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HEALTH POLICY AND ETHICS |
Alison Snow Jones is with the Division of Public Health Sciences, Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC. W. David Austin is with the Community and Health Education Research Program of the Public Health and Environmental Division of RTI International, Research Triangle Park, NC. Robert H. Beach is with the Food and Agricultural Policy Research Program, RTI International. David G. Altman is with the Center for Creative Leadership, Greensboro, NC.
Correspondence: Requests for reprints should be sent to Alison Snow Jones, PHS/SSHP, WFUHS, Medical Center Blvd, Winston-Salem, NC 27157 (e-mail: asjones{at}wfubmc.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONTHE MASTER SETTLEMENT AGREEMENT...STRUCTURE OF MASTER SETTLEMENT...ALLOCATION OF MASTER SETTLEMENT...THE 2004 TOBACCO BUYOUTWHERE THE MONEY SHOULD...References |
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Changing political and economic forces in 1 tobacco-dependent state, North Carolina, demonstrate how the interplay between these forces and public health priorities has shaped current allocation of Master Settlement Agreement funds. Allocation patterns demonstrate lawmakers’ changing priorities in response to changes in the economic climate; some of the agreement’s funds targeted to tobacco farmers appear to reflect objectives favored by tobacco manufacturers.
Funds earmarked for health have underfunded youth tobacco prevention and tobacco control initiatives, and spending for tobacco farmers in North Carolina has not lived up to the rhetoric that accompanied the original agreement. We discuss the implications of these findings for future partnerships between public health advocates and workers as well as tobacco control strategies.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONTHE MASTER SETTLEMENT AGREEMENT...STRUCTURE OF MASTER SETTLEMENT...ALLOCATION OF MASTER SETTLEMENT...THE 2004 TOBACCO BUYOUTWHERE THE MONEY SHOULD...References |
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North Carolina provides an excellent case study. It is a major tobacco-producing state with above-average tobacco use, 2 factors likely to diminish lawmakers’ and constituents’ interest in tobacco control.1,2 State lawmakers face a complex array of competing interests and political issues: the tobacco lobby continues to exercise considerable political strength, tobacco-dependent communities face fragile economic futures, the substantial loss of manufacturing jobs in non–tobacco-dependent communities has introduced new pressures for economic development,3 and shrinking tax revenues combined with rapidly rising Medicaid costs have created a constrained economic climate. Additionally, North Carolina tobacco farmers’ phase 2 settlement payments are being replaced by tobacco quota buyout payments. Although neither of the latter 2 funding sources is controlled by the state, their purposes and those of MSA funds are intertwined.
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THE MASTER SETTLEMENT AGREEMENT IN NORTH CAROLINA |
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TOPABSTRACTINTRODUCTIONTHE MASTER SETTLEMENT AGREEMENT...STRUCTURE OF MASTER SETTLEMENT...ALLOCATION OF MASTER SETTLEMENT...THE 2004 TOBACCO BUYOUTWHERE THE MONEY SHOULD...References |
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The second phase, which was the direct result of intervention by North Carolina’s then attorney general, Michael Easley, tobacco-producing states negotiated a plan to compensate tobacco quota owners and tobacco growers for revenue losses resulting from declines in demand because MSA payments forced tobacco manufacturers to raise prices.5 This phase 2 settlement established the National Tobacco Growers’ Settlement Trust Fund, into which the 4 participating cigarette manufacturers were to pay $5.15 billion over 12 years. Allotment of funds among states was based on 1998 tobacco quotas, with North Carolina receiving the largest share (38%). Funds were to be paid directly to individual quota holders and producers, with no restrictions on use.
