensive Tobacco Control Programs," found that across the nation, state funding for comprehensive tobacco prevention and control programs is "sorely inadequate." The report concludes that the more tobacco settlement money states spend on prevention and control, the greater the reduction in smoking. It said long-term investments in comprehensive programs yield immense, lasting effects.


A Good Start  

In the early days after the tobacco settlement, Dr. Smith says, the Coalition for Healthy Texans, cofounded by TMA and the Texas Hospital Association, did a good job of rallying awareness of the need to dedicate the tobacco funds to health care. The coalition of more than 40 health care and consumer organizations stopped tobacco dollars from being diverted into non-health care projects.

The 1999 and 2001 legislatures invested $1.5 billion of the tobacco settlement funds into endowments for education, health care, and research. Specifically, the endowments reserved money for medical schools and universities, children and public health, emergency medical services and trauma care, allied health, minority health research and education, and capital improvements to rural health facilities and community hospitals.

The 1999 legislature also allocated $200 million for a Permanent Endowment for Tobacco Education and Enforcement. Up to 7.5 percent of the interest generated from the trust each year finances a tobacco prevention and cessation program known as the Texas Tobacco Prevention Initiative.


Success in Southeast Texas  

In 2000 and 2001, the state managed tobacco prevention pilot programs in 18 East Texas communities. The programs differed in comprehensiveness.

Port Arthur launched the most robust program, at a cost of $3 per capita. It focused on implementing CDC-endorsed school courses, working with community groups to educate minority students, surveying tens of thousands of students and adults over the phone, and curtailing the sale of cigarettes to minors through enhanced law enforcement efforts. It also developed media campaigns aimed at children and teenagers and provided up to three free telephone sessions of cessation counseling by trained bilingual counselors.

The program worked. Survey results released in 2001 showed Port Arthur reduced smoking by 40 percent among sixth and seventh graders. In addition, tobacco use among youths in sixth to 12th grade declined from 35 percent to 21 percent in Jefferson County as a whole. In the same region, tobacco use decreased from 35.7 percent to 26.6 percent among adults aged 18 to 22 from 2000 to 2004.

The December 2006 DSHS "Progress on Achieving Texas Tobacco Reduction Goals: A Report to the 80th Legislature" says less-intensive programs in communities with funding ranging from 25 cents to $2.50 per capita showed no measurable reduction in tobacco use in adults or children.

Noting the success of the Texas Tobacco Prevention Initiative, the 2002-03 state budget included $12.5 million per year to expand the program into Harris, Fort Bend, Jefferson, and Montgomery counties.

The return on the investment was evident. The DSHS progress report cites a Kaiser Permanente study that examined the Southeast Texas program. By investing $3 per capita, or about $4.3 million, in 2003 alone, the region saved more than $252 million in medical care costs and lost productivity. The initiative also resulted in 29,800 fewer adult smokers.

The report indicates that investing $3 per capita, or approximately $68 million, in a statewide program would result in about 163,600 fewer smokers in Texas. Five years after implementation, the state would save $1.4 billion in medical care costs and lost productivity. (See " Tobacco-Related Monetary Costs in Texas .")

Vincent Fonseca, MD, MPH, DSHS state epidemiologist, cites CDC data that the combined direct and indirect costs of tobacco use total $12.3 billion per year in Texas. Investment in comprehensive programs would lower those costs.

"We knew it [Southeast Texas project] was going to cost a lot to fund it initially, but we would have great benefits in not only those direct and indirect costs, but also in preventing people from starting smoking and helping people quit smoking," Dr. Fonseca said.

Dr. Dunnington says the project proved that pumping funds into a comprehensive package encompassing education in schools, targeted media messages, stings on sales of tobacco products to minors, and community intervention could cut down on smoking.

Eduardo Sanchez, MD, MPH, director of the Institute for Health Policy at The University of Texas School of Public Health in Austin and former DSHS commissioner, agrees that a comprehensive program yields the greatest results for communities.

