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An Ounce of Prevention

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See also: "A Taxing Problem" & "Pack O' Numbers"

Sixteen-year-old Ashley Forte was trying to prove a point.

"I want y'all to close your eyes," she said to the roomful of Raleigh high school students sprawled across rows of blue flip-up chairs. "This is an activity that lets you hear how many people tobacco kills."

Forte, who's a junior at Southern High School in Durham, then reached into a cardboard box loaded with workshop props. She dug past a pile of T-shirts and a bag of charcoal, and pulled out several small jars--some empty and others filled with BBs.

"Heroin and cocaine kill 16 people a day," Forte said, letting that number of balls from one jar drop slowly into another, making a noise like the start of a hailstorm on a tin roof.

"Alcohol is bad," she continued. "Three-hundred and forty-two people a day die alcohol-related deaths." Another round of BBs rained down.

"For tobacco, it's 1,180," Forte said, tipping a container crammed with gray pellets slowly into a waiting jar. A sound like machine-gun fire bounced off the walls of the auditorium for what seemed like several minutes.

"Now, open your eyes," Forte said, rolling up the sleeves of her dark blue sweatshirt and looking around the room. "And think about how you can use this as an activity at your school."

A member of the Durham-based Question Why Youth Empowerment Center, Forte is a seasoned smoking- prevention educator. She and her co-workers spend 10 hours a week planning and leading workshops for area community groups and schools.

The message they deliver is simple: Smoking is the country's leading preventable cause of death and disease and it's being promoted by an industry that deliberately targets youth. Studies show 90 percent of smokers pick up the habit by the time they're 18, and programs led by peers are among the most effective ways to discourage kids from starting to smoke.

But few in state government are listening. Currently, North Carolina spends only $750,000--a fragment of its $2 billion budget--on programs to curb smoking. The logical source of funds for those programs is the $4.6 billion in tobacco-settlement money the state is slated to receive over the next 25 years. Those dollars were won as a result of lawsuits states filed against cigarette manufacturers to recover the costs of treating sick smokers.

But right now, not a dime of North Carolina's share of the settlement is targeted for smoking prevention. The Health and Wellness Trust Fund Commission, the agency set up to help distribute the health-care portion of that money, is expected to approve a $5 million prevention plan Feb. 13. By comparison, state trust funds aimed at tobacco communities have spent $30 million in settlement money on retrofitting tobacco barns and $250,000 on marketing the pork industry.

The situation has left programs like Question Why in a quandary. When its startup grant from the Robert Wood Johnson Foundation runs out at the end of the year, the center will be without a budget to continue its work in 39 counties, and Ashley Forte will be out of a job.

Program Coordinator Bronwyn Glenn says the group had been counting on tobacco- settlement money to keep going. "Now, we're not sure what we're going to do."

Where's the rest of the money going? Under an agreement negotiated by Gov. Mike Easley when he was state attorney general, three- quarters of North Carolina's settlement is set aside for economic assistance to tobacco growers and communities. Prevention advocates had hoped that a hefty portion of the remaining funds would go to stop-smoking efforts. Instead, they watched as a prescription drug program backed by the governor gobbled up almost all of those resources.

In December, the Health and Wellness Trust Fund Commission voted 14-1 to spend $105 million--practically all of the money it has on hand for the next three years--to set up a prescription assistance program for seniors. The decision fulfills a key campaign pledge made by both Easley and Lt. Gov. Beverly Perdue, whom the governor appointed to chair the commission.

It also has many health leaders wondering why the state bothered to set up a commission, since it has yet to approve a plan of its own. And it has anti-smoking activists scrambling to do with the leftover $5 million what they'd hoped to accomplish with five times that amount.

"It's a big disappointment," says Deborah Bryan, of the American Lung Association of North Carolina. "It's pitiful compared to what's being done in other states."

In places like California, Massachusetts and Florida, statewide stop-smoking campaigns have saved millions in health-care costs and made major dents in teen smoking rates. Florida's managed to cut teen smoking among middle school students nearly in half since launching its program in 1998. Even fellow tobacco state Virginia is now putting more settlement funds into prevention--$19.2 million as of this year.

But in North Carolina, leaders responsible for paying out those dollars have turned their backs on the very reasons the state signed the tobacco agreement. Gov. Easley, who played a key role in arranging that deal, had his eye on the settlement from the start to help deliver on his campaign agenda. So, despite paying lip service to the need for smoking prevention, the state has ended up allowing short-term politics to obscure the solutions to long-term health problems.