The public health community had strong reasons to expect that a significant portion of MSA funds would target tobacco control programs. Senator John McCain, a major architect of the MSA legislation, described the general agreement among state governors, saying that the money would be used "on smoking cessation programs."6 Resolutions passed by the National Governor’s Association in 1999 and 2001 indicated a commitment by the governors to spend "a significant portion of the settlement funds on smoking cessation programs."7 Reports in the press and elsewhere reflected a belief that similar commitments would be made.8,9 However, several studies have documented that, with few exceptions, only a small proportion of MSA funds have been devoted to tobacco control.2,10–15 Gross et al. showed that the average state received $28.35 per capita from the settlement in 2001 but allocated only 6% of these funds, approximately $1.70 per capita, to tobacco control programs.2
One possible explanation for the low proportion of MSA funds devoted to tobacco control in tobacco states is the redirection of funds to provide assistance to tobacco farmers and tobacco-dependent communities, an objective that formed the basis for the decision by North Carolina’s then attorney general, and now governor, Michael Easley, to join the original lawsuit.5,16 Also, during the 1990s, some tobacco control advocates recognized that the economic health of tobacco-dependent communities and tobacco growers was an important determinant of physical health and well-being for both. Consequently, some advocates have collaborated with growers to address both public and economic health simultaneously.17,18
Any detailed examination of states’ MSA allocation decisions after the agreement was signed must be considered against a nationwide backdrop of dwindling state tax revenues in those early years. Schroeder provided evidence that increasing percentages of MSA payments were diverted directly into state coffers to alleviate budget shortfalls.11 In 2003, nearly half (47%) of MSA funds were diverted, a sharp increase from 29% in 2002 and 16% in the 3 preceding fiscal years. There is evidence that state governors, whose budgetary discretion varies by state, regard fund diversion as simply reflecting structural flexibility that is codified in the MSA by Public Law 106–31 (signed into law by President Bill Clinton on May 21, 1999, without mandated set-asides for tobacco control or farm community assistance).19 This flexibility may reflect the varying bases upon which states initially sought legal remedy. Some complaints did not cite Medicaid or health care costs, while others did, possibly leading states to view allocation of MSA funds as discretionary. North Carolina’s governor had both incentive and ability to exploit this flexibility because the state constitution requires the governor to balance the budget in every year,20 and North Carolina budget shortfalls ranged from $702 million in fiscal year 2000 to 2001 to $1.555 billion in fiscal year 2001 to 2002.21
If the diversion of funds away from tobacco prevention had been the result of decreases in smoking prevalence, public health advocates would be less concerned. However, this diversion appears to reflect political considerations and economic changes rather than decreased tobacco use. Loss of manufacturing jobs in North Carolina increased lawmakers’ interest in economic development, especially in communities that lost textile, furniture, and other manufacturing jobs, regardless of their dependence on tobacco.3 Added to this were unprecedented fiscal pressures from rapidly dwindling tax revenues coupled with increasing Medicaid costs. These pressures combined with increased sentiment against taxes generally. MSA funds may have enabled lawmakers to avoid or reduce tax increases or budget cuts and their political consequences by diverting these funds to satisfy balanced-budget mandates.
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STRUCTURE OF MASTER SETTLEMENT AGREEMENT FUNDS |
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TOPABSTRACTINTRODUCTIONTHE MASTER SETTLEMENT AGREEMENT...STRUCTURE OF MASTER SETTLEMENT...ALLOCATION OF MASTER SETTLEMENT...THE 2004 TOBACCO BUYOUTWHERE THE MONEY SHOULD...References |
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We extracted grant award data from the Web sites of the 3 North Carolina MSA-based foundations and from the phase 2 Web site.22 HWTF data were compiled from a table that contained total commitments through fiscal year 2003 to 2004.23 GLF total expenditures for fiscal years 2000 to 2004 were compiled from the awards list by year and by sector on the GLF Web site.24 TTF total expenditures for fiscal years 2001 to 2003 were compiled from the awards list by year and by sector on the TTF Web site (no awards were made in 2004 because of diversion of funds by the legislature).25
GLF grants were classified as focused on agriculture, economic development, or work-force preparedness, according to definitions within GLF priority areas. GLF also defined certain economic development grants as economic stimulus or for "shovel-ready" certification of industrial development sites. Within the agriculture-focused category, tobacco diversification–focused projects were defined broadly as any project that directly targets tobacco farmers to assist in diversifying to other enterprises or that produces knowledge, techniques, markets, financing, and so on that could assist tobacco farmers to diversify. Grants made by TTF and HWTF were categorized by each foundation’s specific focus area.