"If you spend what you have throughout the state, you may end up with less effect than you would if you concentrated dollars in certain parts of the state and put comprehensive programs there," he said.


The Good Times End  

The Texas Tobacco Prevention Initiative received a blow the following fiscal year, when the 2003 legislature decreased funding for prevention in the 2004-05 budget to $7.4 million a year. As a result, only Beaumont and Port Arthur continued to receive $3 per capita in expenditures. Other counties received tobacco prevention funds, but at less than $3 per capita.

In fiscal year 2006, Texas spent $7 million on prevention. As of Aug. 31, 2007, that amount dropped to $5.4 million.

Dr. Smith worries when states cut funding for tobacco prevention and control.

"A lot of states have used tobacco settlement monies as general funds to plug in a lot of different holes. I don't think that was the intent of the settlements. I think there is reason to be concerned, particularly when we could be preventing needless deaths," he said.

In 2007, DSHS recommended the legislature expand the $3 per capita comprehensive tobacco prevention program to other areas of Texas through $54 million in appropriations. That didn't happen. Instead, the legislature appropriated $21.5 million to develop a statewide program to reduce the use of tobacco products for fiscal year 2008-09 - about $10.5 million and $11 million, respectively. The legislature restructured how it appropriates money for comprehensive tobacco prevention programs. Despite the success of the Texas Tobacco Prevention Initiative, as of this month, the program will no longer receive state funding.

In its place, Southeast Texas counties will have the option of joining other communities across Texas in submitting requests for proposal for a portion of approximately $1.3 million the legislature appropriated for the Tobacco Prevention and Control Coalition Program.

The four to six communities to receive funding in 2008 must conduct in-depth needs assessment regarding community tobacco use and tobacco-related health consequences among youths and adults; address building capacity needs; and plan, implement, and evaluate evidence-based tobacco prevention and control strategies designed to address tobacco use among adults and youths.

According to Carrie Williams, DSHS assistant press officer, the new community-based projects will take effect Feb. 1. Money can be used to fund local health departments, school districts, or any entity that wants to launch a comprehensive prevention program. Ms. Williams says performance and the availability of funds will be the basis of decisions to renew contracts with communities in 2009.

Sen. Jane Nelson (R-Lewisville), chair of the Senate Health and Human Services Committee, says awarding grants to local entities is a solid approach to reducing and preventing smoking statewide, allowing the state to get "the most bang for our buck."

When asked why the legislature has failed to appropriate $3 per capita to fund a statewide program, she responded, "I advocated for the statewide expansion of community- and school-based prevention efforts because projects such as the one in East Texas have been extremely effective. If we can keep young Texans from taking up the habit as teenagers, it is less likely that they will become adult tobacco users. DSHS estimated that about $21 million would be needed to accomplish this. We requested that amount but ended up with about half."

She added that to succeed in antismoking efforts, "the medical community must educate more legislators and the leadership, some of whom remain unconvinced that these investments will result in a long-term savings."

Joel Romo, vice president of advocacy for the American Heart Association, says his organization agrees with legislative expectations that program participants be subject to reporting requirements and use of evidence-based interventions for tobacco prevention.

But he says the $21.5 million for a statewide program in 2008 and 2009 "isn't even a drop in the bucket."

"We're asking the 2009 legislature to revisit the distribution of funds from the tobacco settlement and to put more in prevention and cessation programs for the benefit of Texas tax payers and the public health of citizens," Mr. Romo said.

The heart association, along with the American Cancer Society and other stakeholders, is a member of TMA's Public Health Coalition. The group, formed this year, addresses cancer, tobacco usage, stroke, and obesity in Texas.

Dr. Sanchez appreciates the dramatic effect smoking cessation can have on residents and the tremendous return on investment in terms of reduced health care costs.

