Evaluation of the Arkansas Tobacco Settlement Program: Progress During 2008 and 2009
Jun 17, 2010
The Impact of One State's Investment in the Health of its Residents
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In November 2000, Arkansas voters passed the Tobacco Settlement Proceeds Act, a referendum to invest the state's share of a multibillion-dollar tobacco settlement in health-related programs focused on reducing and preventing smoking, improving access to medical care, and bolstering health education and research. Researchers from RAND Health are conducting an ongoing evaluation of these programs and their impact on Arkansas residents' health and smoking behaviors. Results from the most recent analysis, presented in RAND's fourth biennial report, show that Arkansas' investment is paying dividends. The programs have been a force behind the state's downward trend in smoking rates, especially among vulnerable populations. Smoking rates among these populations—teens, young adults, and pregnant women of all ages—have all declined below what would be expected in the absence of the tobacco settlement programs. In 2009, smoking rates for all adults remained significantly below what they had been prior to initiation of the programs. Although some programs have not achieved the long-term goals specified in the act, many interim programmatic goals have been achieved, and all programs have made substantial progress.
In November 1998, nearly every U.S. state signed the Tobacco Master Settlement Agreement, which ended years of legal battles between the states and the major tobacco companies. Under the terms of the agreement, the tobacco companies are now paying participating states more than $206 billion over a period of 25 years. Arkansas receives less than 1 percent of these payments. But among the 46 participating states, Arkansas is unique in that the state invests all of its share of the funds in health-related programming.
Arkansas used the tobacco settlement funds to create seven programs (Table 1). Only one of these, the Tobacco Prevention and Cessation Program, is completely dedicated to smoking prevention and cessation; this program, however, receives about 30 percent of the state's settlement funds. Following guidelines established by the U.S. Centers for Disease Control and Prevention (CDC), TPCP's activities include community prevention programs, school education programs, enforcement of youth tobacco control laws, public awareness campaigns, minority initiatives, and other efforts. Four of the programs target the short-term health-related needs of disadvantaged Arkansans: Delta Area Health Education Center, Arkansas Aging Initiative, Minority Health Initiative, and Medicaid Expansion Programs. Two programs expand public health education and the state infrastructure for public health research: College of Public Health and Arkansas Biosciences Institute.
|Tobacco Prevention and Control Program (TPCP)||Using CDC recommendations for tobacco cessation and prevention activities, TPCP develops programs aimed at reducing the initiation of tobacco use and resulting negative health and economic impacts among Arkansas residents||Community prevention programs|
|School education and prevention programs|
|Enforcement of youth tobacco control laws|
|Tobacco cessation programs|
|Public awareness and health promotion campaigns|
|Statewide tobacco control programs|
|Tobacco-related disease prevention programs|
|Monitoring and evaluation|
|Delta Area Health Education Center (Delta AHEC)||Delta AHEC aims to increase access to health care for residents of the Delta, a medically underserved region||Training and recruitment of students and health care professionals|
|Service provision throughout the Delta region|
|Arkansas Aging Initiative (AAI)||AAI works to (1) improve the health of older Arkansans through interdisciplinary geriatric care (clinical care) and innovative education programs and (2) influence health policy affecting older adults||Clinical services|
|Minority Health Initiative (MHI)||MHI identifies special health needs of Arkansas' minority communities and implements health care services to address these needs||Public awareness of minority health issues|
|Health screening programs|
|Database development (biographical, screening, cost, and outcomes data)|
|Medicaid Expansion Programs (MEP)||MEP seeks to expand access to health care through targeted expanded benefits packages that supplement the standard Arkansas Medicaid benefits. The programs are managed by the Arkansas Department of Human Services||Pregnant Women's Expansion Program|
|Medicaid-Reimbursed Hospital Care Program|
|Fay W. Boozman College of Public Health (COPH)||COPH offers professional education, research, and services to the public health community of Arkansas||Degree and continuing education programs in public health|
|Health services research|
|Policy and advisory resources|
|Arkansas Biosciences Institute (ABI)||ABI develops new tobacco-related medical and agricultural research initiatives intended to improve the health of Arkansans, improve access to new technologies, and stabilize the economic security of Arkansas||Research and collaboration among member institutions|
|Public dissemination of research results|
The 2000 state referendum also created the Arkansas Tobacco Settlement Commission (ATSC), which is responsible for monitoring and evaluating the performance of the seven public health programs. The commission contracted with RAND to evaluate the effects of the programs on smoking and other health-related outcomes and to assess the programs' progress in accomplishing their goals.
RAND's analysis of smoking-related health outcomes for Arkansas focused on three key trends: adult smoking behavior; youth smoking behavior; and smoking-related health indicators, including low-weight births, heart conditions, stroke, pulmonary conditions, and diabetes.
