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Balancing the tobacco settlement Advocates for smoking research, cessation programs argue over how to spend the money Tuesday, May 23, 2000 By Christopher Snowbeck, Post-Gazette Staff Writer
The only method former Pirates manager Jim Leyland ever tried to quit cigarettes was going cold turkey. And treating himself to a cigar every now and then.
Needless to say, it didn't work.
A pack-and-a-half per day smoker, Leyland faced fines from Major League Baseball and angry letters from health-conscious fans throughout his 11 seasons with the Pirates because he occasionally smoked cigarettes in the dugout at Three Rivers Stadium.
Now, he's wearing a nicotine patch and hasn't lit up for about three weeks.
That's not long enough to say he's kicked the habit, but hope springs eternal in the hearts of those trying to stop smoking.
"This has really encouraged me not to smoke because it eliminates my craving," Leyland said of the patch he wears. "It's a heck of a program for me. Whether it works for everybody, I don't know."
How well smoking cessation and prevention programs work is part of the continuing debate in Harrisburg about how best to spend Pennsylvania's share of the national settlement with tobacco makers.
Gov. Ridge has recommended that 15 percent of the money be spent on these programs. Dr. Ronald Herberman, director of the University of Pittsburgh Cancer Institute, has called instead for diverting much of that money to research programs. The scientific evidence behind many prevention and cessation approaches isn't strong, Herberman has argued.
With the legislature poised to pass parts of Ridge's tobacco plan into law in the next six weeks, public health advocates contend prevention and cessation efforts -- not research -- have been crippled by a lack of funding. They say the patches that Leyland is turning to, and other methods, do work, provided people get access to them.
"We know what works," said Bill Godshall, director of SmokeFree Pennsylvania, an anti-smoking group based in Pittsburgh. "There's been far more money put into research than into programs to end smoking."
Pennsylvania has estimated it would take in $11.3 billion over 25 years from the national tobacco settlement. That total is now expected to be much lower due to declines in tobacco use, but the settlement still will provide a tremendous infusion of cash.
Ridge announced in January that he wanted all the money spent on health programs. In particular, he called for 15 percent of the total to go to smoking prevention and cessation. Ten percent would go to research.
That set the stage for Herberman's February testimony in Pittsburgh before the state House Appropriations Committee, where he said researchers should get two-thirds of the anti-tobacco allotment.
Herberman testified that people who stopped smoking five, 10, 15 or 20 years ago are still at significantly increased risk of developing cancer. He also told legislators that the "large majority" of smoking cessation and prevention programs are "a waste."
Finally, he took aim at the Department of Health's antismoking billboards, including placards that shows a teen's head morphing into a cigarette. The word "butthead" is scrawled next to the picture.
"We would suggest that a good proportion of that money be allocated or be intended specifically for more research on the behavioral problems, about why people smoke, why it's so difficult to stop smoking," Herberman told legislators. "We don't believe that the state of the art, the current billboards or media campaigns and so forth, are nearly close enough to address some of the problems."
That outraged Godshall and other anti-smoking advocates.
"The state of the art is in California, Florida and Massachusetts," Godshall said. "The problem is we need to get some of the state of the art in Pennsylvania -- we don't have the state of the art because Herberman is lobbying against it."
Anti-smoking groups have outlined a tobacco control budget for Pennsylvania that is modeled on those successful programs. It includes money for school programs, increased law enforcement to prevent youth smoking and cessation programs. Money would also fund TV, radio and print ads to discourage smoking.
Godshall said the research behind all prevention and cessation programs is not perfect, but it more than meets the standards used throughout medicine for justifying treatments. Researchers have already spent years studying why people smoke and why it's so difficult for them to stop, Godshall said.
Godshall also criticized Herberman's statements about the long-term cancer risks for smokers. There are risks of getting cancer 20 years down the road if you quit smoking, he acknowledged, but emphasizing these risks misrepresents scientific evidence showing that the risk of developing certain kinds of cancers is cut in half within just a few years of quitting.
As for "butthead," Godshall conceded he doesn't care for the Department of Health's billboards, but one bad billboard shouldn't doom the whole effort. Massachusetts has seen a 35 percent decrease in smoking over the past 10 years, Godshall said, in part because of counter-marketing efforts that include billboards.
Some of the Massachusetts billboards didn't work, including one that sported the slogan "Let's make smoking history." Some smokers jokingly argued that the slogan encouraged users to break records for cigarette use, Godshall said, so Massachusetts modified the message.
In March, Godshall asked Herberman to retract his comments; Herberman responded last week that his comments were misunderstood.
"I don't see this being a dichotomy between research and prevention," Herberman said in an interview. "But, rather, I feel strongly that the issue of preventing people from starting to smoke and trying to get people who are smoking to stop is a topic of great importance for research."
Herberman isn't alone in his skepticism about the effectiveness of prevention and cessation programs. Many employer-sponsored health plans don't cover the costs of nicotine-replacement aids, including patches, gum and medicines.
Highmark Blue Cross Blue Shield offers a limited number of members access to a program that provides group therapy, nicotine-replacement treatments and financial incentives to kick the habit. The StartSMART program enrolled 420 participants in 1999 and had a quit rate of 39 percent for 325 of the participants surveyed after six months; after 12 months, 30 percent of 290 participants surveyed were still smoke free.
Aside from programs like this one, though, "employer interest [in covering medicine costs] has never been very high," said spokesman Michael Weinstein.
HealthAmerica reimburses members for the costs of smoking cessation programs, but only after completion. The HMO does not cover the cost of prescription or over-the-counter aids.
Neither Aetna US Healthcare nor the UPMC Health Plan cover the drugs either, although UPMC gives members the option of enrolling in behavior modification classes. If the member stays smoke free for three months after the class, UPMC will reimburse for three months worth of Zyban, a prescription drug that helps some smokers quit.
Because so many third-party payers have resisted paying for cessation classes, organizations such as the Center for Health Hearts and Souls in Wilkinsburg have seen the tobacco settlement money as a way to expand their programs. The church-based program has operated for about one year and, thus far, has a 54 percent quit rate at six months for its roughly 120 participants.
Dr. Bruce Block, the medical director for the program and a primary care doctor at UPMC Shadyside, says that quit rate likely will drop as time goes by, but the program offers smokers tremendous community support to quit through regular meetings.
"You never finish this program," said Mattie Woods, community program manager. "When you're talking about the community and the church community, they're always there."
Saul Shiffman, a professor of psychology at the University of Pittsburgh, questioned the effectiveness of hypnosis and acupuncture treatments to help people stop smoking, but said there is evidence that pharmaceutical approaches and support groups do help. Shiffman has offered advice to Leyland on the patch the former Pirates manager is using.
In studies where the quit rate for a control group might be 10 to 20 percent, Shiffman said, the rates double for study participants using behavioral treatments.
"There are literally dozens of studies showing that things like nicotine replacement work," he said. "It's more a question of picking the right treatments and doing them well."
Sen. Tim Murphy, R-Upper St. Clair said legislators have heard Herberman's concerns about the efficacy of cessation and prevention programs and will respond by closely watching their effectiveness once the money is spent. Murphy said he believed the 15 percent for prevention and cessation money would be preserved in the coming legislation.
"If we know that smoking kills and smoking hurts, at what point do you stop studying it and start taking action?" Murphy said. "It's time to act on this."
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