Ex-Allies Feud Over Use of Smoking Tax

Backers of Proposition 99 and the anti-smoking programs it has created say California’s pioneering efforts to reduce tobacco use are in jeopardy.

Legislation allowing the state to spend the 25-cents-a-pack cigarette tax imposed by voters five years ago will expire Friday, and lawmakers are deciding how the tobacco revenue is to be divided in the years ahead.

Allies who once worked side by side against the nation’s biggest tobacco companies to pass Proposition 99 are today bitter rivals in the battle over the best way to spend the hundreds of millions of dollars raised by the cigarette tax.

The debate is between those who want to spend the money on health care for the poor and those fighting to protect a variety of innovative and often controversial anti-smoking programs.

Underlying the debate is a California budget crisis that has made the competition for public dollars ever more intense. There also is less cigarette tax money to go around as anti-smoking programs succeed--and tobacco use declines.

During its first few years, the Proposition 99 tax took in almost $700 million annually; next year, it will bring in about $446 million.

Because lawmakers are unwilling to raise cigarette taxes or come up with other sources of revenue, they will have hard choices to make. On the one hand is an award-winning anti-tobacco advertising campaign, anti-smoking activities for teen-agers and tobacco disease research. On the other are health-screening exams for impoverished teen-agers, prenatal care for low-income women and hospital services for the poor.

As required by Proposition 99, most of the cigarette taxes--$2.3 billion of the $3.1 billion collected since 1988--have been spent on health care for the poor. The quarrel is over the 20% of tobacco tax money that is required to be spent on anti-smoking education and the 5% intended for research.

Although Proposition 99 broadly defined how the money should be spent, it left the Legislature and the governor to sort out the details.

On one side of the debate--urging that anti-smoking efforts be funded as the ballot initiative requires--are a number of private nonprofit health organizations, such as the American Lung Assn., American Cancer Society and Americans for Nonsmokers’ Rights.

Opposing them are the California Medical Assn., the state’s hospitals and the Western Center on Law and Poverty--organizations that want to see more of the money going to health care for the poor.

Invisible in this very public debate are the tobacco companies. None of the major tobacco companies--or the industry-funded Tobacco Institute--have been openly lobbying the Proposition 99 funding legislation this year.

“It wouldn’t make any difference what we did,” said Tobacco Institute Vice President Walker Merryman, “so we’ve just decided to stay away from the issue entirely.”

However, health education groups, such as the lung association, accuse the industry of working behind the scenes in collaboration with doctors and hospitals.

The rhetoric has become shrill.

“Our incredibly successful tobacco education program is on the edge of a legislative cliff and about to be shoved off by the medical establishment and the tobacco industry,” said Carolyn Martin, a volunteer with the American Lung Assn., one of the sponsors of the 1988 initiative.

Martin and others argue that tobacco companies would like to kill the advertising and community action programs because they have proven their effectiveness in reducing sales. In contrast, health-screening programs, even those requiring doctors to deliver an anti-smoking message, do not cut smoking, the argument goes.

Providing anything less than 20% of the tax money for health education is illegal, argued Mark Pertschuk of Americans for Nonsmokers’ Rights. The group is suing Gov. Pete Wilson and other top state officials to return $166 million that it contends was illegally diverted to non-educational purposes in the past.

This year’s budget battle “is really about killing Proposition 99,” Pertschuk said.

The fight exemplifies “the politics of scarcity,” said the medical association’s top lobbyist, Steven M. Thompson, who added that he is tired of hearing that the doctors group is in bed with the tobacco industry. He reminded a reporter that the medical association helped pass the initiative against strong tobacco industry opposition in 1988 and sponsored a successful bill to add an additional two-cent-a-pack cigarette tax for breast cancer research and treatment.

Today, Thompson is fighting to ensure continued funding for the state’s Child Health Disability Prevention Program, which pays doctors and clinics to provide low-income youngsters with checkups and immunizations. The health-screening program requires that doctors talk with the youngsters and their parents about the dangers of smoking, which justifies the funding, Thompson said.

The Wilson Administration agrees that the $54-million-a-year program, like other health care programs partly funded by tobacco education money, should be protected.

Opponents of this proposal cite statistics showing that they have no impact on smoking behavior.

UC San Diego Prof. John P. Pierce, who conducted the state-funded evaluation of Proposition 99 anti-smoking programs, found that anti-smoking advice by physicians had no effect on tobacco use. In a spirited letter to state health officials last month, he said the state would do better to drop the program and use the money for other proven approaches.

Caught in the cross-fire is Assemblyman Phillip Isenberg (D-Sacramento), author of the tobacco-tax funding bill and chairman of the Assembly-Senate conference committee that must settle the issue.