In Arkansas, the 2008 adult smoking rate of 22 percent was four percentage points lower than the five-year average preceding TPCP programming. This decline is equivalent to 16 percent fewer adult smokers over that time period. However, the smoking rate was only slightly below the rate that would be expected if the pre-2002 baseline trend had continued; furthermore, it did not match the expected decrease that would have followed implementation of a comprehensive smoking control program (comparable to the one launched in California). Nonetheless, this trend represents a major improvement for the health of Arkansans (Figure 1). Findings for specific groups of adults revealed the following:
|Population||2000 Rate||2005 Rate||2007 Rate||2008 Rate||Percentage of Decrease Between 2000 and 2008|
|High school studentsa||35.8||26.3||20.7||20.3||43.3|
|Pregnant teenagers (14–19)b||21.5||16.1||16.1||15.6||27.4|
NOTE: The estimated decrease is significant at the 5 percent level for the populations examined.
a2009 Arkansas Youth Risk Behavior Survey.
bRAND analysis based on birth certificates, adjusted for change in population demographics.
As with adults, fewer young people in Arkansas in 2008 were smoking than baseline trends would predict. As seen in Table 2, findings for specific groups showed the following:
Because the data on smoking rates for youth and pregnant teens come from two different surveys, they independently confirm the large decline in youth smoking.
As part of the outcome analysis, researchers examined hospital discharges for conditions related to smoking, including strokes, heart attacks, asthma, pneumonia, diabetes, and low-weight births. It is possible that reductions in smoking by people with serious health conditions have led to healthier outcomes for this group. It is also possible that reductions in exposure to secondhand smoke have had health benefits.
While some of these trends are promising, none should be considered definitive evidence of the impact of tobacco settlement programming. These conditions are influenced by other factors as well. The rates for Arkansas should be monitored in the future and compared with national rates to provide continuing evidence regarding the impact of smoking control activities.
RAND's evaluation also examined each program's activities and described its progress toward program goals during 2008–2009. In addition, the evaluation analyzed spending trends for each program and made recommendations for each program as it moves forward. Highlights of the program evaluations appear below.
Tobacco Prevention and Cessation Program. TPCP continues to pursue prevention and cessation efforts in accordance with the CDC program components.
Aside from the tobacco-related health outcomes described above, other outcomes for TPCP include those related to smoking policies and enforcement.
RAND's recommendations for TPCP focus on strengthening the implementation and utilization of the web-based reporting system for all its grantees and on communication and coordination among the different grantees.
The Delta Area Health Education Center. Through dozens of programs and services, Delta AHEC has strengthened its ability to recruit and train health students and professionals and provide education and health-related services to communities and clients throughout the Delta region.
RAND's recommendations for the Delta related to improving the efficiency and effectiveness of the services offered to community members and professionals.
The Arkansas Aging Initiative. AAI's activities during the last two years have resulted in increased access to quality, evidence-based education and clinical services for older Arkansans.
RAND's recommendations for AAI focused on continuing and expanding current activities and developing a plan for securing sustainable funding.
Minority Health Initiative. At the end of 2009, MHI completed a strategic planning process that identified specific awareness, screening, and intervention strategies to address its priorities.
MHI's strategic planning process identified six new goals for FY 2010 and FY 2011, focused on screening, education, and coordination efforts. RAND's primary recommendation was to monitor and measure progress toward these new goals.
Medicaid Expansion Programs. MEP's four expansion programs provide access to health care for vulnerable populations in Arkansas.
RAND's recommendations for Medicaid programs emphasized understanding the size and needs of populations targeted by MEP and improving access to those programs.
College of Public Health. Over the past two years, COPH has continued to develop its education programs, research activities, and service efforts.
RAND's recommendations for COPH focused on strengthening its degree programs and enrollment to help ensure the institution's future.
Arkansas Biosciences Institute. ABI focuses on research and collaboration among its member institutions.
RAND's recommendations emphasized continued growth in ABI's research and collaborative efforts to address sustainability issues across the member institutions.
The seven programs supported by the tobacco settlement funds have continued to expand their reach in improving the health of Arkansans. The results of the outcome evaluation indicate that, collectively, the tobacco settlement programs are contributing to reduced smoking and improved health in Arkansas. There have been significant decreases in smoking rates for adult women, high school students, and pregnant teenagers. Overall, smoking rates for adults in Arkansas are significantly below what they were before initiation of tobacco settlement programming. There is also evidence of improvements in smoking-related health conditions, including strokes and heart attacks.
Despite progress, there is still room for improvement. Although Arkansas is a national leader in spending a considerable portion of its tobacco settlement money on smoking prevention, the state still spends only about half the amount recommended by the CDC for prevention efforts. Increasing the funding to CDC-recommended levels would help Arkansas extend its gains in smoking reduction. Investments in health may show returns only after many years. Maintaining a long-term commitment and support for programs will be necessary to ensure continued progress toward improving the health for the residents of Arkansas.
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