North Carolina's certainly not alone in failing to direct tobacco-settlement funds to stop-smoking efforts. The National Conference of State Legislatures reports only 5 percent of the more than $21 billion cigarette companies have paid out so far has been used for smoking prevention. Perdue likes to point out that in states like Tennessee, tobacco settlement money's going to fill holes in the state budget and potholes in the roads.

Tobacco companies aren't exactly thrilled about being raked over the coals to pay for the ill effects of smoking, only to see states spending their settlement checks on political projects of the moment.

"We're disappointed that, to date, more states have not taken advantage of the opportunity to use these funds to support programs that can help reduce youth smoking," says Carolyn Levy, a senior vice president for Philip Morris, in a statement responding to a new report on how states are using tobacco-settlement dollars.

Health activists and some lawmakers can't help but feel betrayed by how few of those dollars are going to address the issues that led to lawsuits against Big Tobacco in the first place.

"At the start, the tobacco settlement was all about health," says Bryan, of the American Lung Association. "Now, it's the last and littlest slice."

"We finally win a big one [lawsuit] and we basically give the money away," says state House Rep. Martin Nesbitt, a Buncombe County Democrat. "It doesn't make any sense."

Treating people made sick by smoking costs far more than any proposed prevention program, Bryan and other activists point out. The federal Centers for Disease Control and Prevention reports that North Carolina now spends $200 million a year on health care for people with tobacco-related illnesses. Twenty-one percent of all deaths in the state are associated with tobacco use. And without a focus on prevention, health leaders say, those costs will only increase. It's estimated that 24,200 kids will take up smoking this year in North Carolina.

Trust fund commission members--the few who will talk publicly about their recent decision on prescription drugs--admit to some "mixed feelings" about having so little money left over for reducing smoking. But when the governor and the lieutenant governor are lobbying hard for something, political appointees aren't about to say no.

"We are under the control of the legislature and the governor's office, and this was something they felt strongly about," says commission member Betsy Locke, president of the Charlotte-based Duke Endowment--and one of the few who did not refer questions from a reporter to the lieutenant governor's office. "It would have been very strange and awkward for us to say, 'We are just not going to do that.' The feeling was, this money [for the prescription drug program] is being spent for a good purpose. Let's do this and get on with spending the rest of the money for other things."

The law that created the Health and Wellness Trust Fund says its grants can be used for "preventing, reducing and remedying the health effects of tobacco use"--among other health needs. While that may not add up to a legal mandate to put prevention first, public health activists say the commission has a moral obligation to do so.

"We have more than 11,000 survivors and victims of tobacco-related diseases in North Carolina each year and their voice is not being heard in the current debate," says Adam Goldstein, an associate professor of family medicine at UNC-Chapel Hill and medical advisor to the statewide Survivors and Victims of Tobacco Empowerment Project (SAVE). "The irony of course is that the new prescription drug benefit program is paying for prescriptions for those with obstructive pulmonary disease and emphysema. But no money right now is committed to preventing the decades of addiction that led up to those conditions."

There wouldn't be a health trust fund--or even, some say, a national tobacco settlement--if it weren't for Mike Easley. Back in 1998, when he was attorney general, North Carolina was not among the 41 states that sued giant cigarette-makers to help recover Medicaid money spent treating sick smokers. The Tar Heel state was locked out by a law the General Assembly passed two years earlier banning class-action suits against tobacco companies. Still, North Carolina politicians were hoping they'd gain something from concessions the tobacco industry was being forced to make in other state courts.

Hopes for a national tobacco settlement nearly died that summer when cigarette companies set off a public relations bomb opposing a $368 billion plan then before Congress. When that plan failed, Easley stepped into the fray with an idea for a broader settlement package that would apply even to states that had not yet sued the industry.

He was one of six state attorney generals chosen to continue the bargaining. In the weeks that followed, Easley used his status as a tobacco state politician and his personal connections with tobacco industry lawyers to help hammer out what became the Master Settlement Agreement.

Under the final accord reached in November, tobacco companies agreed to pay $206 billion over 25 years to 46 states--some that had sued the industry and others that hadn't. Payments, which would become available in 2000, were based on a complex formula involving the number of cigarettes sold. There were no strings attached on how states could spend the money.