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ALLOCATION OF MASTER SETTLEMENT AGREEMENT FUNDS |
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on this page presents grant categories by fund. Detailed data in Table 1 show that GLF grants for agricultural purposes decreased from 51% in 2000 to 4% in 2003 to 2004. Across all 4 years, 13% of total awarded grants targeted agriculture, and 87% funded economic development. These large changes in grant allocation percentages were primarily a result of GLF’s decision in 2003 to provide $60 million for a Biotechnology Training Consortium composed of major educational institutions. Total annual allocation between 2002 and 2003 to 2004 jumped significantly (from $12.6 to $70.9 million), because GLF policy temporarily departed from its policy of restricting grants to investment income. There is evidence that the consortium funding decision was influenced by the governor and powerful state legislators and that the decision likely prevented GLF funds being diverted to the state’s general fund.26 Table 2 shows that GLF grant recipients were initially varied, with 8 types of recipients receiving at least 3% of GLF funds in 2000. By 2003 to 2004, there were only 4 such recipients, with the majority of funds awarded to universities or the community college system, mainly because of the Biotechnology Training Consortium.
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| Master Settlement Agreement Fund Grant Categories Agriculture (Tobacco Trust Fund and Golden Leaf Fund [GLF])
Inclusive economic development (GLF)
Health (Health and Wellness Trust Fund)
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In keeping with TTF’s intended purpose, $46 982 161 (97%) of its funding targeted agriculture and 3% targeted economic development. However, only 6.9% of agriculture funding was targeted to tobacco diversification. In a move that was arguably counterproductive to tobacco control, 89% of TTF dollars was directed to supporting tobacco farmers to grow tobacco. The largest portion of this amount, $41 million, was provided to tobacco farmers for retrofitting flue-cured tobacco barns. One conjecture is that this funding came at the behest of some tobacco manufacturing companies, who feared that the discovery that traditional curing methods increased nitrosamine levels in cured leaf would expose the industry to more lawsuits.27 Most tobacco farmers, however, believed that the tobacco barn retrofits, which were then certified by the manufacturer and a requisite for contracting, were simply a mechanism for the industry to push forward with plans to eliminate the tobacco auction system in favor of a farmer-to-manufacturer contracting system (Betty Bailey, executive director, Rural Advancement Foundation International, oral communication, March 2003). Despite TTF attempts to please tobacco farmers and manufacturers, lawmakers diverted a total of $157 million—75% of the original allocation—from the fund to the state’s general fund through 2004.
Of $130 million total in grants awarded by HWTF, $28 million, or 21%, went to youth tobacco use prevention and cessation; the remaining 79% targeted 3 other health objectives: medication assistance, prescription drug assistance, and obesity prevention. In addition, $97.9 million, 43% of total HWTF funds, was diverted by lawmakers to the state general fund through 2004. Despite the relatively small share of funds allocated to youth tobacco prevention, this was a substantial improvement in North Carolina’s efforts to curtail youth smoking. Prior to 2003, the state spent no MSA funds on tobacco prevention. In 2003, North Carolina spent $6.2 million to reduce smoking. This figure has risen steadily through 2005 to $15 million and represents an increase from 15% to 35% of the amount recommended by the Centers for Disease Control and Prevention (CDC) for the state.28
Phase 2 funding to eligible tobacco growers and quota owners totaled $665.8 million for the first 5 years of payment, ending in 2003 (Table 3). With no restrictions on these funds, individual tobacco farmers could spend them in any way, including diversifying, growing more tobacco, paying off farm debt, or funding retirement. The lump sum value of the stream of phase 2 payments to growers was projected to significantly exceed grower losses caused by the MSA. However, total grower losses (caused by the MSA, excise tax increases, and declines in tobacco exports) would exceed the projected value of all phase 2 payments.29
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also provides a detailed breakdown of MSA funds with and without phase 2 payments and amounts diverted to general funds between 2000 and 2004. Funding of health projects through MSA-only funds was the largest component, at 45.1% of the total. The bulk of this amount, about 70% of total health-related funds, went to medication assistance and a prescription drug initiative that fulfilled campaign promises made by Governor Easley.30 Phase 2 payments ($665.8 million) were more than twice the total allocation through the 3 MSA funds ($290 million). Consequently, when phase 2 payments and diverted funds are included in the calculation (last column, Table 3), agriculture accounts for the largest fraction (60.3%), economic development is 7.8%, and health accounts for only 10.8% of total funds allocated. A large portion (21.1%) was diverted to general funds. The largest single allocation (55%) was unrestricted, direct phase 2 payments to tobacco quota owners and farmers. Tobacco diversification (1.4% or 5.8%, with and without inclusion of phase 2 and diverted funds, respectively) and teen tobacco use prevention and cessation programs (2.3% or 9.6%, with and without inclusion of phase 2 and diverted funds, respectively) were allocated very small fractions of total dollars that accrued to the state and its tobacco farmers as a result of the MSA and the related phase 2 payments. Economic development grants were allocated a larger percentage (7.8% or 32.6%, with and without inclusion of phase 2 and diverted funds, respectively).
