‘Utterly devastating.’ Tobacco still takes high human, financial toll in Kentucky.
The below article was written by Bill Estep for the Lexington Herald-Leader, published on Feb. 20, 2022 and features UK College of Nursing's Dr. Ellen Hahn. The original article is available here.
The state is No. 2 in smoking and No. 1 in lung cancer. Why is so much of the state still addicted to cigarettes, and what needs to change?
Kentucky has one of the highest smoking rates in the nation, with thousands of early deaths and hundreds of millions in health care spending to show for it, but the state’s response has been among the most anemic in the country, tobacco control advocates say. The state spends a fraction of what’s recommended to prevent people from starting to smoke and help smokers quit, and its tax rate on cigarettes is among the lowest in the country.
Last year, state legislators didn’t even hear two bills that would allow communities to set their own rules aimed at reducing adult smoking and vaping among young people. To health groups, it was another example of the legislature bowing to the tobacco industry — a lost opportunity to protect public health and reduce the physical and financial damage from tobacco.
“We should not be addicting a whole new generation and we should be helping people who want to quit,” said Shannon Smith, director of government relations for the American Heart Association in Kentucky, Ohio and Michigan. In its latest annual report on tobacco control, released last month, the American Lung Association said the rate of smoking among adults in Kentucky was 21.4 percent. It was even higher in some counties.
That was based on 2020 survey information from the Centers for Disease Control and Prevention, the latest data available.
That 21.4 percent adult smoking rate was down from 30.5 percent in the lung association’s 2003 report, but was still the second-highest rate in the nation, behind West Virginia at 22.6 percent. Kentucky has been first at times in the annual ranking. The national rate was 14 percent. The smoking rate among high-school students, at 8.9 percent, was among the highest in the nation as well. The state pays a heavy price. For example, the lung and bronchus cancer rate in Kentucky from 2014 through 2018 was 88.1 per 100,000 people, compared to the U.S. rate of 57.3. Kentucky had the highest rate in the nation, said Eric B. Durbin, director of the Kentucky Cancer Registry.
Another advocacy group, the Campaign for Tobacco-Free Kids, estimated that 8,900 adults die in Kentucky annually because of smoking, and that health-care costs tied to smoking total $1.92 billion a year, not counting any impact from secondhand smoke. The organization said nearly $600 million of that spending is through Medicaid, a taxpayer-funded program. The state and federal tax burden per household in Kentucky from smoking is $874, the campaign said. “With the highest lung cancer incidence and death rates, and the second highest smoking rate in the nation, the toll of tobacco in the commonwealth is utterly devastating,” said Shannon Baker, director of advocacy in Kentucky and Tennessee for the American Lung Association.
HISTORY, TAXES, WEAK LAWS ... AND HIGH SMOKING RATES
Smoking remains high in Kentucky because of a number of factors, including history, relatively low taxes and weak laws, and little spending on efforts to reduce the use of tobacco, according to advocacy groups. Tobacco was the linchpin of the state’s agriculture economy for decades, aided by a program the federal government adopted in the Great Depression to prop up farm income by controlling over-production of tobacco and providing minimum payments. The program allowed farmers to make more on an acre of tobacco than on other crops and meant that even small farmers, without sufficient land for crops such as soybeans and corn, could make money growing tobacco. Tobacco production permeated rural Kentucky, with a financial impact and shared experience that stretched from farms to businesses, courthouses and schools.
“The culture here in Kentucky has been steeped in tobacco,” said Ben Chandler, head of the Foundation for a Healthy Kentucky. “It was a way of life. Kentucky society to large extent in the rural areas was built on it.” In 1964, tobacco made up nearly 50 percent of farm income in Kentucky. A decade later, money from tobacco sales amounted to more than 10 percent of all personal income in 38 counties, and in the early 1980s, more than 74,000 farms reported growing tobacco. In the 1990s, the value of the state’s tobacco crop averaged more than $800 million annually. William Snell, an economist at the University of Kentucky, calculated in 1996 that $1 million in tobacco production contributed $3.6 million to the economy, according to a report cited by the Appalachian Regional Commission. That history and economic reach gave tobacco a lot of clout in the legislature, where many lawmakers were reluctant to do anything that might be seen as hurting the industry.
For decades, lawmakers kept taxes low on cigarettes, turned aside requests for tougher controls on tobacco products and, in the mid-1990s, approved a law that bars cities and counties from having their own rules on the use, display, sale and distribution of tobacco products. The law means communities can’t limit the visibility of cigarettes in convenience stores, for example, or prevent vape shops from locating close to schools. That law is sometimes referred to as preemption because it preempted local tobacco rules, aside from allowing cities and counties to bar smoking inside public places such as restaurants. The tobacco industry pushed for preemption laws in Kentucky and other states. The laws meant cigarette makers didn’t have to fight individual battles over tobacco control in numerous places. The amount of tobacco grown in Kentucky, and the number of people growing it, dropped after the federal government ended the price-support program in 2004. Only 2,618 farms reported growing tobacco in 2017, down from more than 74,000 in the early 1980s.
However, the crop remains important in the farm economy; the 2021 crop brought in an estimated $258 million. And history still influences policy in the state, tobacco control advocates said.
TOBACCO’S STRONG LOBBYING PRESENCE
In addition, the tobacco industry has continued to have a strong lobbying presence in the state.
