The Case for a Concerted Push to Reduce Place-Based Disparities in Smoking-Related Cancers.


In this issue of JAMA Internal Medicine, Lortet-Tieulent and colleagues1 demonstrate the grim consequences of statelevel disparities in smoking prevalence. They identify substantial disparities in the smoking-attributable cancer mortalityamongUSstates.As theauthorssuggest, it is likely that only a small amount of the variation in smokingattributable cancer mortality is due to differences in population demographic characteristics among states. Rather, most of the disparity in state smoking-attributable cancer mortality is driven by the inequitable distribution of strong tobacco control policies across states and the uneven level of funding for state tobacco control programs. To illustrate,we compared state policies by level of smoking-attributable cancer mortality in the 10 states with the highest and lowest rates (Table). Results confirmed weaker policy environments in the 10 states with the highest rate— substantially lower cigarette excise taxes, no comprehensive smoke-free policies, triple the rate of preemption of tobacco control policies, and modest program spending. With thedisparities incancermortality thatLortet-Tieulent andcolleagues1 identified, the 10stateswith thesehighest rates couldbeconsideredaprioritypopulation, akin toothervulnerable or high-risk groups that are defined by age, income, race, sexual orientation, or geography (eg, rural). States comprising this group are Kentucky, Arkansas, Tennessee, West Virginia, Louisiana,Alaska,Missouri,Alabama,Oklahoma, andNevada. Centers for Disease Control and Prevention (CDC) investigators reviewed states’ progress on implementing tobacco controlpolicies andconcluded that therehasbeena“BigStall,” such thatprogress toward increasingcigarette excise taxesand promoting smoke-free air policies has recently stagnated.3 Given the lag between reduction in smoking prevalence and smoking-attributable cancermortality, theBigStall raises concerns that thedisparities amongstateswillworsenbefore they improve. The cure for the chronic condition that characterizes theBigStall is evidence-basedpolicy intervention.4,5 Since 1965, tobacco control efforts haveprevented8millionpremature deaths in the United States.4Many examples of the positive impact of state tobacco control programs exist. For example, in California, a 1989 tax increase coupled with progressive smoke-freeair lawsandawell-fundedmedia campaign produced substantial declines in smoking prevalence, cigarette consumption, health care costs, and lung cancer incidence.6 However, California is 1 of 3 states (including Missouri and North Dakota) that has not increased its cigarette tax in this century (although there is a $2.00 tax increase on the November 2016 ballot). A stagnant, low cigarette tax threatens to erode health gains and cost savings and couldundermine future progress towardhealth equity. Thus, there may be multiple definitions of “stalled states.” What will reduce smoking-attributable cancer mortality and eliminate disparities among states? The solution requires more resources and political will to address the major obstacles facingstalledstates.Obstinate state legislaturesmust investmore than the 2.4%of the $24 billion that states raised from tobacco excise taxes andMaster Settlement Agreement payments4 fromtobaccocompanies.Manyof the stalled states are in the southeastern United States, where tobacco has traditionally been grown and manufactured, and others are in areas with historically little investment for public health or tobacco control. One partial remedy to state inaction is policy innovation at local levels.Forexample, afterNewYorkCity raised thecigarette excise tax from $0.08 to $1.50, banned smoking in bars andrestaurants, andoffered freenicotine replacementpatches in 2002 through 2003, the city observed an 11% relative decrease in smoking prevalence, equivalent to approximately 140000 fewer smokers.7 Related article


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