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THE 2004 TOBACCO BUYOUT |
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WHERE THE MONEY SHOULD GO |
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TOPABSTRACTINTRODUCTIONTHE MASTER SETTLEMENT AGREEMENT...STRUCTURE OF MASTER SETTLEMENT...ALLOCATION OF MASTER SETTLEMENT...THE 2004 TOBACCO BUYOUTWHERE THE MONEY SHOULD...References |
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Is it enough? Clearly, by most public health standards it is not. North Carolina continues to be above the national average for tobacco use among both adults and teens.36 There is significant evidence of the efficacy of tobacco control interventions,36–42 and the CDC has recommended that North Carolina spend a minimum of $42.6 million annually on them. North Carolina’s allocation of $15 million from MSA funds for tobacco use prevention in 2005 was only 35% of the CDC’s recommended minimum.12 Funds for tobacco use prevention were 8.3% of tobacco revenues, including tobacco settlement payments and tobacco taxes, and was dwarfed by the state’s estimated $1.9 billion annual smoking-related health costs.43 Moreover, North Carolina’s almost exclusive focus on teen smoking prevention did little to reduce negative health and cost sequelae among adult smokers or among nonsmokers exposed to environmental tobacco smoke.44,45
Is directing MSA funds away from tobacco control a better use of these funds? It is difficult to compare benefits from senior drug programs and economic development projects or from direct payments to tobacco growers and quota owners with benefits that would accrue to individuals and the state through tobacco control programs. However, research on the economic benefits of tobacco control programs and excise taxes provides some insight into the large potential gains from these interventions.46–48 Cutler et al. demonstrated that the MSA will produce significant health benefits simply from increased cigarette prices and from mandated anti-tobacco youth advertising campaigns.46 They estimated that price increases alone would increase smoking cessation and, consequently, longevity by roughly 5.1 to 6.5 years per never smoker or quitter. Valuing the longevity increase in monetary terms, they estimated that every MSA dollar paid by cigarette companies generated $6 in health benefits.
Why did North Carolina shift away from tobacco control and support for tobacco farmers in transition? It is clear that supporting economic development initiatives, balancing the state budget, and fulfilling campaign promises for a drug program for seniors were high priorities for North Carolina lawmakers. If these shifts represented more efficient allocations of MSA dollars to initiatives that would yield higher net benefits for all North Carolina residents, then the flexibility granted to MSA fund overseers was justified. But if these shifts represent lawmakers’ abandonment of original MSA objectives and North Carolina MSA trust fund priorities in favor of political benefits that would accrue primarily to their political careers or to their campaign supporters, then the absence of set-asides for tobacco farmer diversification and tobacco prevention defeated the implied purpose of the MSA.
Why did tobacco control advocates not had a stronger voice in MSA allocations? Certainly the climate of diminished tax revenues, antitax sentiment, and rising health care costs helped to drown out the voice of tobacco control advocates. But other factors also may have contributed. Pollack and Jacobson noted that tobacco control advocates had succeeded in passing strong national policy initiatives but had less success at the state level.49 They attributed this difference to smaller, more stable regulatory and policy arenas that were often shielded from public view. Another factor may be that political constituencies were more homogeneous at the state level. Dennis et al. examined the US Senate’s vote on the North American Free Trade Agreement and found that for highly visible and controversial policy issues (such as tobacco control in a tobacco state), constituency variables were more important predictors of legislators’ votes than were legislators’ ideologies when constituencies were homogeneous in opinion.50 Although their study was conducted at the national level, their results suggest that if constituencies were more homogeneous in favoring tobacco production and consumption at the state level, then votes and other actions taken by lawmakers to advance or hinder tobacco control would more likely reflect the will (or lack of opposition) of their constituents.
