Staying Focused During Times of Uncertainty

We have now entered an era of uncertain federal support for tobacco control programs following 8 years of a federal government that worked to accelerate the decline of tobacco use. As Dr. Mike Fiore summarized in the October 13, 2016 issue of the New England Journal of Medicine, smoking rates declined annually about 0.78 percentage points during the Obama presidency, compared with 0.36 under George W. Bush, and 0.28 under Clinton. While many factors contributed to this accelerated decline, federal policies were influential. These included the 62 cent per pack federal cigarette excise tax rate increase in 2009, the mandating of coverage for smoking cessation counseling and medications included in the 2010 Affordable Care Act (ACA), the Prevention and Public Health Fund that was part of the ACA and that provided funds for the CDC to be used for state tobacco control activities, Community Prevention and Transformation Grants provided for tobacco control in many communities, and the powerful stop smoking media campaigns of both the CDC and the FDA.

Although tobacco control was not a focus of the Trump presidential campaign, key presidential appointees, including the vice president, are at best neutral and often opposed to tobacco control. Does that mean that after years of progress we can expect to see smoking rates begin to climb? I don’t think so, and here is why. First, much vigorous tobacco control remains at the state and community levels. There are still regions that have yet to enact comprehensive smoke-free legislation, and dedicated advocates will work to make that happen. And, in contrast to smoke-free ordnances—which can cover no more than 100% of the population—there are more opportunities where tobacco taxes can be raised by states or local communities. California’s $2/pack increase just went into effect April 1, 2017 and will surely cause many of that state’s 3.4 million smokers to either quit or cut back. As a consequence, California (11.6%) could overtake Utah (9.1%) as the state with the lowest smoking prevalence.

Another reason not to despair, is the momentum behind increased smoking cessation efforts among those vulnerable populations where smoking is now concentrated: those with mental illnesses and/or substance use disorders; the homeless; persons involved with the criminal justice system; the LGBT population; and persons living in geographical areas of higher smoking prevalence, such as the Southeast. Based on work we and others have done, we are impressed that there is a growing movement to address smoking cessation among these groups, many of which were previously thought to be out of reach. And the good news is that many do want to quit, some are able to, and increasing numbers of champions are emerging to help make that happen and thereby to improve health of the public.

We at the Smoking Cessation Leadership Center pledge to continue our efforts, which do not depend on federal support. We are impressed at the courage of tobacco control advocates we have met in the 14 states that have conducted behavioral health smoking cessation Leadership Academies, including states that lack a sympathetic state policy environment. The many clinical champions among the various clinical disciplines are doing all they can to encourage their colleagues to become better smoking cessation advocates. And the dedicated staff at the voluntary agencies such as the American Cancer Society, American Lung Association, North American Quitline Consortium, National Alliance on Mental Illness, Community Anti-Drug Coalitions of America, National Council of Behavioral Health, Campaign for Tobacco- Free Kids, Americans for Nonsmokers Rights, Tobacco Control Legal Consortium and many others will not abandon their efforts. Sailing into a head wind may require more tacking than sailing with a tailwind. But we know where we want to go, and are confident we will get there.