Cover Story - December 2007
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
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
"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
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
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
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.
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
"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
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
Success in Southeast Texas
In 2000 and 2001, the state managed tobacco prevention pilot
programs in 18 East Texas communities. The programs differed in
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
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
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
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
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,"
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
"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
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
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
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
The Evolution of Tobacco Settlement Funding
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
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
FY 07 Tobacco Prevention Spending
Percentage of CDC Minimum
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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
Dr. Sanchez estimates that simply increasing the instance of
physician counseling to 90 percent could save 3,220 lives in
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
or call Stephanie Gonzalez at (800) 880-1300, ext. 1469. A
PDF can also be downloaded on the Web site,
. And on the site, you can access the self-study continuing medical
education course, Tobacco Intervention and the Healthcare
HIT Can Help
To track and document smoking cessation counseling, TMA endorses
DocSite Registry, available online at
. 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
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
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
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
Smoking and Tobacco-Use Cessation Counseling
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
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
"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
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
- 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
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