Analysis: How can Missouri improve on its failing smoking grade?
This article first appeared in the St. Louis Beacon, Jan. 27, 2009 - The good news about Missouri’s failing grade on the American Lung Association's nationwide report card on tobacco control policy is that the student wants to buckle down and get better.
Released Jan. 13, the report, “State of Tobacco Control 2008,” rates states in four categories: tobacco prevention and control spending, smoke-free air laws, cigarette tax rates and coverage for cessation treatment. Missouri, along with six other states -- Alabama, Kentucky, North Carolina, South Carolina, Virginia and West Virginia -- received failing grades in all four categories. Illinois got a mixed report card. For instance, it got an A for smoke free air, but an F for program spending.
“Missouri ranks at the bottom of the list in the whole country when it comes to battling tobacco use and the public health problems that it causes,” said Michelle Bernth, senior vice president of communications for the American Lung Association of the Central States.
But the picture is not entirely bleak. The Missouri Foundation for Health, a non-governmental funder of health activities, is in the middle of a nine-year, $40 million initiative to reduce tobacco use statewide. In 2007 and 2008, the foundation funded a statewide tobacco survey, managed by the Missouri Department of Health and Senior Services. It found that Missourians in general want to do more to combat tobacco use. According to the survey of almost 50,000 people, 56 percent of Missouri adults favor laws to prohibit indoor smoking and most people who do smoke report a desire to quit.
An Incredible Addiction
For now, the Lung Association’s report card stands as a reminder of how far the state must go to catch up with the rest of the nation.
“It's depressing that we would do so poorly,” said Bryan Meyers, chief of thoracic surgery at Barnes-Jewish Hospital and Washington University School of Medicine, who was not involved with the report. Specializing in diseases of the lungs and chest, Meyers sees first hand the consequences smoking has on his patients, many of whom have diseases like lung cancer, esophageal cancer, and emphysema. “Almost 90 percent of lung cancer cases are related to smoking,” Meyers said. “I think anything we can do to reduce smoking will reduce those consequences.”
Quitting, however, is no small task.
“It's an incredible addiction,” said Meyers, seeing many of his patients continue to smoke, even after lung cancer surgery. “You'd think that a brush with death in the face of lung cancer would shock someone into not smoking,” he said. “But some still smoke despite their best efforts.”
According to the report, almost 25 percent of Missouri's adults smoke, followed closely by the state's high schoolers, at almost 24 percent. The report estimates that tobacco cost Missouri - with some of the highest smoking rates in the country - more than $4.7 billion a year in health care costs and lost productivity between 2000 and 2004. Tobacco-related illness is the leading cause of preventable death in the United States. Without stronger tobacco control policies, Bernth said, “We will keep generating smokers in this state and continue to have the economic costs and deaths attributable to smoking.”
Contributing to the failing grades were Missouri's low spending on tobacco control programs, a lack of laws that bar smoking in places like bars and casinos, a cigarette tax of only $0.17 a pack, (higher only than South Carolina's $0.07 a pack,) and a lack of Medicaid coverage for medicines and counseling to help smokers quit. “We haven't addressed these issues,” said Bernth, “And our smoking rate continues to be high.”
“We are not funding programs that are proven effective in helping adults quit smoking and keeping youths from starting to smoke,” said Bernth. The $2.6 million Missouri now spends on tobacco control programs falls short – 28 times short – of the minimum $73 million recommended by the Centers for Disease Control and Prevention. Funding smoking prevention and cessation efforts can reduce health care costs.
Surgical patients who smoke have a higher risk of complications after surgery and tend to remain in the hospital longer, Meyers explained. “The cost of their care is measurably higher than patients who are nonsmokers,” he said.
Missouri's $0.17 cigarette tax is seven times lower than the national average of $1.19 a pack. Bernth said that smoking rates go down for both youth and adults when the cigarette tax increases. While acknowledging that tax increases are frequently unpopular, Meyers said this one should appeal to the nonsmoking majority. “If there is one tax we should all embrace, it ought to be increased taxation on smoking,” she said.
According to the U.S. surgeon general, any exposure to second-hand smoke, no matter how small, poses a health risk and that supports the argument for prohibiting smoking in all indoor areas, including bars and casinos. “Smoke-free laws help protect the health and rights of nonsmokers,” said Bernth. While smoking is prohibited in Missouri's public schools and child-care facilities, it is only restricted in public and private workplaces, stores, and restaurants. At bars and casinos, there are no required restrictions at all.
A new category in the 2008 report, this grade assessed the states' requirements for smoking cessation treatment coverage from private insurers, state employee health plans and Medicaid. In Missouri, Medicaid, which helps those in lower income groups, provides no coverage for medication and no coverage for counseling. Bernth calls this a travesty, especially since those on Medicaid have higher than average smoking rates.
“We're talking about people who can't afford to get help on their own, want to quit smoking, and we're not doing anything as a state to help make that happen,” she said, pointing out that these people will continue to smoke and require expensive health care at taxpayer expense. “It's a vicious cycle that we could change if we made an effort to help them quit smoking,” she said. While each of these four categories is an important indicator of the state of tobacco control, Bernth said, “We know that the combination of these things – that's the important part -- is proven to drive down smoking rates.”
While failing grades on Missouri's report card reflect a lack of action on tobacco policy, Matthew Kuhlenbeck, program officer for the Missouri Foundation for Health's Tobacco Prevention and Cessation Initiative, sees opportunities. “We want to help communities make positive policy change and address health equity around tobacco use,” he said. The foundation’s statewide tobacco survey looked at individual counties. It revealed attitudes about smoking in different areas and showed that counties with high smoking rates also have poor health care coverage. The new information could inform local strategies to reduce smoking and help communities take action, said Beverly Pfeifer-Harms, director of communications for the Missouri Foundation for Health.
In taking action, both Pfeifer-Harms and Kuhlenbeck explained the importance of tailoring tobacco interventions to the community. For example, smoke-free efforts in Columbia would look different from cessation services in Missouri's Bootheel region where the smoking rate is over 30 percent and fewer people have health insurance.
“Communities with higher rates of tobacco use may be more highly targeted for media messaging,” said Kuhlenbeck. He also talked about the importance of culturally appropriate interventions. He explained that traditional cessation classes are not always effective, especially when smoking is a strong part of the culture, like in the Bosnian immigrant community in St. Louis, for example.Community Voices
The foundation's efforts show the benefits of investing in smoking prevention and cessation and support the argument for increased government funding. Kuhlenbeck spoke in monetary terms. “It's been documented repeatedly that the return on investing in tobacco use prevention and cessation is substantial,” he said. And to make it happen, Kuhlenbeck emphasized the importance of individual voices. “Without them, there's nothing to prompt people to make change,” he said.
Bernth agreed. “The most important thing is to speak out to legislators and local policy makers,” she said. “Let them know that Missouri is tired of being at the bottom of the list. We want to see real changes on this front.”
Julia Evangelou Strait is a freelance science writer based in St. Louis. She has a master's degree in biomedical engineering and works in hospital epidemiology for BJC HealthCare.