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Public Health & Tobacco Control – Return on Investment

Dec 26, 2012, 9:00 AM, Posted by Kelly Buettner-Schmidt


This is an exciting time for the U.S. health care system or, as I prefer to call it, the U.S. health system (because health “care” system limits what one includes as part of the “system”). As a public health professional for nearly 30 years—about 20 years as a frontline public health nurse, and now 10 years in academia—I have discovered the need to educate people on all that the state and federal public health systems do to improve the health of not only individuals and families but also communities.[i] [ii]

More than half of my professional career, both as a practitioner and academic, has focused on tobacco prevention and control policies.[iii]  Professional and nursing colleagues, acquaintances, friends, and family often think of my work in tobacco control policy as separate from my public health nursing career. The reasons for this, I believe, are at least two-fold. First, nursing is often equated with direct client care; second, the tobacco industry effectively confuses many into believing the science of tobacco control is controversial and thus spending public health and tax dollars on tobacco control seems wasteful to the public. (As an aside, many nurses are involved in tobacco control. Please join us!)[iv],[v],[vi]

Only recently has there been economic data to support the fact that prevention saves not only lives, but dollars.[vii] As if saving lives is not enough of a return! It has been calculated that there is more than $5.00 return for every $1.00 invested in a statewide tobacco control program. [viii]  If we all invested in stocks that did as well, we’d be ecstatic! The science is solid and now political willpower is needed for each state to have this type of investment and return, in lives and dollars. Components of comprehensive tobacco control programs are proven effective. [ix],[x],[xi] Unfortunately, only two states, North Dakota and Alaska, are funded near or at levels recommended by the Centers for Disease Control and Prevention for successful comprehensive tobacco control programs.[xii],[xiii],[xiv]

There are many avenues for funding comprehensive tobacco control programs in each state.  The 1998 Master Settlement dollars and tobacco taxes are clear funding choices. The Master Settlement directs the tobacco industry to send more than $25 billion dollars into state coffers each year.  With less than 2 percent of this spent by legislatures for tobacco prevention and cessation, human suffering and death continue unnecessarily.[xv]

A second funding source for tobacco control is state tobacco taxes, but again here, not enough of these dollars are spent on tobacco control. Logically, this money should be spent to prevent tobacco use and help those who are trying to quit. States today have many needs and possible uses for this money, but the return on the investment for tobacco control should incentivize them to use it for its original intention. North Dakota voters took the issue into their own hands after the legislature declined to do so for 10 years, passing an initiated measure in 2008 directing a portion of the tobacco settlement dollars to fund the North Dakota Center for Tobacco Control and Prevention Policy.[xvi]

A third funding option for tobacco control programs is the Affordable Care Act and President Obama’s Executive Order 13544, Establishing the National Prevention, Health Promotion, and Public Health Council.[xvii]  This portion of the ACA “lays the foundation for prevention”[xviii] including potential funding for tobacco control.

Although the country has other compelling priorities, such as stemming the epidemic of obesity, I would argue that we need to stay the course on tobacco control. Tobacco use is responsible for one of every five deaths in the U.S., including deaths from secondhand smoke. Certainly, the suffering and illness from tobacco use extends way beyond the mortality rates. While this blog is focused in the U.S., I’d be remiss to not mention that, worldwide, tobacco kills 6 million people per year.

This is a matter of social justice. [xix] First, the tobacco industry continues to effectively market its products and addict new smokers.  Second, certain populations have higher rates of tobacco addiction including communities of color, Lesbian, Gay, Bisexual and Transgendered communities, and people with low socioeconomic status.[xx]  Last, those burdened by tobacco addiction need access to cessation resources. My 2013 New Year’s wishes for the U.S. health system include:

·         Each person achieving their optimal health through their choices and through supportive communities and environments,

·         Effective tobacco control policies to prevent youth from starting to use tobacco,

·         Accessible and affordable cessation resources and products to all who desire to quit,

·         Fully funded, comprehensive tobacco prevention control programs to provide social norming messages, policy support, and community programs, and

·         A healthy and happy 2013 to all!

Learn more about the RWJF Nursing and Health Policy Collaborative at the University of New Mexico.


[i] http://www.ndhealth.gov/  (click on “A day in your life thanks to public health”)
[ii] www.apha.org
[iii] http://www.minotstateu.edu/hci/index.shtml
[iv] http://nightingalesnurses.org/Default.aspx
[v] Buettner-Schmidt, K. (2005). Youth and Tobacco Use: Nurses take a stand.  Journal of Pediatric Health Care, Vol. 19 (6), 396 -399.
[vi] Malone, R. E., & Buettner-Schmidt, K. (2012). Taking Action: The Nightingales Take on Big Tobacco. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee. Policy and Politics in Nursing and Health Care, (5th ed.) (pp. 691-699). St Louis, MO: Saunders. 
[vii] http://www.rwjf.org/content/rwjf/en/research-publications/find-rwjf-research/2012/01/return-on-investments-of-a-medicaid-tobacco-cessation-program-in.html?cid=XEM_1095291
[viii]  Dilley et al. Am J Public Health. 2012 Feb;102(2):e22-8. doi: 10.2105/AJPH.2011.300506. Epub 2011 Dec 15.
[ix] http://www.cdc.gov/tobacco/stateandcommunity/best_practices/index.htm;
[x] http://www.thecommunityguide.org/tobacco/index.html;
[xi] http://www.tobaccofreekids.org/research/factsheets/pdf/0045.pdf
[xii] http://www.stateoftobaccocontrol.org/state-grades/state-rankings/tobacco-prevention-control-spending.html
[xiii] www.breathend.com
[xiv] http://dhss.alaska.gov/dph/Chronic/Pages/Tobacco/default.aspx;
[xv] http://www.tobaccofreekids.org/what_we_do/state_local/tobacco_settlement/
[xvi] http://www.breathend.com/about/
[xvii] http://www.healthreform.gov/newsroom/acaprevention.html
[xviii] http://www.healthreform.gov/newsroom/acaprevention.html
[xix] Buettner-Schmidt, K., & Lobo, M.L. (2011). Social Justice: A Concept Analysis, Journal of Advanced Nursing, 68: 948–958. doi: 10.1111/j.1365-2648.2011.05856.x

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.