Erik Abbey, a smoker for more than half his life, once believed that cigarettes would be the end of him.
“I thought I’d die with a cigarette in my hand,” Abbey, 39, said. “I think a lot of people feel that way. They know it would be best if they quit, but they’re afraid they may not be able to.”
The Brunswick man smoked for more than 20 years, starting with Marlboros as a kid and eventually burning through four packs a day. He’d watched his father die from lung cancer. He knew the health risks and sensed that his own lungs were suffering.
Then he saw a flyer for the Maine Tobacco Helpline, a free service that provides counseling and medication to people trying to kick the habit. Three years ago he gave the helpline a shot, speaking to a counselor who helped him identify hunger as his trigger to smoke. He found a replacement habit — eating vegetables when a craving hit.
Through the helpline, he also received nicotine lozenges in the mail. After one false start, he started using them regularly over the course of four months.
It’s now been more than two years since Abbey last lit up.
“I go weeks without a craving,” he said. “And it comes and goes so quickly now.”
But the state-funded helpline, like other proven anti-smoking efforts, has become less visible in recent years, as Maine spends dwindling dollars on its fight against tobacco. That’s despite the fact that tens of millions of dollars flow into Maine each year for exactly that purpose.
The money, paid out by tobacco companies as the result of a landmark 1998 legal settlement, was originally intended to help states recover smoking-related medical costs. But Maine and other states increasingly turned to the money to plug budget holes, leaving fewer dollars for programs that prevent tobacco use and help Mainers to quit.
Now, Maine’s newly elected Gov. Janet Mills is eyeing a bonus payment of the tobacco settlement money to fund expansion of MaineCare. While tobacco prevention advocates support the expansion, they want some of the settlement money to support its intended purpose. They point out that tobacco companies spend an estimated $47 million on marketing each year in Maine alone — essentially balancing out what the Big Tobacco forks over in settlement funds. Maine spends about a tenth of its settlement money on programs that prevent tobacco use and help people quit.
More than half of the roughly $46 million in annual tobacco settlement dollars are siphoned away to pay for MaineCare, the state’s Medicaid program. That money funds medical bills that may have nothing to do with illnesses caused by tobacco, even though Maine has a high rate of cancers linked to smoking.
Maine was once lauded for its anti-tobacco efforts. It ranked first in the nation for spending on tobacco prevention between 2002 and 2007, dedicating nearly $17 million a year at the end of that period. It was among only three states, along with Delaware and Colorado, that funded such programs at or above the minimum level recommended by the U.S. Centers for Disease Control and Prevention.
A 2009 report credited the state’s “well-funded tobacco prevention program” with reducing youth smoking over the prior decade, slashing rates by 71 percent among middle school students and 64 percent among high school students.
Now, Maine ranks 16th in the country for the amount of money it dedicates to tobacco prevention, according to the Campaign for Tobacco-Free Kids. The state will spend an estimated $5 million on such programs in fiscal year 2019, the smallest amount since the tobacco settlement was reached more than 20 years ago and marking a 70 percent plummet since 2007.
While Maine could do worse than placing 16th nationally — spending about 30 percent of the CDC-recommend level of $15.9 million — the bar is set low, said John Schachter, director of state communications for the Campaign for Tobacco-Free Kids.
“We have no states at 100 percent and only two states above 70 percent,” he said.
Almost all of the money Maine spends on anti-tobacco efforts comes from the Master Settlement Agreement, a $206 billion deal reached in 1998 between a consortium of tobacco companies and attorneys representing 46 states. The states, including Maine, receive the money in perpetuity.
Under the settlement agreement, states can use the revenue however they see fit. But Maine lawmakers created the Fund for a Healthy Maine in 1999 to disburse the money, earmarking the funds for seven health-related purposes: smoking prevention and cessation, home visits to pregnant and new mothers, child care, Medicaid, prescription drugs for seniors, dental care for low-income residents, and substance abuse prevention and treatment. They later added obesity prevention and school health programs.
Lawmakers specifically stated that allocations from the fund must supplement, rather than supplant, revenue from the state’s general fund, which pays for overall state operations. But since the fund’s inception 20 years ago, $203 million has been used for purposes outside those enumerated in the law, according to a 2017 analysis by the Maine Public Health Association.
In recent years, the fund has proven a flashpoint of partisan division, with Republicans viewing it as a source of revenue for various purposes and Democrats defending its intended uses. Some are optimistic that with Democrats now in control of the Blaine House and the Legislature, Maine will return to its position as a leader in anti-tobacco efforts.
Yet the association’s analysis points out that “independent, Democratic and Republican governors have all presented budgets that used the Fund for a Healthy Maine for outside purposes, and these budgets have been supported by legislatures with Democratic majorities and Republican majorities. The vulnerability of the Fund for a Healthy Maine to budget pressures transcends partisanship.”