Easley's plan for North Carolina's share was to use half of the funds for a private foundation that would make grants to help tobacco towns recover from the hit the industry was taking. Democratic legislators largely backed the attorney general's plan. Republican lawmakers, though, supported calls for direct payments--and more of them--to farmers and tobacco growers.

Weeks of debate followed, climaxing in a noisy "tractorcade" protest outside the legislative building in Raleigh. In the end, the General Assembly approved a compromise version of Easley's plan: Half of the settlement funds would go to create the Golden Leaf Foundation to assist "tobacco-dependent communities." The other half would be split evenly between a trust fund for tobacco farmers and one for health care. The legislature could dissolve the trust funds or divert payments at any time.

Public health leaders had mixed feelings about how the settlement had shaken out. Some saw the creation of a trust fund as a victory because it would ensure a steady flow of settlement funds to health needs. But others viewed the 25 percent share as less than the bare minimum.

Dennis McBride, then the state's public health director, told lawmakers that health deserved more on the order of half the total settlement receipts. Adam Searing, project director of the N.C. Health Access Coalition, urged lawmakers to consider using half of the tobacco foundation's resources for health programs, as well. "It's a real historic opportunity to bring these [tobacco] communities up to the same health standards that other communities in the state enjoy."

The governor pushed hard for independent agencies to pay out settlement funds, rather than leaving that choice to legislators. Setting up the foundations and the trust funds was "the only way to protect this money for the purpose it ought to be used, from the outset," Easley told a reporter for The News & Observer.

But as Easley's 2000 campaign for governor revved up, it became clear he had his own plans in mind for the health trust money. Among his first campaign proposals was a call to use up to $30 million in tobacco-settlement funds for a prescription drug assistance program for seniors.

"I'm Mike Easley. I have a plan to help seniors pay for prescription drugs," his TV ads declared.

Easley won the fall election by a 52-46 margin over Republican Richard Vinroot. As he set about making his campaign promises a reality, he had a powerful ally in Lt. Gov. Beverly Perdue, who had built her political reputation around health-care and other issues of concern to the elderly. Perdue was one of Easley's six appointments to the 18-member health trust commission and she was quickly installed by the other members as chair. The remaining members were chosen by leaders of the state House and Senate.

From the start, it was clear that a prescription drug plan would top the commission's agenda. Several members say they were asked where they stood on the issue even before they were appointed.

"I don't think we were ever asked specifically to approve it," says Charles Willson, a professor of pediatrics and an assistant dean at East Carolina University School of Medicine. "We were asked our feelings about it." Willson, who was appointed by House Speaker Jim Black, voted for the drug plan.

At the commission's first meeting in May of last year, Easley made a folksy, but pointed appeal to members. "I'm only asking you at this point to do one thing," he said, in a kickoff address. "As you know, we are in a budget shortfall and there are people in this state, our seniors, who cannot afford their prescription medications." From then on, commission members and political observers say, it was clear where the bulk of the trust fund's initial payments would go.

If the urgings of the governor and lieutenant governor weren't enough of a hint, legislators stuck a special provision in last year's state budget directing the commission to give prescription drug assistance for elderly and disabled citizens top billing.

As the commission geared up over the summer and fall, health-care activists found themselves engaged in a battle of good versus good. Prescription drugs and teen smoking prevention were both identified as priorities for the health trust money. But with the state budget crisis worsening and the events of Sept. 11 closing out the possibility that the federal government would pick up the tab for prescription drugs, it looked like the governor's plan would come out on top.

Health leaders had already pared down their request for funds for smoking prevention. A $25 million blueprint that a coalition of groups had presented to the commission was considerably less than the $42.6 million recommended by the CDC. Anti-smoking activists were optimistic when a subcommittee of the commission approved that plan in October. Still, without knowing the scope of the prescription drug program, funds for prevention remained a big question mark.

And Perdue was keeping things close to the vest. While she warned commission members that they should act quickly to keep the General Assembly at bay, her office refused to make details of the prescription plan--or even minutes of past commission meetings--public. Questions remained about the final price tag for the program and how much big pharmaceutical companies would be asked to contribute.

Still, some trust fund members were eager to act on the lieutenant governor's advice. At a commission retreat in August, press reports described how Jeffrey Houpt, dean of the School of Medicine at UNC-Chapel Hill, moved for approval of a $50 million drug plan before being reminded that no votes could be taken at the informal retreat.

