The thought of a man with no jaw leaves fifth-graders at Russell Boulevard Elementary School gasping and shuddering.
The conversation in Columbia police officer John Warner’s weekly Drug Abuse Resistance Education class is energized and frank. Before math class on this Tuesday, it has led a curious 10-year-old to ponder the effects of mouth cancer from tobacco.
Warner isn’t there to scare his students but to reason with them.
“Imagine if there was a shoe company that if you wear their shoes, you’re gonna die,” he says. “Would you buy their shoes?”
Warner is endowing his audience with mental weapons to defend against peer pressure, curiosity and tobacco company efforts to engage young smokers. But somewhere between Warner’s enthusiastic classroom and Missouri’s soaring teen-smoking rates, that message sours.
In Missouri, more than 27 percent of adults and more than 30 percent of teenagers smoke, according to the state Department of Health and Senior Services. That’s the third highest rate in the country, behind Kentucky and West Virginia — both major tobacco producers.
The majority of smokers nationwide pick up the habit before they turn 18, with an average starting age of 13.
For many who oppose smoking, hope came in the form of the Master Settlement Agreement of 1998, an arrangement between tobacco companies and the 46 states suing the companies for reimbursement of health-care costs. This settlement placed restrictions on marketing and required the tobacco manufacturers to pay $206 billion to states over 25 years.
Missouri has collected nearly $822 million from the agreement, which granted states access to the money beginning in 2002. But none of that money has gone toward improvements in smoking prevention and treatment. In each of the past two years, Gov. Bob Holden diverted the funds to mend the struggling state budget.
Lori Pickens thinks she knows how to combat Missouri’s tobacco problem. As the St. Louis-based chief executive officer for the American Lung Association of Missouri, Pickens has seen the fruits of prevention and cessation programs in states including California and Massachusetts, which began their efforts with tobacco tax funds in the late 1980s.
“We spend very little on this issue, and this is really why we are where we are in Missouri,” she said.
Pickens remembers the stir of optimism and advocacy around how the settlement money should be allocated and the disappointment when Holden steered the money elsewhere.
In 1999, the federal Centers for Disease Control and Prevention released recommendations for comprehensive anti-smoking plans specific to each state. The report, a combination of successful programs across the nation and the evaluation of individual state needs, suggested that Missouri would need to spend between
$33 million and $92 million to curb its soaring smoking rates.
Janet Wilson, chief of the Health Promotions Unit at the state Department of Health and Senior Services, relies on a $1.5 million annual CDC grant that she said is barely enough to pay staff salaries and maintain some presence in Kansas City, St. Louis and Springfield.
Wilson’s staff focuses on educating the residents of these areas about the dangers of second-hand smoke. It works with local schools and advocacy organizations to form youth groups to educate the communities about tobacco use.
“We’ve not been able to expand beyond that so far,” Wilson said, adding that she is ready to begin a major effort at the first sign of steady financial support.
Wilson draws from a well of statistics to plead her case.
“California found that for every $1 spent for prevention, they saved $3.62 in health-care costs and productivity losses,” she said, adding that investments in prevention can have tremendous financial benefits.
Yet prevention is largely undervalued in our health-care institutions, said Kay Fauss, an Ellis Fischel Cancer Center nurse practitioner and member of the Boone County Coalition for Tobacco Concerns.
“It’s a direct link between smoking and the cost on our economy,” she said.
Missouri incurs an estimated $1.66 billion in annual smoking-related health costs, according to the Campaign for Tobacco-Free Kids, an organization that tracks smoking-related activities. And even though successful prevention programs create less strain on the economy than the subsequent cost of care, she said the health-care system does not accommodate preventive efforts.
“For a patient to come and talk to a doctor about quitting smoking is not a billable visit to the insurance company,” said Fauss, who leads an eight-week program to help smokers quit. “To see a pulmonologist about that for the first time can be as much as $250.”
Fauss said she believes it is the professional responsibility of all providers to ask their patients if they smoke, encourage them to quit and support them through the process.
Schools’ efforts are sporadic
As the only nurse for more than 1,600 students at Rock Bridge High School, Tammy Adkins relies on guidance counselors and teachers to help her talk to teens about smoking. She has pamphlets in her office and says she is ready to accommodate anyone wanting to quit, but she can’t recall a time during her eight-year tenure that such a plea surfaced.
Adkins said students receive “anti-smoking empowerment” during Kick Butts Day each spring, from their health classes and from their memories of the elementary school DARE program.
“It’s easier to make an impression at the elementary school level than at a high school level when they’ve already made up their minds,” Adkins said. “It’s easier to prevent the behavior before they start the behavior.”
In her office, posters announce the number of DVDs and large pizzas students could buy for the price of smoking a pack of cigarettes a day.
In Columbia’s public schools, tobacco education stops and starts through the years. Students’ first academic awareness of the subject comes around age 10 through the nationwide, 10-week D.A.R.E. initiative against drugs, alcohol and violence. The next time the curriculum covers tobacco is in health class, a required one-semester course offered in ninth grade and above. Most students get it over with in their last year of junior high school.
In the gaps, there are parents, friends, Philip Morris anti-smoking ads and school posters.
“It’s hard for the health teachers and the school nurses to find time in students’ schedules to let in anybody else,” said Chris Coffman, a nurse supervisor with the Columbia/Boone County Department of Health, who says academic requirements leave no room for extra smoking education.
