Guidelines for Comprehensive Tobacco Control Programming in Michigan The CDC’s new Best Practices for Comprehensive Tobacco Control Programs is the long-awaited update of the original guidelines issued in 1999. The purpose of the guidelines is: to describe an ideal state program that would carry out proven, evidence-based interventions – that’s the “best practices” part; and to identify the funding levels needed to achieve the goal of substantially reducing tobacco use. The guidelines strongly emphasize comprehensive programming and substantial and sustained funding. The take-home message is that the whole is greater than the sum of its parts.

Goals for Comprehensive Tobacco Control Preventing initiation among youth and young adults Promoting quitting among all smokers Eliminating exposure to secondhand smoke Identifying and eliminating tobacco-related health disparities among population groups The new guidelines are divided into four basic tobacco control goals. These goals provide a foundation for the specific program components described by the guidelines. The goals also mirror those in Michigan’s Five Year Strategic Plan to Reduce and Prevent Tobacco Use

Five Program Components State and community interventions Health communications interventions Cessation interventions Surveillance and evaluation Administration and management The guidelines confirm that, “A comprehensive approach – one that optimizes synergy from applying a mix of educational, clinical, regulatory, economic, and social strategies – has been established as the guiding principle for eliminating the health and economic burden of tobacco use.” To accomplish the four tobacco control goals, the guidelines advocate the implementation of five program areas that, when carried out concurrently and with sufficient resources, create a powerful synergy.

Program Components … State and Community Interventions Includes statewide projects and initiatives that enhance the effectiveness of population-based interventions Relies strongly on a community-based local infrastructure Creates synergy and magnifies the effect of individual program activities The guidelines are premised on the understanding that multiple societal resources, working together, have the greatest long-term population impact. Examples of community-based action includes … Training local community coalitions in the legal and technical aspects of smoke-free regulations by statewide partners with experience in providing these services. Funding community-based organizations to strengthen their capacity to influence social norms regarding tobacco use and build relationships between health departments and grassroots efforts.

Program Components … Health Communications Interventions A powerful tool for preventing youth initiation, promoting cessation and shaping public attitudes and behavior The CDC recommends that a health communications campaign should deliver strategic, culturally appropriate, and high-impact messages Media interventions prevent tobacco use initiation, promote cessation and shape social norms. It is well understood that targeted, sustained information and messaging is important. The tobacco industry continues to use media communications very effectively to increase the allure of smoking and promote its products to youth and other targeted segments of the population. We need to counteract that.

Program Components … 3. Cessation Interventions Health care system-based interventions, including screening, advice and assistance Population-based interventions, such as quitlines available to anyone who wants to quit Public and private insurance coverage for tobacco cessation counseling (individual, group and telephone) and FDA-approved medications Tobacco use treatment is highly cost-effective. The effective model of treatment recognizes tobacco use dependence as a chronic illness that requires effective treatments (pharmacological aids as well as professional support/coaching, tailored to the needs of the individual, and that are ongoing for as long as needed – much like the treatment model for any chronic disease/illness.

Program Components … 4. Surveillance and Evaluation Publicly financed programs need to have accountability and demonstrate effectiveness Requires more data collection, use of currently established surveys and other data systems to identify and monitor tobacco-related attitudes and behaviors Surveillance systems and methods to track changes in specific population groups. State surveillance is the process of monitoring tobacco-related attitudes, behaviors and health outcomes at regular intervals of time, focusing on the achievement of the four primary program goals. An important function of surveillance is to accurately observe and report needs and LACK of progress as well documenting successes and achievements.

Program Components … 5. Administration and Management Strategic planning Recruiting, developing qualified technical, program and administrative staff Awarding, monitoring contracts and grants Managing, tracking expenditure of funds Ongoing training and development at local level Creating and maintaining an effective, integrated communications system Educating the public and decision-makers The implementation of complex, integrated programs requires experienced staff.

HOW MUCH?? Obviously, any long-term program that is sustained over a period of time is not inexpensive.

Michigan funding recommendations for 2007 Per Capita State Totals State and Community Interventions II. Health Communication Interventions Cessation Interventions Surveillance and Evaluation Administration and Management TOTAL: $4.94 $49.9 M $1.66 $16.9 M $3.83 $38.7 M $1.04 $10.5 M $0.52 $ 5.3 M $11.99 $121 M This slide is a brief compilation of a page from the CDC newly revised Best Practices entitled “Michigan Recommended Program Budget” Here we see the five recommended components for a comprehensive tobacco prevention program, a per capita recommendation, and a total based on the current population of Michigan. These numbers are based on solid research and a model formula that takes into account numerous variables from one state to another. The formula is the same for all states, but the amount per capita and total per state differs based on past effectiveness of tobacco prevention programs, demographic make-up, variations in media market amounts, etc. -- to name a few variables.

This is what it would look like This shows the breakdown in pie chart form. It highlights the CDC’s recommendation that the lion’s share of state tobacco control funding should go to cessation services and to local community organization and infrastructure, with key statewide initiatives included. Health communications would take a significant portion followed by surveillance evaluation activities. Administration would rightly take a much smaller percentage of a larger budget.