Houpt and others were doing exactly as Easley and Perdue had hoped. But not everyone was sticking to the script.

Robert Parker shifted his lanky frame uneasily in his seat. The Health and Wellness Trust Fund Commission was about to vote on its first allocation of state tobacco-settlement dollars and as a member, Parker knew he was going to have to speak up.

The lieutenant governor had just finished describing a $105 million, three-year prescription drug program that she hoped the commission would approve that morning. Helping 100,000 lower-income seniors pay for medications for three targeted diseases, Perdue said, was right in line with the commission's charge to improve health care in North Carolina.

While he'd heard the broad outlines of the plan discussed before, Parker hadn't actually seen it until that morning--nor had many other members of the commission. He was concerned that it contained no mention of how the drug program would be paid for after three years. And he felt strongly that the proposal wasn't cost effective because it focused on helping people who were already sick, rather than on keeping people from smoking.

After Perdue sat down and asked for comments, Parker cleared his throat and raised his hand. In his lilting Tidewater accent, the longtime public health administrator began to explain why he'd be voting against the drug plan. He stressed that while prescription assistance for seniors is a worthy cause, "This was not the mandate of the General Assembly, it was the tobacco and youth issue. Putting money into diseases after they occur is the poorest way to address health. The majority of our funds should be spent on prevention."

There was a brief silence before Perdue jumped back in, citing the special budget provision as a big green light from the legislature. Commission member Carole Bruce, head of the group's task force on teen smoking, said "The only thing worse than not seeing this plan three years from now is not starting it today."

Others were more equivocal, describing a need for "pragmatic" choices.

"We're going to get there on prevention, but we need to address the short-term issue of seniors," said Willson, of East Carolina University. "It's not a one or the other type of question."

But in the end, with the prescription program taking up 85 percent of available funds, it was.

Parker cast the only "no" vote on the plan. He says he's still surprised, given the depth of health-care experience on the commission, that none of his colleagues chose to do likewise. Parker's own track record as a champion of preventive care led health leaders to lobby hard for his appointment to the commission. A native of rural Northampton County, he's been a school teacher and a family planning educator. During his tenure as health director of New Hanover County, officials there approved the state's first countywide ban on smoking in public places.

Parker, who now works as a vice president for North Carolina Baptist Hospital in Winston-Salem, insists he's still not opposed to helping seniors pay for prescription drugs. But he'd rather see a plan that focuses on improving access for all seniors, rather than assistance to some--and one that calls on the drug companies to pay a share.

The bottom line, Parker says, is "This just wasn't the right pot of money to do it with. I think by spending $100 million on prevention, we can save $100 billion on prescription drugs in the future. I'm willing to make that hard decision."

For their part, Easley and Perdue remain unapologetic about their decision to fund a prescription drug program with tobacco-settlement money. The governor's role in lobbying a hand-picked commission to deliver on a campaign pledge isn't part of the official spin. Instead, both Perdue and Easley insist that decision was made on the merits.

"The commission is an independent body," says Easley spokeswoman Cari Boyce. "The governor asked them to fund a prescription drug plan and they thought it was important enough to go ahead and do that."

Even a report ranking North Carolina at the very bottom in the percentage of state tobacco-settlement dollars spent on smoking prevention doesn't alter the political rationale. (The report by the national Campaign for Tobacco Free Kids came out a day before the commission's most recent meeting in Greensboro and so, garnered more than the usual media attention.)

"I hear what the prevention folks are saying," Perdue says, when asked about the state's last-place showing. "But we were careful in the way we crafted [the drug plan] to tie it to diseases that are linked to smoking. So the money is indirectly tied to tobacco."

The prescription drug issue is "one that's important to people, it's not just a political issue," she adds. "As soon as we can get the program up and running, we can see some tangible results, and I hope the same can happen with teen smoking."

Others aren't convinced. If the commission didn't cave in to lobbying by politicians, then why is smoking prevention getting the shortest possible end of the stick?

"The tobacco-settlement money is public money and it's naive to think that politics wouldn't enter into how it's spent," says Searing of the Health Access Coalition. "When the governor made prescription drug assistance a campaign issue, it was very unlikely that the health trust wouldn't consider that very carefully."

How secure is the trust fund's money? Some legislators say if tobacco-settlement checks aren't going first and foremost to reduce smoking, they should revert back to the general fund where lawmakers can make better use of them.