Coffman has seen efforts to penetrate schools with messages of prevention fail for just that reason.
Mary Whitener, a school nurse at West Junior High, said teens require a nontraditional approach to prevention because of what she refers to as a “teenage cocoon.”
“Kids are often pretty knowledgeable that tobacco is harmful, but they don’t think it applies to them yet,” she said.
Instead of quoting statistics about heart disease, Whitener appeals to the stamina of an athlete or the dread of bad breath. She tells some students they should take offense that tobacco companies are manipulating them.
“They can disregard the health effects of smoking because they think addiction takes a long time to occur,” she said.
Taxation could prevent smoking
Justin Arnold, 16, started smoking “for the thrill of it” when he was 11. The Hickman High School junior said he remembers the DARE warnings of cancer and death but insists that kids will always be tempted to sneak cigarettes because they are forbidden.
Puffing on a Marlboro Red during his lunch hour, Arnold estimated that 85 percent of Missouri teens smoke. In reality, that number is nearly one-third of that, but his perception is telling of how widely accepted smoking is among teenagers.
Like many of his friends and fellow smokers, Arnold has tried to quit and said he will not smoke as an adult.
“I got better things to do when I go to college,” he said.
A pack-a-day smoker, Arnold said he usually buys his cigarettes without being asked for identification. When he is asked, Arnold pretends to have left his wallet at home and is still sold tobacco, he said. He and friends gathered outside the Dairy Queen during lunch hour agreed that they would probably stop smoking if cigarette packs cost more than $5.
Whitener, the West Junior High nurse, advocates for stricter control of cigarette sales and higher prices on tobacco.
Missouri has one of the lowest excise tax rates on cigarettes in the country — 17 cents per pack, compared with the national average of 72 cents.
Jim Blaine, chairman of the Missouri Partnership on Smoking or Health, said he believes a sharp rise in price could be an important preventive measure.
“For every 10 percent increase in the price of tobacco, there is a 7 percent decrease in use by children,” Blaine said, citing a 2001 study by the University of Illinois at Chicago and the University of Michigan Institute for Social Research.
According to a 2003 Missouri Department of Health and Senior Services taxation report, nearly 60 percent of Boone County smokers would support increasing the tax on cigarettes if the money were used for prevention programs. More than one-third of the respondents think the tax should be $1.25 or more per pack.
“We’ve been trying for years to obtain funding for prevention efforts in Missouri,” Blaine said, “but so far we haven’t gotten it.”
Those who fight the spread of smoking are used to taking what they can get and making the most of it. Blaine’s organization just received a $1 million grant from the Missouri Foundation for Health.
Attorney General Jay Nixon is also boasting a new settlement agreement that will bring $7 million in tobacco money to Missouri. Rallying political and social support at high schools across the state, Nixon publicized the settlement with some smaller tobacco companies that recently entered into the Master Settlement Agreement. He is urging legislators to create a commission of state departments, local coalitions, advocates and health-care professionals to enact programs designed to reduce teen smoking.
“The research has already been done,” Nixon said during a speech at Hickman High School this month. “There are success stories out there.”
Nixon acknowledged disappointment with previous years’ diversion of tobacco settlement funds and warned that without further action, the new allocation will head for the same fate.
“We are trying to escape the general appropriations process,” Nixon said. He said he hopes that if the money goes to much needed programs, teen smoking rates will decrease by 20 percent to 30 percent within several years.
The American Lung Association also is receiving new funds to expand its activities beyond the metropolitan areas and into central Missouri. A $2.3 million grant will accommodate 30 counties in what Pickens describes as “very targeted work for the different needs of each county.”
The advertising war
In its recommended budget for a tobacco-action plan in Missouri, the Centers for Disease Control and Prevention allots up to $16 million for marketing efforts to counteract the tobacco industry’s $337.8 million annual marketing push. This is the second-highest sum in the CDC’s suggested anti-smoking budget for Missouri, after cessation support programs. Although the Master Settlement Agreement and legislation have curtailed marketing strategies such as cartoon mascots and smoking advertisements near schools, experts agree that the tobacco media machine is very much alive.
In fact, many Missouri children and teens only see anti-smoking commercials sponsored by big tobacco companies. “There’s a marketing benefit to Philip Morris that could drive people to smoke,” Pickens said. “They are getting their name out there.”
Pickens said it is common sense to be suspicious of such commercials. After all, she said, if their message of prevention was successful, the tobacco companies would be putting themselves out of business.
In a Missouri Department of Health and Senior Services program called Smokebusters, teens learn how to get media savvy and how to use that knowledge to their health advantage. The three-year program, implemented through state and local health departments, begins with Teens Against Tobacco Use, in which volunteers learn how to stay smoke-free and mentor children on smoking prevention. Participants also give presentations to community businesses and organizations.
In their second year, the Smokebusters participate in Stop Tobacco Among Many People, in which they learn about the tobacco industry’s marketing efforts and counteract with their own involvement in local media and advertising.
Busting Big Tobacco, the final stage of the program, introduces third-year participants to legal avenues for tobacco reform as teens work to influence state and local environmental policies.
Pickens and other anti-smoking activists hope increased awareness and funds will spread the availability and effectiveness of these programs throughout the state. Pickens said local organizations will bring Teens Against Tobacco Use and expanded Freedom From Smoking programs to central Missouri in the next few years.