Correspondence

State Expenditures for Tobacco-Control Programs and the Tobacco Settlement

N Engl J Med 2003; 348:663-664February 13, 2003

Article

To the Editor:

Gross et al. (Oct. 3 issue)1 provide a timely study of the effects of the November 1998 Master Settlement Agreement with tobacco companies. Unfortunately, their summary of state efforts does not include Arkansas, a state with one of the highest rates of tobacco-related deaths in the nation, minimal previous expenditures on tobacco control, and low per capita income.2,3 Despite the findings of Gross et al. that these characteristics are associated with decreased funding of tobacco-control efforts, Arkansas allocated all funds from the Master Settlement Agreement to new health programs and prioritized funds according to guidelines of the Centers for Disease Control and Prevention.3

Through a nonpartisan effort, the citizens of Arkansas passed the Tobacco Settlement Proceeds Act of 20004 by a two-thirds majority. This act established a $100 million Arkansas Healthy Century Trust Fund and allocated current and future revenue from the settlement as follows: 31.6 percent for programs for tobacco control and prevention; 29.8 percent for expansion of Medicaid coverage; 22.8 percent for tobacco-related medical research; and 15.8 percent for new state programs, including a College of Public Health, an Area Health Education Center in the Mississippi Delta, a Minority Health Initiative, and geriatric clinical centers throughout the state. As the provisions of an initiated act, these allocations have withstood state budget pressures and promise to lead the state to a healthier future.

On the basis of an empirical assessment of health burdens and their causes, the nonprofit, clinical, public health, educational, business, and political communities in Arkansas achieved what Schroeder calls for in his editorial in the same issue.5 Arkansas has pursued a course unlike that of other states, and the long-term effects of these investments of funds from the Master Settlement Agreement warrant examination.

Joseph W. Thompson, M.D., M.P.H.
Arkansas Center for Health Improvement, Little Rock, AR 72204
thompsonjosephw@uams.edu

I. Dodd Wilson, M.D.
University of Arkansas for Medical Sciences, Little Rock, AR 72204

Mike Huckabee
Governor's Mansion, Little Rock, AR 72202

5 References

1. 1

   Gross CP, Soffer B, Bach PB, Rajkumar R, Forman HP. State expenditures for tobacco-control programs and the tobacco settlement. N Engl J Med 2002;347:1080-1086
   Full Text | Web of Science | Medline

2. 2

   1999 Mortality statistics and 1999 behavioral risk factor surveillance data. Atlanta: Centers for Disease Control and Prevention, 2002. (Accessed January 9, 2003, at http://www.cdc.gov/scientific.htm.)
   

3. 3

   National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Best Practices for comprehensive tobacco control programs, August 1999. Atlanta: Centers for Disease Control and Prevention, 1999.
   

4. 4

   Arkansas Tobacco Settlement Proceeds Act of 2000, Ark. Code Ann. § 19-12-101 et seq.
   

5. 5

   Schroeder SA. Conflicting dispatches from the tobacco wars. N Engl J Med 2002;347:1106-1109
   Full Text | Web of Science | Medline

Author/Editor Response

We applaud the efforts of the citizens of Arkansas in establishing the Health Century Trust and approving legislation that requires investment of almost a third of the resultant annual revenue in tobacco-control programs. In our analysis of the funding of such programs, we included only those funds that were allocated directly to the programs for their use during fiscal year 2001. We also reported that many states established trust funds that serve as “endowments” from which funds will emanate in subsequent years. However, only 13 percent of the total dollars allocated were invested in these funds, and in many states, it is not clear what proportion of the subsequent revenues, if any, will be devoted to fighting tobacco use.

The statutorily directed investment of settlement dollars in tobacco-control programs has catapulted Arkansas into the upper echelon of states in terms of expenditures on such programs, increasing its expenditures by over 150 percent between fiscal years 2002 and 2003.1 In contrast, eight states have decreased their investment in tobacco-control programs by more than 20 percent during the same period.1

Leaner financial times will only make it more difficult to make decisions about prioritization of scarce state budget dollars. The political leaders of Arkansas are therefore to be commended not only for directing settlement funds to their state tobacco-control programs, but also for allowing the citizens to have a voice in the allocation process. By placing the settlement-allocation plan on the ballot, they ensured that the process was transparent and, more important, consistent with the wishes of the public. Voters in Montana recently approved a similar initiative, directing 32 percent of that state's revenues from the settlement to tobacco control.2 We can only hope that other states will follow suit.

Cary P. Gross, M.D.
Yale University School of Medicine, New Haven, CT 06520
cary.gross@yale.edu

Peter B. Bach, M.D.
Memorial Sloan-Kettering Cancer Center, New York, NY 10021

Howard P. Forman, M.D., M.B.A.
Yale University School of Medicine, New Haven, CT 06520

2 References

1. 1

   State legislated actions on tobacco issues: midterm update. Washington, D.C.: American Lung Association, August 2002:14-5.
   

2. 2

   Establish a statewide tobacco-use prevention program using tobacco settlement funds. No. I-146. Washington, D.C.: National Conference of State Legislatures, 2002. (Accessed January 24, 2003, at http://www.ncsl.org/ncsldb/elect98/profile.cfm?yearsel=2002&statesel=MT.)