"The first thing the governor and the General Assembly did when they were short of money was go raid the health care trust fund to create a program that ought to be funded out of the general fund," says House member Nesbitt.

If the legislature fails to do the right thing with public money, "people can throw that crowd out and put another crowd in," Nesbitt adds. "People can assemble and address government and ask for the money. That's what politics is. What it's not is holding nice, quiet, peaceful little meetings and divvying up the bounty in private."

A lawsuit filed last month in Wake Superior Court by Raleigh attorney Eugene Boyce takes the same tack. In it, he claims that allowing appointed commissions to distribute tobacco settlement money violates the constitutional spending power reserved for the legislature. Boyce, a veteran courtroom presence, says problems with the process go back to the way the Master Settlement Agreement was reached with cigarette companies.

"The lawyers for the tobacco companies and the attorney generals--including Mike Easley--were the only ones present. It wasn't done in open court," he says. "That money should be turned over to the state treasurer so that when the money comes in, it can't be diverted to other purposes."

But given the state's widening budget crisis, health leaders say legislators will be even less likely to fund smoking prevention than the health trust commission has been. Estimates of the revenue hole now range as high as $900 million and legislative budget leaders are refusing to give any program a pass when it comes to potential cuts.

Easley won't comment on whether tobacco-settlement funds will be used to boost the budget. "It's premature at this time," says his spokeswoman, Cari Boyce. When asked if the governor is committed to seeing the health trust's remaining $5 million spent on smoking prevention, Boyce puts that decision all on the commission.

"The governor worked hard to see that that money was set aside in a trust fund to be spent by an independent group of people," she says. "And that's what they are doing."

Even states that have invested in smoking prevention haven't always followed through. Just last month, funds for Massachusetts' model tobacco-control program were slashed by two-thirds in order to balance that state's budget. Acting Governor Jane Swift invoked emergency powers to make the cuts, despite studies showing the programs were saving the state $2 in health-care costs for every dollar spent on prevention.

Health-care leaders say anti-smoking programs are vulnerable because the payoff isn't immediate.

"The return on investment from these programs is awesome," notes Parker. "But it's long term. And politics runs year to year."

For Wade Hampton, the clock has already run out. Because of the hole in his throat, he can't sing, smell or taste very well, and if he's not careful, he could drown in the shower.

Hampton started smoking when he was 15 and continued at a "pack-a-day-or-better" clip for more than 30 years. In 1994, he was diagnosed with throat cancer and soon afterward, had an operation that removed his voice box.

The surgery saved his life, but it left him breathing through an opening in his throat and speaking through a plastic pipe that travels from that hole to his esophagus. (Hampton keeps a battery-operated voice box on hand as "backup.") Since then, the 54-year-old father of three has spent much of his time crisscrossing the state from his home in Norwood to speak to teenagers about the dangers of smoking.

Hampton, who's a member of SAVE and president of the statewide Group to Alleviate Smoking Pollution (GASP), says he applied to serve on the health trust commission to represent the voices of "victims" of tobacco use. "I got nowhere with it," he says, in a voice that's husky, but can still rise and fall naturally.

To him, the idea that the state is proposing to spend only $5 million of its expected billions in tobacco-settlement funds on prevention is "an abomination. That means people will continue to suffer and there's no effort to even try to educate them or dissuade them from it."

Breaking that cycle was the point of the lawsuits that resulted in the tobacco settlement, Hampton says. Unless there's money for smoking prevention, "What politicians are doing is selling out anybody who could be a victim."

In his talks to high school and middle school students, Hampton points out that smoking causes more deaths than alcohol, AIDS, car crashes, illegal drugs, murders and suicides combined. He tries to describe the addiction that had him lighting up "from the moment my feet hit the floor in the morning until I went to bed at night"--including the night before his operation.

In the end, Hampton says, prevention is a hard sell, not because this is a tobacco state, but because the people most vulnerable to the dangers of smoking are the ones with the least clout. After all, tobacco companies, drug companies--even seniors--are powerful political lobbies. But teenagers don't vote.

Hampton sees the value of funding prevention first, even if politicians and political appointees don't. Since his surgery, "I'm living a different life for different reasons," he says, his words trailing off while he takes a breath. "My real interest is in prevention and youth. That's the only thing that's going to make a dent." EndBlock

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