In past years, he has been able to win a broad consensus on how to spend the cigarette tax money.

Now a frustrated Isenberg is critical of groups battling to reserve a quarter of the money for anti-tobacco programs and research, saying that “they have taken on the garb of a religious crusade.” Many of the same groups now arguing against spending tobacco education money on health-screening and prenatal care programs have agreed to do so in the past, he said.

“These are not evil people making the argument (for the anti-smoking programs),” Isenberg said in a recent interview. “The reason they are reticent about talking about the consequences of what they want is because they do feel guilty about taking money away from poor women and children.”

But critics accuse Isenberg and other lawmakers of aiding and abetting the tobacco industry.

UC San Francisco researcher and anti-tobacco gadfly Stanton Glantz said: “Mr. Isenberg is Mr. Integrity and Mr. Intelligence. But he’s going to go down in history as the guy who put another nail in the coffin of the most important public health program in this century.”

Assembly Speaker Willie Brown (D-San Francisco) says the inflammatory rhetoric is “insane.”

“You either are with the anti-smoking terrorists, which is what I call them, or you’re a bad person,” Brown said. “There is absolutely no room for legitimate debate among them.”

Although Isenberg said he endorsed Proposition 99, he makes it clear that he finds its allocation of funds overly rigid. And he contends that programs such as those run by various chapters of the American Lung Assn. that receive a share of the cigarette taxes for education programs have come to depend on the revenue.

“If tobacco is addictive, the receipt of public money is equally addictive,” he said, “and they both have the same unsavory characteristic, which is withdrawal.”

What Isenberg would like to do is work through the long list of programs funded by the tobacco tax and continue only those programs shown to be effective.

“There’s no fraud and abuse in this program, but there’s a lot of silliness,” he said.

One item on the conference committee’s agenda is to cut research funding from 5% of revenue to 3%--freeing up almost $9 million for health care or anti-tobacco programs. Isenberg also has his eye on $21 million in research money that could not be spent this year because Wilson allowed the research program to expire in December. “We call it the pool of opportunity,” Isenberg said.

He has raised questions about the way that the University of California has awarded research grants to public and private universities and foundations. He and others argue that too much has been spent on esoteric laboratory science and not enough on evaluating smoking prevention.

Isenberg also questions the funding of Smiles Plus, a $2-million study to see if training orthodontists to teach their patients about the effects of tobacco can reduce smoking among teen-agers. And he objects to a study to test whether smoking does cause skin wrinkles.

“If money is no problem, you can afford the luxury of repeating studies to show that your skin wrinkles if you smoke or that your teeth turn yellow if you’re a kid and you smoke, but is there any doubt in the academic community that it’s true?” Isenberg asked.

Charles L. Gruder, who directs the UC program that determines how the research money is used, defends the decisions to fund these and other scientific studies.

The university has set up an independent peer review system, similar to one used by the federal government, in which out-of-state experts in each field decide which research proposals receive money.

Gruder vigorously defended the decisions of the review teams. Smiles Plus, he said, is a well-conceived, large-scale experiment to determine whether orthodontists--or for that matter any other care givers--can, with training, change smoking behavior. “The study is very, very good scientifically,” Gruder said.

He also defended the study on wrinkles as one of the few careful looks at the impact of smoking on skin.

“Only one of five proposals is successful,” he said. “We are funding only the best.”

Gruder said his advisory committee has responded to criticism from legislators and others that too much Proposition 99 money has gone to laboratory science and not enough to studying how to get smokers to stop. He has appointed a new team of scientists to review studies of the effects of public policy changes, such as workplace smoking bans, and he promises that a bigger proportion of funding will go to determine which anti-smoking programs work best.

Isenberg is also proposing changes in the large piece of tobacco tax funding that is distributed to the state’s public schools. Most of the money--$146 million over the past five years--has been doled out to school districts in proportion to their enrollment.

Some districts have used the money to hire counselors and psychologists--positions cut because of the state’s budget crisis. And much of the anti-smoking effort has been concentrated on students in the early grades and not on teen-agers, who are more likely to take up smoking.

One study of the effectiveness of the school programs by the Southwest Regional Laboratory shows that between the 1992 and 1993 school years there was no measurable difference in smoking use by students.

Isenberg complained that “we have not a clue as to whether (the school programs) are doing any good.”

Isenberg wants a more thorough evaluation of how all the Proposition 99 money is being used, as does the Wilson Administration.

“We deliberately and knowingly refused to set up meaningful evaluation of any of the spending programs,” Isenberg said. “It was stupid.”