Rhode Island has made strides implementing cancer-fighting public policies, but there is still much room for improvement – according to the 17th annual “How Do You Measure Up?” report issued by the American Cancer Society Cancer Action Network (ACS CAN), which was released on Thursday.
Of eight evaluated areas related to fighting and preventing cancer – which includes access to Medicaid; access to palliative care (care which provides relief from chronic illnesses, such as cancer); policies that provide access to managing pain; cigarette tax rates; smoke-free laws; tobacco prevention and cessation funding; Medicaid coverage for tobacco cessation services; and indoor tanning policies – Rhode Island scored positively (green) on five.
Rhode Island ranked “yellow,” denoting more improvement needed, in the areas of pain policy and coverage of tobacco cessation services through Medicaid. But the main focus of the report in terms of Rhode Island is its spending on tobacco prevention and cessation programming, which is the lone area where the state scored a “red” mark, meaning it is falling short of the American Cancer Society’s benchmarks.
“This report highlights the important progress we’ve made in passing policies proven to reduce suffering and death from cancer,” said Robert Dulski, Government Relations Director for ACS CAN Rhode Island in the organization’s press release announcing the report. “But there’s still more work left to do to make a difference for Rhode Islanders by implementing proven cancer-fighting policies.”
The big policy areas that ACS CAN will look to influence in the next legislative session? Increasing funding to the state’s tobacco prevention and cessation programming and enacting a law prohibiting the sale of tobacco products to anybody under the age of 21.
Dulski spoke on Monday about ACS CAN’s efforts to make legislators see the long-term benefits of increasing funding for programs and initiatives that not only help people quit smoking, but actually prevent people from ever starting.
“ACS CAN supports the tobacco control program because they use evidence-based techniques to prevent people from smoking and help them quit,” he said. “This is for proven methods that have worked in the past, not just in other states but in some cases across the entire world.”
The Center for Disease Control makes recommendations regarding how much state should spend on such programming. No state has attained the CDC’s full recommendation – Alaska is the closest, spending $9 million of the CDC’s recommended $10 million, and California is second spending $250 million of the recommended $350 million (about 72 percent).
Rhode Island, however, spends the 12th lowest amount on prevention and cessation among all other states, with just $390,926 of a recommended $12.8 million spent on such programming in FY19. That amounts to just 3.1 percent of the CDC’s recommendation. This number has steadily decreased from the state’s highest benchmark spending amount of $3.2 million in 2001.
For context, Rhode Island brings in about $150 million a year in tax revenue from the sale of all tobacco products. Throw in another $46 million from the federal Master Settlement Agreement and the state accrues nearly $200 million each year from tobacco-related means. The $390,000 spent on tobacco prevention and cessation amounts to about 0.19 of one percent of this revenue.
Proponents like Dulski argue that spending more money now on tobacco cessation and prevention programs bring about much bigger savings down the line in the way of decreased healthcare expenses, due to fewer people contracting health problems such as cardiovascular disease and cancer. According to Dulski, over 6,500 people in Rhode Island will be diagnosed with cancer this year.
“We owe it to them—and to everyone at risk of developing this disease—to do everything in our power to prevent cancer and improve access to screenings and treatment,” he states in the press release.
According to the report, California’s tobacco control program – which is second in the nation in terms of relative spending – has reduced healthcare costs in the state by $134 billion from 1989 to 2008, while spending just $2.4 billion on such programming during the same span. In Massachusetts, the report contends, they estimate $85 million in healthcare cost savings, “averaging a savings of $2 for every $1 spent.”
But the message of “pay now, reap savings later,” may be a difficult sell in Rhode Island.
“We look at that, but everybody makes that argument,” said House Majority Leader K. Joseph Shekarchi. “Everybody says give me more money now because you'll make more down the road. That doesn’t affect my view personally. You have to balance it and look at everything.”
