The recent elections resulted in Republican takeover of the White House and retention of control of both houses of Congress. In addition, several initiatives regarding tobacco taxation and marijuana legalization were featured on state ballots. What do these election results portend for the future of tobacco control? Although President-elect Donald Trump did not campaign on the issue of tobacco, he repeatedly vowed to repeal the Affordable Care Act (ACA), which contains a number of public health measures, as well as to reduce the size of the federal government.
Because the Trump campaign was more thematic than specific, experts are now trying to predict how his themes will be translated into action. Many have speculated that the ACA will be difficult to repeal as a whole, but that portions of it will likely be dismantled. Of special relevance for tobacco control is the Prevention and Public Health Fund of the ACA, which in fiscal year 2016 provided $126 million for CDC’s Office of Tobacco Control plus $160 million for block grants that focus on the leading causes of death and disability, and thus can potentially apply to tobacco-related programs. Those funds helped maintain many state quit lines and also supported the successful Tips Campaign featuring former smokers that is credited with stimulating hundreds of thousands of smokers to quit. Other aspects of ACA ‘surgery’ that would impair tobacco control would result if the 20 million newly covered Americans lost their health insurance, and thus access to smoking cessation counseling and FDA-approved medications. In addition, ACA-mandated health insurance coverage of smoking cessation services (counseling and medications) could disappear. These potential losses of infrastructure support, health care coverage, and mandated coverage for cessation services would be problematic for tobacco control. In addition, block grants to states for Medicaid services would increase intra-state competition for health and other resources. Tobacco control programs have not done well in previous such competitions, because of a lack of strong advocacy compared with better-funded claimants such as hospitals, health professionals, and advocacy groups representing middle class issues such as breast cancer. Furthermore, there is the sense that the tobacco war is being won and thus it is time to move on to other battlegrounds. Less money for state tobacco control efforts translates into less counter- advertising, less support for quitlines, and other missed opportunities to help smokers quit.
Indeed, progress is being made. As announced by the CDC this month, adult 2015 smoking prevalence was at an historic low of 15.1%. Yet, 36.5 million smokers remain, and 540,000 premature deaths from smoking-induced causes still occur each year. Rather than back away from tobacco control, this is precisely when efforts need to be intensified, in order to reduce suffering, prolong life, and lower costs from medical expenditures.
Another unknown is who will be chosen to fill federal positions that can support or inhibit tobacco control efforts. These include cabinet level appointments as well as critical agencies such as the CDC, HRSA, SAMHSA, and the FDA. The Obama administration has been noteworthy in its appointments of tobacco control champions to many of these positions. It is probable that the next wave of federal health appointees will be less focused on tobacco control, and that may be reflected in the priorities of the agencies they will lead.
One policy that helps to reduce smoking is tobacco taxation. California, the state with the second lowest smoking prevalence but the largest number of smokers (by dint of its huge population), strongly passed a $2 per pack increase, which will take it from 37th in the nation to 8th in terms of state tobacco tax. That hefty boost should, in turn, further reduce state smoking rates. By contrast, Missouri, which has the lowest state tax at 17 cents/pack, defeated a measure to raise the tax by $1.75. Five states voted on legalizing marijuana for adult use. In four of these—California, Maine, Massachusetts, and Nevada—the measure passed, and in one (Arizona) it was defeated.
How can we maintain and increase recent gains in tobacco control in the face of potential loss of resources? Key to sustaining efforts must be keeping the evidence front and center that smoking remains the number one killer of Americans and the single largest cause of disability. This will require insistent messaging from national and state champions, especially health professionals and disease advocacy groups such as the American Cancer Society, American Diabetes Association, American Heart Association, American Lung Association, and the National Alliance on Mental Illness. It is likely that action will dominate at the state level, where resource allocation decisions occur at budget time. We at the Smoking Cessation Leadership Center have conducted 15 state academies that have involved representative state agencies, health care providers, and advocacy groups that coalesce around the goal of reducing smoking prevalence among those with behavioral health conditions. We have been impressed that the zeal with which the problem has been approached has been completely non-partisan, with both blue and red states pushing equally hard toward the common goal of lowering the burden of smoking. Tobacco control should not be a partisan issue. Indeed, in this time of intense partisan divide, reducing death and disability is one of only a few issues that can engage both political parties. Let us continue to do all we can to achieve that goal.