Snyder et al. found that state governor party affiliation was the most important political predictor of spending for tobacco control programs, with Democrats outspending Republicans.1 North Carolina is a Republican state with a Democratic governor who was state attorney general when the state joined the MSA lawsuit and when the MSA was signed. This combination may help explain the low, but rising, level of tobacco control funding from MSA funds in recent years. Also, as in other parts of the country, sentiment about smoking seems to be changing in North Carolina.51–54 If this trend continues, then changed constituent attitudes may produce the tobacco prevention programs that MSA funding alone could not. In this case, tobacco control advocates would do well to strengthen ties with local leaders and their constituencies.
Finally, what about the tobacco farmers and their communities? Remedy for them was a main focus of North Carolina’s original decision to join in the MSA complaint.5,16 Tobacco farmers appear to have fared better than did tobacco prevention programs, at least in the short term. Despite relatively small allocations from MSA funds, there have been significant financial gains for farmers from phase 2 and the later quota buyout payments. It remains unclear whether these short-term payments will have lasting effects that go beyond easing short-term financial burdens among the relatively few people living in tobacco-dependent communities. Moreover, the large amounts paid to farmers under these programs belie the disproportionate share that has been and will be paid to a few owners of large tobacco farms.
It is estimated that 20% of tobacco farmers will receive more than 75% of total payments under the buyout, with roughly 270 in North Carolina receiving at least $1 million.55,56 Median payout will be less than $15000 annually for 10 years. Coupled with the high indebtedness of most small farming operations and the disproportionate concentration of small farmers in Appalachian and Piedmont counties (where costs of farming are high, alternative enterprises are more difficult to cultivate, access to markets for enterprises such as organic produce is low, and off-farm jobs are in short supply), it appears that neither phase 2 nor the buyout will bring the kind of comprehensive, structural economic assistance these vulnerable communities and families will need to survive in the long term.
Because of phase 2 payments, state lawmakers may have concluded that MSA funds were not needed by tobacco farmers or their communities. Alternatively, lawmakers may have anticipated the diminishing political power of tobacco farmers and their communities that would result from reductions in the number of small tobacco farms after the buyout.18 Political pressures from constituents with stronger political voices, such as those who can tie their objectives to economic development, have certainly increased as economic forces diminished manufacturing jobs.3 These developments are unfortunate, because tobacco farmers face significant barriers in diversifying. Without institutional support, the proportion of diversification successes may be low.38
Public health advocates must continue to provide political support to still-vulnerable farmers and farm communities until these populations receive needed assistance for the transition away from tobacco production. In so doing, advocates will advance farm community health and signal their sustained commitment to this partnership as well as to future partnerships formed with workers and communities that depend economically on the production of goods that have negative health effects. In turn, these partnerships can fuel and strengthen constituent demands to lawmakers about the importance of comprehensive tobacco control programs.
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Acknowledgments |
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The authors acknowledge the contributions of several collaborators: Steve Johnston, RTI International; Betty Bailey, Rural Advancement Foundation International-USA; Amy Richardson, University of North Carolina–Chapel Hill School of Public Health; and David Richmond, Wake Forest University School of Medicine. We are also indebted to anonymous reviewers for extremely helpful comments and suggestions.
Human Participant Protection
This study was approved by Wake Forest University Health Sciences’ institutional review board.
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Footnotes |
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Contributors
A. Snow Jones, as principal investigator, provided funding for the study and public health economics expertise in framing policy issues. She did most of the writing and revision to develop and frame policy issues. W. D. Austin helped originate the study, collected data, conducted the analysis, and wrote preliminary drafts of the article. R. Beach helped originate the study and provided guidance, editing, and sources for agricultural economics issues, particularly related to tobacco farmers’ issues and behavior. D. G. Altman helped originate the study and provided background information and guidance and writing to develop and frame tobacco control policy issues.
Accepted for publication February 18, 2006.
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References |
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TOPABSTRACTINTRODUCTIONTHE MASTER SETTLEMENT AGREEMENT...STRUCTURE OF MASTER SETTLEMENT...ALLOCATION OF MASTER SETTLEMENT...THE 2004 TOBACCO BUYOUTWHERE THE MONEY SHOULD...References |
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2. Gross CP, Soffer B, Bach PB, Rajkumar R, Forman HP. State expenditures for tobacco-control programs and the tobacco settlement. N Engl J Med. 2002;347:1080–1086.
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