"The best I can figure is that at the end of the day when the legislators have considered all the different things they have to think about investing state general revenue in, their list looks different than perhaps a physician-generated list would look," he said. "It is vexing because both the health impact and the cost effectiveness of reducing tobacco use are overwhelmingly conclusive that we could have decreased disease and a positive effect on the state's bottom line."

Crystal Conde can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at  Crystal Conde .  



See also: The Evolution of Tobacco Settlement Funding  [ PDF ]




Tobacco Prevention Spending, by State

You may be wondering how Texas stacks up to neighboring states when it comes to tobacco settlement expenditures focused on tobacco prevention.

According to the U.S. Centers for Disease Control and Prevention (CDC), Arkansas and New Mexico have committed substantial expenditures of at least 50 percent of the CDC minimum toward funding prevention programs. Louisiana and Oklahoma have pledged modest funding at 25 percent to 50 percent of the CDC minimum.

Texas trails this year with an allocation of less than 25 percent.




FY 07 Tobacco Prevention Spending  

CDC Minimum


Percentage of CDC Minimum  

State Ranking  


$15.10 million

$17.91 million




$8 million

$27.13 million



New Mexico

$7.70 million

$13.71 million




$10 million

$21.83 million




$5.2 million

$103.29 million



Source: Tobaccofreekids.org  

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Smoking Cessation Counseling: It's Up to You

Although funding is lacking at the state level, physicians can make a difference in curtailing smoking. Former state health commissioner Eduardo Sanchez, MD, believes physicians can often be the catalyst for motivating patients to quit smoking.

"Physicians may not realize the effect they can have. The effect occurs at a population level. It may be one or two people, but when you multiply what doctors can do over the population, you start having that dramatic effect," he said.

The Partnership for Prevention reports that an additional 42,000 lives could be saved annually if physicians provided counseling, medication, and assistance to quit to 90 percent of smokers. Currently, only 28 percent of smokers receive such services.

Race and ethnicity also play a role in delivery of preventive services. Compared with white smokers, Hispanic smokers are 55 percent less likely to receive cessation counseling from a health care professional. According to the Texas Department of State Health Services, access barriers to health care such as insurance, income, and availability of and proximity to physicians can impede equitable health care delivery in certain racial and ethnic populations.

Dr. Sanchez estimates that simply increasing the instance of physician counseling to 90 percent could save 3,220 lives in Texas.

To help physicians with smoking cessation counseling, TMA offers its new Tobacco Cessation Pocket Guide, available through the Physician Oncology Education Program (POEP). The guide instructs physicians on a five-step intervention protocol: ask, advise, assess, assist, and arrange. It also features information on nicotine replacement therapies.

POEP, established in 1987, educates primary care physicians in Texas on the lifetime screening guidelines for the early detection of cancer and carries out the recommendations of the Texas Cancer Plan regarding physician education. A 21-member steering committee of cancer prevention and control experts advises POEP.

To order a free guide, e-mail  POEP  or call Stephanie Gonzalez at (800) 880-1300, ext. 1469. A PDF can also be downloaded on the Web site,  www.poep.org . And on the site, you can access the self-study continuing medical education course, Tobacco Intervention and the Healthcare Provider.

HIT Can Help  

To track and document smoking cessation counseling, TMA endorses DocSite Registry, available online at  www.docsite.com . The registry offers resources that help physicians ask the right questions about a patient's tobacco use, correctly determine which patients require follow-up care, measure the consistency and effectiveness of delivered care, and share patient needs with each member of the health care team.

DocSite LLC is the technology partner of the Physicians' Foundation for Health Systems Excellence, created by the settlement of the federal class action antiracketeering lawsuit against the nation's for-profit HMOs by TMA and other state medical societies and physicians. TMA will receive a set number of prepaid DocSite licenses and one-year subscriptions. Physicians interested in participating can call TMA's Health Information Technology Department at (800) 880-5720 or e-mail  HIT .