Current Tobacco Program Budget, 2007- 2008 [This slide NOT presented at the TFM meeting] If you take by the CDC’s recommended programming components and apply it to MDCH’s budget, the pie allocation looks like this. Note that these percentages represent much less money - $5.5 M vs. the CDC’s recommendation of $121 M. So, for example, our current allocation for State and Community Interventions funding is 49% compared to the 41% recommended by CDC; however, our 49% represents only $2.65 M while the CDC recommended 41% is equal to $49.6 million. Also note that in the last few years we are making strides in funding Cessation Interventions, and it now represents 18% of our funding vs. the 32% recommended by the CDC. Conversely, this pie shows – and lack of budget prevents, too little funding for Surveillance and Evaluation, and Health Communications. The largest discrepancy between the ideal and the real is that 22% of our current funding pie goes for Administration and Management vs. 4% recommended allocation by CDC. If you use the analogy of a small child whose head is bigger that his/her body, and as the rest of the body develops and grows, the head becomes smaller by comparison. We should consider this ‘out-of-proportion’ budget allocation a ‘body’ of work in development.

Are You Serious? This is the question that we must be prepared to answer when advocating for higher funding with legislators, the media and others.

$121 Million in Context The substantive question is: “$121 Million ... compared to WHAT?” That is the context in which me must answer the question.

Causes of Preventable Death Michigan Residents, 2005 Tobacco kills more people in Michigan than AIDS, alcohol, auto accidents, cocaine, heroin, murders and suicides - combined. First, consider the expenditure of $11.99 per person in the context of efforts to combat the 17,000 deaths caused by tobacco in Michigan every year. It isn’t much. Deaths/Year Source: Michigan Department of Community Health, Division for Vital Records and Health Statistics and Centers for Disease Control and Prevention; Smoking Attributable Morbidity, Mortality and Economic Costs (SAMMEC).

Michigan’s Annual Revenues from Tobacco Sources $1.629 billion $170 million - Sales Tax $279 million - MSA $1.18 billion - tobacco excise tax Next, consider the fact that Michigan takes in $1.6 billion in tobacco revenues every year. Note that the MSA total includes the new annual ‘bonus’ payments of $28.5 million for the next 10 years. Also note that MSA payments in the future will be less based on the fact that over half of Michigan’s allocation from the MSA has be securitized. These numbers will be revised when we have new data. Regardless, state revenues will continue to far exceed the recommended funding amount by the CDC. $121 million (7.4%)

Michigan’s Annual Tobacco-related Healthcare Costs $3.4 billion $1.1 billion in tobacco-related Medicaid Costs Third, compare the recommended CDC tobacco control level against the current costs of treating tobacco-related disease. We, Michigan’s taxpayers, subsidize Medicaid expenditures to the tune of $1.3 billion dollars annually for treating preventable tobacco-related illnesses, and the cost is going up. $121 million (3.4%)

Source: Federal Trade Commission Industry’s Cigarette Advertising and Promotional Expenditures in Michigan 1998 - 2005 (Millions of dollars) Fourth, consider how much more the tobacco industry spends to market addiction in our state. This slide illustrates that if we spent the recommended CDC amount, it would still be only 29% of the cigarette companies’ marketing expenditures here. Right now, our legislature allocates $3.6 million for tobacco cessation and prevention, which means that Big Tobacco outspends us 115 to 1. It’s high time that our legislature and governor take fighting the tobacco epidemic seriously. Note new, unpublished estimates in California: over 15 years, applying a comprehensive program resembling CDC’s guidelines … tobacco control program cost about $1.5 billion … resulted in savings to state of about $82 billion. It saved thousands of lives and an extraordinary amount of money for the state through reduced health care costs and lost productivity. Source: Federal Trade Commission

The Composite Picture The big, ugly picture in MI 2005-2006 Note: Tobacco companies spend 115 times more $$ annually in Michigan to promote tobacco products than the state does to prevent and reduce tobacco use This slide is a composite of the three previous – an overview comparison of: State revenues from tobacco sales, MSA, etc (green column) State costs (including Medicaid) for tobacco-related health card costs (red column) State appropriation for tobacco prevention and reduction (yellow column) Tobacco industry advertising and promotion in MI (blue column) The good news is that (as noted earlier) MI currently takes in about $1.6 Billion annually from tobacco sales tax, tobacco excise tax and the master settlement payments. We can add an additional $28.5 M (bonus payment) that will come from the MSA from 2008-2018 -- in addition to what we already receive annually. The bad news is that we currently spend $3.4 billion (and the numbers are going up) on tobacco-related health care costs. At least $1.3 B of that cost is paid by state government (taxpayers) via the Medicaid system. It’s a perverse reality that the tobacco industry also spends over $400 M in advertising and promotion in Michigan. By comparison, the legislature has allocated a miniscule $3.6 M for tobacco prevention and reduction. The $121 Million recommended by the CDC -- which is obviously a much bigger number, is only 3.4% of the total tobacco revenues coming into our state.

The cost for a cure to the tobacco epidemic in Michigan? $11.99/per person annually A bargain price for the benefits and rewards

Find the CDC’s complete “Guidelines for Comprehensive Tobacco Control Programs” online at http://www.cdc.gov/tobacco/tobacco_control_programs/stateandcommunity/best_practices/index.htm For further information about funding recommendations for Michigan Please call the MDCH Tobacco Program at 517-335-8376