‘Ample resources to do both’
Newly elected Maine Gov. Janet Mills was on the campaign trail last year when she first proposed using a bonus payment of the tobacco settlement money for initial Medicaid expansion costs. In her capacity as attorney general, she’d negotiated with the tobacco companies for the extra, one-time payment of $35 million, resolving a years-long legal dispute.
The Legislature incorporated the money as a funding source in its last bipartisan Medicaid expansion bill, which was later vetoed by then-Gov. LePage.
Mills is due to present her budget by Feb. 8 and her administration “continues to consider the additional $35 million as a funding option for the first year as it also pursues long-term funding for the program,” according to spokesman Scott Ogden.
The proposal puts public health advocates in the delicate position of supporting Medicaid expansion while also pushing for Maine to spend more of the settlement money on its tobacco prevention program.
“We are concerned about the significant cuts that the program has had,” said Lance Boucher, senior division director of state public policy in the east for the American Lung Association. “There’s ample resources to do both, we believe, so we would love to see an adequately funded tobacco program. It is an appropriate use of settlement dollars to provide health care to those who need it.”
Medicaid expansion is projected to cost the state’s general fund up to $55 million in the first year, according to the Office of Fiscal and Program Review.
Medicaid had a surplus of roughly $38 million at the close of the last fiscal year, which ended on June 30. Add in the $35 million bonus tobacco payment and that’s more than enough to pay for both expansion and boosting tobacco prevention spending to the recommended $16 million annually, Boucher said.
The less Maine spends on prevention, the more it must spend on treating costly and avoidable diseases caused by smoking, said Hilary Schneider, Maine government relations director for the American Cancer Society Cancer Action Network. Maine should be able to fund both, with Medicaid expansion preferably paid for through the general fund, she said.
MaineCare coverage for tobacco cessation products was axed in 2012 but later reinstated under the Affordable Care Act.
“Gov. Mills will work with the Legislature and stakeholders to determine how the state can best meet the health needs of Maine people,” Ogden said. “As a general principle, she believes it is more cost effective to keep people healthy than it is to treat them when they’re sick, which is why she believes it is best for the state to properly invest in funding for preventive care initiatives.”
‘We know what works’
Roughly a decade ago, the Maine Legislature passed a trio of anti-smoking laws that led to a dramatic decline in tobacco use, said Schneider, who chairs a statewide anti-tobacco coalition.
In 2002, Maine increased funding for tobacco prevention, including campaigns to counter the tobacco companies’ substantial marketing efforts. The following year, it strengthened its smoke-free laws, extending the prohibition on smoking from restaurants to nearly all workplaces. Then, in 2005, Maine increased the cigarette excise tax, doubling the fee from $1 to $2 per pack.
Smoking rates subsequently fell, to about 20 percent among adults after hitting as high as 30 percent in 1990.
“We know what works. We have decades of research,” Schneider said.
During the LePage administration, the Legislature approved further cuts to Maine’s tobacco control program. Maine’s adult smoking rate began to level off, even as many other states saw further declines, she said.
Maine’s estimated smoking prevalence in 2017 was about 17 percent, roughly the median rate for all states. The percentage of smokers who have quit long-term hasn’t budged.
Among youth, the state has maintained small but steady declines in its smoking rate, and the latest CDC data for 2017 suggests that those teenagers are remaining tobacco free as they become adults. Experts anticipate that Maine’s new minimum smoking age of 21, which took effect in July, will push rates down further among youth.
But electronic cigarettes represent a new frontier in anti-tobacco efforts.
One in four Maine youth report using tobacco in the last 30 days, with electronic cigarettes overtaking combustible ones in that age group, said Boucher, of the lung association.
“We’re seeing the gains we’ve made erased, and if we’re not careful we could see a whole new generation of youth using tobacco” in the form of e-cigarettes, he said.
A new crop of legislation aims to reinvigorate Maine’s fight against tobacco. One bill, sponsored by Sen. Rebecca Millett, D-Cape Elizabeth, would prohibit the sale and distribution of flavored tobacco products.
A broader bill, sponsored by Rep. Joyce “Jay” McCreight, D-Harpswell, would fully fund tobacco prevention at the CDC-recommended level, increase the tobacco excise tax and apply the tax to all tobacco products, such as cigarillos and e-cigarettes. Evidence shows that making cigarettes more expensive can discourage kids from picking up the habit and encourage adults to quit, but Maine hasn’t increased the excise tax on tobacco since 2005.
The Maine Tobacco Helpline can be reached at 1-800-207-1230.
Maine Focus is a journalism and community engagement initiative at the Bangor Daily News. Questions? Write to firstname.lastname@example.org.