Hospitals Already Counseling  

Physicians' offices aren't the only sites conducive to counseling. TMF Health Quality Institute, the Medicare quality improvement organization for Texas, is evaluating adult smoking cessation counseling for hospital patients treated for heart failure, acute myocardial infarction, or pneumonia.

The Centers for Medicare & Medicaid Services (CMS) requires acute care hospitals to report counseling patients on smoking cessation through administrative or medical record data.

Since 2006, TMF has witnessed an increase in the percentage of patients receiving this counseling:


Adults Receiving Smoking Cessation Counseling  


Q1 2006

Q1 2007

Heart failure



Acute myocardial infarction






TMF Senior Vice President of Operations Kevin Warren says patients hospitalized with one of the health conditions measured and directly suffering the consequences of smoking may be more receptive to advice on quitting the habit.

"Not all heart attacks are from smoking, but it's an opportunity to teach patients that it's a factor," Mr. Warren said.

Although smoking cessation intervention in a physician's office isn't a health quality measure reported to TMF, Mr. Warren recognizes that counseling patients before they end up in the hospital is valuable, as well.

"We do encourage that discussion to occur within the office setting. When you look at the impact that physicians have, any time a doctor has that teachable moment opportunity to talk to a patient who smokes, we're in favor of that," he said.

For more information about TMF's smoking cessation counseling or other quality improvement measures, contact the organization at (800) 725-9216.

Physicians and other health care professionals can learn more about smoking cessation counseling documentation, sessions, and coverage information by visiting the CMS Web site and downloading the " Smoking and Tobacco-Use Cessation Counseling Services " [ PDF ] brochure.




Smoking: Nip It in the Bud

Because smokers often develop the habit early on, physicians, legislators, the Centers for Disease Control and Prevention (CDC), and the Texas Department of State Health Services (DSHS) recognize the need to provide school programs that educate students about the dangers of smoking. In fact, DSHS will enter into a partnership with the Texas Education Agency (TEA).

The legislature has appropriated $3 million annually for fiscal year 2008-09 to fund a school-based program focused on preventing and reducing tobacco use among children in grades 4 through 12. The program must follow the CDC's Guidelines for School Health Programs to Prevent Tobacco Use and Addiction, including teacher training, parental involvement, cessation services, and linking school efforts with community coalitions and statewide media and education campaigns.

Targeting antismoking messages to children is an important step in the state's journey to become smoke-free. James Gray, director of government relations for the American Cancer Society, says his organization's involvement in the Smoke-Free Texas Coalition, of which TMA is a member, helps boost antismoking activity at the local level.

"I think what you clearly have is a real sense that Texas is moving in the smoke-free direction. It's inevitable that the state and the entire country will be smoke-free," he said. "Texas will be well positioned to enact smoke-free legislation by 2009."

TMA backed smoke-free legislation in 2007, but to no avail. House Bill 9 by Rep. Myra Crownover (R-Lake Dallas) and SB 368 by Sen. Rodney Ellis (D-Houston) would have eliminated smoking in all workplaces and public places, including places of employment and venues where outdoor events take place. It also would have prohibited smoking within 15 feet of an entrance, operable window, or ventilation system of an enclosed area.

The legislation was watered down during the legislative process and eventually died in the Senate.

TMA will continue to champion smoke-free legislation in future sessions.




Tobacco-Related Monetary Costs in Texas

  • Annual health care expenditures in the state directly caused by tobacco use: $5.83 billion
  • Annual health care expenditures in Texas from secondhand smoke exposure: $317.6 million
  • State Medicaid program's total health expenditures caused by tobacco use: $1.6 billion
  • Smoking-caused productivity losses in Texas: $6.44 billion
  • Smoking-caused health costs and productivity losses per pack of cigarettes sold: $9.90

Note: The productivity loss amounts above account for death from smoking. Smoking-caused work absences, on-the-job performance declines, and disability account for additional work productivity losses totaling tens of billions of dollars nationwide.

Source: Campaign for Tobacco-Free Kids, The Toll of Tobacco in Texas  

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