For Whom Prevention Pays

This post is part of a âglobal health blog carnivalâ effort that Christine Gorman at Global Health Report has just launched. The theme for todayâs posts is âprevention vs. treatmentâ â visit this post for links all participating posts.

Although my post focuses largely on the U.S. experience, itâs an example of a universal difficulty in justifying and funding prevention programs.

Maggie Mahar and Niko Karvounis have posted some disturbing news at their Health Beat blog: The war against tobacco is slowing down. Many strategies that have helped lower the U.S. smoking rate to under 20% (counseling, quit lines, cessation clinics, and medications) simply canât compete with other spending needs:

Slowly but surely, states have been getting out of the tobacco control business. A recent report from the American Lung Association found that overall funding for state tobacco control programs declined by 28 percent between fiscal years 2002 and 2005, a slow-down that has serious public health repercussions. A 2005 study published in the American Journal of Public Health (AJPH) concluded that if states spent just the minimum amount recommended by the CDC, youth smoking rates would be 3 percent to 14 percent lower nationwide; a 2008 AJPH study found that if states spent just the minimum amount recommended by the CDC between 1995 and 2003, there would be been between 2.2 million and 7.1 million fewer smokers in the US today.

Whatâs going on here? The short answer is that states are spending the money meant for tobacco control on other things.

States got a total of $206 billion over 25 years from the 1998 Master Settlement Agreement with tobacco companies, but theyâve devoted only a small fraction of that to smoking prevention and cessation programs. The New York Times reports that Florida is about to take half the money from its tobacco settlement endowment in order to patch a huge budget gap, and Michigan, Ohio, and New Mexico are considering similar uses of settlement funds.

Of course, shifting money away from anti-tobacco efforts will only mean higher healthcare bills in the future, as the Health Beat post points out:

The irony of all this is that in the long run, funding smoking cessation efforts actually helps states save money. A 2008 PLoS Medicine study found that between 1989 and 2004, Californiaâs tobacco control program was associated with $86 billion less in health care spending than would have been expected without the program. Savings grew progressively over time, and by 2004 they reached 7.3% of the stateâs total health care bill.

State governments may understand the relationship between cutting current public-health spending and facing higher healthcare costs later, but they probably see it as a choice between cutting anti-tobacco programs and losing essentials like schools or fire stations, and either choice is bad for public wellbeing. Current consequences can also seem much more immediate than future risks. Itâs not surprising that lawmakers choose to cut smoking cessation funding.

States do have one option for raising money while reducing smoking: increasing cigarette taxes. According to the Times, Kentucky, Georgia, and Mississippi are considering raising these taxes. (As they budget, though, they have to realize that as the taxes push smokers to quit, the revenue will decline.) Laws banning smoking in restaurants and other public places are another relatively low-cost option for encouraging smokers to quick; Pueblo, Colorado saw heart attack hospitalizations drop 40% after it passed a law making workplaces and public places smoke-free.

Compared to states, insurance plans have fewer tools and incentives for helping their members quit. Insurers canât control cigarette taxes or public smoking bans, and their long-term payoffs from this and other prevention measures are uncertain. They could spend a few thousand dollars helping a smoker quit, only to see him or her switch health plans a year later.

(To some extent, statesâ smoking-related healthcare expenses will also vary as their Medicaid population changes, but since people living below the poverty level are more likely to smoke, Medicaid is going to be on the hook for these expenses until we get the national smoking rate closer to zero.)

Countries with national healthcare systems are better positioned to invest in smoking cessation programs, since they can be confident that theyâll reap most of the financial benefits. Like U.S. states, though, theyâll face budget gaps and tough choices. Lower-income countries with few tobacco regulations are in a particularly bad position, because their smoking rates are rising and their healthcare expenses will rise along with them. The FAO reports that Africaâs total tobacco demand increased about 3.5% a year in the 1990s, and similar growth is expected through 2010.

The knowledge that smoking prevention and cessation programs will save money in the long run isnât enough to spur the appropriate amount of investment. In some cases, the money simply isnât there. In others, officials will need to use mechanisms to make sure anti-tobacco funds canât be shifted to other purposes.

For anti-smoking and other prevention efforts, weâll keep running into the same barrier: future prevention payoffs donât compete well against current spending needs.