Heading into the 2021 legislative session, anti-smoking advocates lined up Republican legislators to sponsor bills in the House and Senate to scrap the state law barring local control on tobacco products. The measures would “untie the hands of local elected officials to make measurable progress to cut youth vaping, adult smoking and other tobacco use that leads to so much disease and preventable death in our communities,” state Sen. Julie Raque Adams, R-Louisville, said at a news conference in January 2021. Supporters had counted heads and thought they had the votes to pass the bills. But the bills died a quick death. They didn’t get a hearing, much less a vote. Altria, a leading tobacco company, spent $73,627 on lobbying in the first three months of the legislative session as two bills were bottled up in committee, according to legislative records.
That put it among the top 10 companies in lobbying spending. The only two bills that company representatives lobbied on were the measures to do away with preemption, according to their disclosures. The company spent a total of $274,223 on lobbying for all of 2021. “The tobacco lobby is powerful in Kentucky,” Baker said. In the 2018 legislative session, as lawmakers considered increasing the state’s cigarette tax, Altria spent $379,760 on lobbying. That was more than double any other company that session. That year, health advocates had pushed to add $1 a pack to the state’s tax on cigarettes, but legislators added only half that.
Kentucky has a history of relatively low taxes on cigarettes. As recently as the early 2000s, the state had not raised its tax on a pack of cigarettes in more than 30 years and had the lowest levy in the nation. Lawmakers have since raised the tax as they searched for money for programs. The last increase of 50 cents in 2018 pushed the tax to $1.10 a pack on cigarettes. That’s still well below the average state tax of $1.91 a pack, leaving Kentucky’s rate at 37th among 50 states and Washington, D.C., according to the American Lung Association. A higher tax would create an incentive for more people to quit smoking, health advocates said. “The most effective tool policy wise to reduce smoking is price,” said Ellen Hahn, a professor in the University of Kentucky College of Nursing and director of a research organization called BREATHE that advocates for clean air and healthy environments
The Foundation for a Healthy Kentucky said in 2018 that while it appreciated that the tax vote was difficult for many legislators, an increase of $1 a pack, instead of the 50 cents, would have kept an estimated 23,000 young people from starting smoking, led more than 29,000 adults to quit, and cut healthcare costs.
Even at the lower rate, 39 percent of smokers surveyed after the increase said they’d cut back the number of cigarettes they used and 26 percent said they tried to quit because of the higher price, the foundation said. Another factor in Kentucky’s high adult smoking rate is that it has a relatively high percentage of lower-income residents, and there is a correlation between smoking and income levels. Last year, the smoking rate among adults making less than $25,000 a year was 35.6 percent compared to 12.1 percent among people making more than $75,000, according to America’s Health Rankings.
A PITTANCE SPENT ON HELPING PEOPLE QUIT
The issue of trying to prevent people from starting to use tobacco and helping them quit once they are addicted is another sore spot with health groups because the state spends little on such programs. The state is set to receive $495 million in Fiscal Year 2022 in tobacco-related revenue, but has budgeted only $2 million for tobacco cessation and prevention programs, according to the Campaign for Tobacco-Free Kids. The amount the state spends has gone down in recent years.
The state’s spending is just a fraction of the $56.4 million the Centers for Disease Control and Prevention recommends the state should spend helping people quit and preventing others from starting. And it is a pittance against the estimated $246 million the tobacco industry spent in 2020 in Kentucky promoting its products, according to the Foundation for a Healthy Kentucky. Kentucky isn’t alone in providing little money for tobacco prevention and cessation. In the current fiscal year, states will receive an estimated $27 billion from the 1998 tobacco settlement and spend only 2.7 percent on cessation and prevention, according to the Campaign for Tobacco-Free Kids. State lawmakers did approve measures in recent years to require tobacco-free school campuses, levy an e-cigarette tax and bar people under 21 from possessing or using tobacco products, alternative nicotine products or vapor products. Advocates argue that tougher controls protect young people and drive down the state’s smoking rate would be a good return on investment because it would cut health costs and deaths and increase productivity.
One analysis estimated that every dollar spent on a program called Quit Now Kentucky, where people who want to quit can connect with trained coaches, created $4.03 in benefits from things such as reduced healthcare costs and less missed work. The Centers for Disease Control and Prevention estimates that for every dollar spent on strong tobacco-control programs, states receive a benefit of $55, mostly in reduced health care costs. “We can’t afford not to do more, I would argue,” said Hahn.
A coalition of health and tobacco control groups plans to push in the current legislative session for more money for tobacco prevention and cessation programs and an end to the state law barring local controls on tobacco products.
State Sen. Wil Schroder, a Republican from Northern Kentucky, introduced a bill Feb. 14 that would allow local governments to “impose restrictions or requirements on the use, display, sale, or distribution of tobacco products or vapor products that are stricter than those imposed under state law.” It is Senate Bill 166. The tobacco industry is sure to oppose an end to the ban. David B. Sutton, a spokesman for Altria, said the state should avoid a confusing patchwork of local rules and taxes. A non-uniform set of local taxes, fees and regulations “makes operating a business more complex and confusing for retailers trying to operate within the bounds of the law,” and retailers would likely have a hard time complying with rules that varied dramatically across small areas, Sutton said. Ending the ban on local controls on tobacco wouldn’t force communities to do anything, but rather would give them more options, supporters of the bill argue.
“Tobacco’s an addiction. It’s really rampant across Kentucky, so to fix it we need every tool in the toolbox,” Hahn said. “If local communities have their hands tied and they can’t pass rules for instance that make it harder for youth to purchase tobacco products, it just limits our ability to fix the problem.”
