Cigarette smoking and tobacco use
continue as Hawai‘i’s single greatest cause of preventable morbidity and
mortality accounting for over 1,000 deaths annually, 16% of all
resident deaths, and causing approximately $525 million in direct
medical costs and smoking-attributable productivity costs annually.
Hawai‘i’s prevalence rate in 2002 for
cigarette smoking is 21 % for adults (BRFSS) and 24.5% for youth
(HYTS), both below the national average. Rates for adult males have
shown an increase from 24.7% to 26% while rates for adult females have
held constant at 16%. Smokeless tobacco numbers remain
insignificant. Surveillance data point to a downward trend in most
population groups, although an alarming upward trend over the past few
years among 18-24 year olds (30.3%) has caused the overall prevalence
to first plateau and then to climb slightly. Further, an adult tobacco
survey (ATS) will be fielded by the end of the current program year.
Data will be compared to the earlier ATS conducted in 2001. Findings
will be used to track trends and to support program objectives. Data to
identify and eliminate the disparities among populations
disproportionately affected by tobacco use are being utilized to build
program infrastructure and expand community partnerships. Workplace
protections from secondhand smoke were high and have further increased
with the passage of clean indoor air ordinances now in all of
Hawaii’s counties. The focus has now turned to voluntary policies
for smokefree homes and cars and to eventually smokefree bars. Building
a data base, an infrastructure, and components for the development of a
more comprehensive smoking
cessation component is now a priority for the coming year.
Data from the 2002 PRAMS survey identify that 20% of pregnant women
surveyed smoked during their first trimester, and 8% smoked during the
last trimester. Twenty-nine percent of Hawaiian/pt Hawaiian women
reported prenatal smoking vs. 17% of non-Hawaiian women. Further, 14%
of Hawaiian/pt-Hawaiian women reported smoking in the last trimester
compared to 6% of non-Hawaiian women.
Of the $262 million Hawaii spends on direct health
and medical costs (the other $263 million is related to
smoking-attributable productivity costs, totaling $525 million spent
annually) $91 million is estimated to be Medicaid-related. This
represents the burden of tobacco as approximately $520 per household
from the government’s share of expenditures.
Hawaii’s
legislature adopted what has become the foundation of state
statutes for smoking in public places, workplace smoking and the sale
of tobacco products to minors in the mid-1980’s. The legislature
passed additional laws during the early 1990’s to restrict youth
access to tobacco products, restrict advertising and distribution of
promotional materials to youth. Efforts to update the workplace smoking
statute have been attempted and failed for the past 12 years. The need
to improve the current outdated statute, while insuring against any
preemption of local ability to enact stricter ordinances, remains a
TPEP goal.
Cigarette
excise taxes have risen from 60 cents per pack in 1993 to
$1.30 per pack in 2003 and will further increase to $1.40 per pack in
2004. Revenues from tobacco products now total $75 million, up from $40
million only a few years ago prior to the implementation of the
cigarette tax stamp program. Presently the Legislature is considering
measures to institute a licensure provision for retail tobacco sellers,
to support the tax stamp enforcement program, but with opportunities to
impact a seller’s ability to sell tobacco if state and county
laws are violated. Further the Legislature is considering a bill that
would restrict tobacco sales via the internet. The bill primarily is
designed to support the capture of additional cigarette tax revenues,
but would also have potential impact upon youth access to tobacco
products. No earmarking of new revenues are contained in this bill and
other, earlier attempts to gain a portion of the dollars collected
under cigarette tax measures has not been supported by the
Legislature.
In 1999, the Legislature created the Hawaii Tobacco Settlement Special
Fund (Act 304) which
captures all of the Master Settlement Agreement (MSA) money coming to
the state. By statute, the legislation created 3 specific funds with
corresponding percentages for annual distributions from the MSA.
Dollars went to a Tobacco Prevention and Control Trust Fund (25%), to
the DOH for chronic disease prevention and health promotion as well as
children’s programs (35%), and to an emergency budget reserve
fund (40%) A portion of the total dollars (10%) was earmarked for the
Children’s Health Insurance Program. Since that time the Trust
Fund as well as the reserve or ‘rainy day’ fund was cut to
provide dollars to support construction of a new medical school
complex. The Trust Fund allocation now stands at 12.5 %. Each year at
the Legislature there have been attempts to restructure this statute,
take dollars away, and change the intent of the original act. Each year
those efforts have been defeated as other funds have been
‘raided’ and dollars captured. Without raising taxes, there
are few other sources of money, leaving the MSA dollars as a huge
target. Fortunately, the Coalition for a Tobacco-Free Hawaii and its
partners, including the national Campaign For Tobacco-Free Kids, has
been well organized and has been effective in their advocacy to keep
the dollars. In the current Legislative session concerns about the
state’s crystal methamphetamine, or ‘ice’ problem has
fueled efforts to address the issue and to show that actions are being
taken to stem the tide of related violence and control the growing drug
problem. There are a number of active proposals this session to further
cut the Trust Fund and possibly the DOH fund which pose an immediate
and serious threat to the existing funds.
County
government has provided some of the greatest support
recently in enacting clean indoor air ordinances in the absence of
action by the state. Ordinances for either workplaces and or
restaurants have been enacted in all Hawaii jurisdictions. The result
is that likely over 90 percent of all workers have some form of
protection at their place of employment. Presently, only workplaces
(there are protections for restaurants) in Maui County and bars
statewide lack protections from secondhand smoke. Maui County is likely
to introduce a workplace measure in the coming year. Improvements to
those restaurant ordinances which lack provisions where the business is
not responsible for smoking violations will improve compliance and
remains a task to accomplish.
Community-based
Coalitions have been mobilized in all Hawaii’s
counties with additional efforts planned to organize and staff
coalitions on the island of Molokai, part of Maui County and on Oahu.
Coalitions are staffed with full time contractual personnel whose costs
are currently shared between the RWJ funded Coalition for a
Tobacco-Free Hawaii and the Department of Health Tobacco Prevention and
Education Program (TPEP).
Integration of
chronic disease programs within DOH and its community
partners is an ongoing priority. Planning efforts are currently well
underway by DOH to develop and implement such a plan in the coming
year. Participation among diabetes, breast and cervical cancer, asthma,
comprehensive cancer, cardiovascular, nutrition and physical activity
programs, and the MSA funded DOH Healthy Hawaii Initiative’s
“Start. Living. Healthy.” Programs demonstrate a
comprehensive approach to maximizing planning, coordination, resources,
surveillance and evaluation.
School-based
and school age initiatives support objectives to reduce
initiation, promote awareness of health risks, and to understand
tobacco industry targeting and manipulation of youth. TPEP’s
“Thumbs Up, Thumbs Down” movie review program will be
expanding to schools on the neighbor islands in the coming year.
Expanding school standards-based curriculum resources remains a
priority.
Enforcement of minor’s access laws
has been supported by active collaboration among DOH and law
enforcement partners and has resulted in a Synar inspection rate of
6.4%, one of the lowest in the nation. TPEP merchant education remains
a large part in the continued success of the component.
Statewide
programs now encompass expanded linkages to more of the
Filipino and Hawaiian communities, Boys and Girls Clubs, health care
providers now trained in smoking cessation interventions (brief
interventions), and the Gay Lesbian Bisexual Transgender (GLBT)
community.
Counter-marketing remains funded at
$900,000 from the DOH portion of the MSA. Extensive statewide targeted
campaigns in all media venues have resulted in very high awareness of
anti-smoking messages.
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