Shekarchi said that, while he felt the momentum within the House for more tobacco-related policy was “growing,” he needs to see independent, third party analysis that corroborates the promise of cost savings before being able to support ponying up more money for the types of programs groups like ACS CAN promote.
“Like anything else, it's a significant and worthy issue and it takes time and education to discuss,” he said.
Dulski said that the group would continue to push for the changes in the upcoming session.
“It's difficult to send that message about long-term healthcare savings,” Dulski admitted. “We can't give up. We just have to keep pressing.”
The other policy ACS CAN most hopes to be able to implement in the upcoming session is increasing the legal smoking age to 21 years old.
According to the report, which cited an Institute of Medicine report from 2015, smoking prevalence would decline by 12 percent if the national minimum age of sale was raised to 21, which would result “in approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost for those individuals born between 2000 and 2019.”
Increased pressure to raise the age also comes from e-cigarette products, which has seen a dramatic explosion of use among teenagers in high schools and middle schools.
“From 2017 to 2018, e-cigarette use spiked by an astonishing 78 percent among high school students and 48 percent among middle school students, leading to a 36 percent spike in overall tobacco use among youths,” the report states.
Among high school students who reported using tobacco products in 2018, 20.8 percent use e-cigarettes (over 3 million students), which is more than double the number that reported using cigarettes (8.1 percent, or about 1.18 million). Comparatively, only 2.8 percent of adults who reported using tobacco products in 2017 used e-cigarette products.
Dulski said that raising the legal age to 21 would present budgetary challenges, as it would reduce the total number of individuals purchasing tobacco products, which would reduce the state’s tax revenue. ACS CAN estimates this number to be in the $700,000 to $800,000 range in terms of economic impact.
“It’s tough to make that up,” he said in explaining how the proposal has gained traction but ultimately failed to move out of committee in the past session.
“We're in a tough budget year and we have to look at alternative ways to fund it without non-smokers funding that,” Shekarchi said. “We have to look at alternative funding. If you're looking for the state to fund everything, it just increases taxes for everybody.”
However, Dulski pointed out that Rhode Island – despite having the fourth highest tax rate on cigarettes in the country at $4.25 per pack – there is still more that can be done to increase tax revenue and fund the programming they see as vital.
For example, although Rhode Island’s taxes on cigarettes are comparable to surrounding states such as Connecticut, Massachusetts and New York, its minimum wholesale and retail markup rates (2.75 percent and 6 percent respectively) are two to three times less than Connecticut and Massachusetts. This means that, despite having a higher tax, a pack of cigarettes that will cost $9.83 in Rhode Island will still cost significantly more in Connecticut ($10.50) and Massachusetts ($10.74).
Additionally, Rhode Island does not currently charge a tobacco tax on e-cigarette products – only sales tax. This, Dulski said, is a missed opportunity to grow revenue for the state, which can go to funding the prevention and cessation programs. He specifically mentioned a wholesaler tax, borne by retailers, which would ensure the state is getting the biggest bite without overburdening consumers – although he did admit such a measure would increase the prices of electronic cigarette products.
“We have a huge opportunity and we're not going to let off the gas,” Dulski said, adding that Rhode Island has found itself on a different type of island regarding the legal age to buy tobacco products.
If a challenge to the state budget in New Hampshire resolves without affecting their own 21-plus law for tobacco, Rhode Island will be the only state in New England to have not enacted a law restricting the sale of tobacco products to those under the age of 21. New York, New Jersey and even Texas have instituted such laws as well.
For Dulski and ACS CAN, preventing more people from becoming smokers is not only a moral imperative that will potentially save thousands of lives, it is an economically savvy move that shouldn’t be viewed as a gamble. He said that those who would be in charge of running prevention and cessation programs already have a structure in terms of how they would spend additional money.
“If they get the money, they know what targeted method they're going to spend it on. It's not going to surprise them,” he said. “We're not advocating on something where the state doesn’t know what to do with it. They know exactly what to do with it.”