MELISSA BLOCK, host:

From NPR News, this is All Things Considered. I'm Melissa Block. 10 years after the multi-billion-dollar tobacco settlement, smoking rates are down, but tobacco is still the number-one cause of preventable death in the U.S.

This week back in 1998, big tobacco agreed to pay $246 billion to states and transform the way it did business. In exchange, states dropped their lawsuits over the public health costs of smoking, and they were encouraged to use the money for smoking prevention.

This week, NPR's Debbie Elliot is reporting on what has changed since the settlement. Today, what states have and have not done with their tobacco riches.

DEBBIE ELLIOT: It's early on a weekday evening. and Shaela Brown(ph), mother of five, is scurrying around her suburban Seattle kitchen trying to pull dinner together.

Ms. SHAELA BROWN: Some leftover enchiladas from last night for the children.

Unidentified Boy: I'm hungry.

Ms. BROWN: I know.

Unidentified Boy: Mom, I'm hungry.

Ms. BROWN: Well, have a seat.

ELLIOT: After working all day as a social services case manager, Brown comes home to manage her family, seeing to homework for the older kids, giving medicine to her one-year-old, and putting food on the table. What she really wants is a smoke.

(Soundbite of door opening)

ELLIOT: She sneaks out the door to the garage.

Ms. BROWN: We have a little stool here. It's kind of like a little sanctuary, too, just to get a moment away from the kids and come out and have a cigarette and just kind of...

Unidentified Boy: Mom!

ELLIOT: Shaela and her husband, Marcus Golden(ph), spend their nights taking turns watching the kids or going out to the garage to light up. They'd like to quit.

Mr. MARCUS GOLDEN: What we do know is that we've got to do it together. We can't do it separate. I want to quit, and as soon as she's ready, we can quit.

ELLIOT: The family is getting encouragement from an unusual place, their daughter Michaela's(ph) preschool.

Unidentified Woman: Our song is going to be a counting song and a rhyming song. Ready, position. It'll happen any minute.

(Soundbite of singing)

ELLIOT: This is a state-funded program, much like Head Start. Thanks to Washington state's tobacco settlement money, the workers here are now trained in tobacco counseling. Family support specialist Noelle Powell(ph) says parents have always filled out questionnaires about smoking. Now, they can actually get help to quit.

Ms. NOELLE POWELL (Family Support Specialist): The question on the health history has been there. Do you use tobacco in your home? In the past, we really didn't have any education about that, so you'd kind of get to the question and be like, hopefully, they'll say no. But if they say yes, you can - honestly, our response was, well, thank you for you honesty.

ELLIOT: And they moved on to the next question. Today, Powell and her colleague, Cheryl Seaborn(ph), hand out stop smoking kits packed with pamphlets, a planner to track smoking habits, and lots of goodies to help smokers fight their cravings.

Ms. CHERYL SEABORN (Family Support Specialist): We packed up some suckers. Instead of grabbing a cigarette, let's grab a sucker. We have a toothbrush and some toothpaste to kind of help get your breath minty. It's been really helpful for us to be able to have things in front of us to talk about.

ELLIOT: This daycare program is part of Washington state's focus on targeting low-income smokers, where smoking rates have not fallen as fast as other groups according to Paul Ziemann with the King County Health Department. Nationally, about one-third of smokers are poor. Ziemann says many of those who are wealthier have already tapped resources to quit.

Mr. PAUL ZIEMANN (Health Education Consultant, King Country Health Department): We've picked the low-hanging fruit with Washington Quit Line, you know, primary care providers. People can afford medicines that help them quit smoking like Zyban or the patch or the gum, but what we have is people with less money that aren't getting the services as a general population. And so, we thought that's where we need to be dedicating our settlement dollars.

ELLIOT: Washington state has received about $1.25 billion in settlement payments from tobacco farms. The money has consistently gone for public health initiatives and to fight smoking. Washington Governor Christine Gregoire says the results have been dramatic.

Governor CHRISTINE GREGOIRE (Democrat, Washington): We've cut smoking rates for kids in half. We were, in 2000, number 20 in adult-smoking rates. We're now number six. So, you can see, if you do use the money, it works. It works.

ELLIOT: Gregoire is a former attorney general and was a lead negotiator in the tobacco settlement.

Governor GREGOIRE: Far too many states have, in my opinion, used the money for purposes other than what we intended it to be used for.

ELLIOT: Less than five percent has gone for tobacco prevention.

Mr. MATT MYERS (President, Campaign for Tobacco-Free Kids): It is truly one of the greatest historic missed opportunities to bring about public health change this nation has ever seen.

ELLIOT: Matt Myers is president of the Campaign for Tobacco-Free Kids and was a key player in the tobacco talks.

Mr. MYERS: Sadly, the states have used this money as their private piggy bank. Even things like golf carts for a golf course in upstate New York to funding tobacco-related activity in North Carolina, it has gone to whatever the pet project of the local politician is.

ELLIOT: Nearly half the states, including New Jersey and California, securitized their settlements, sold off the future payments for a lump sum to pay down debt or balance budgets. Connecticut doesn't spend any of its settlement proceeds on tobacco control.

Other states had strong programs for a while but cut them in tough economic times - Ohio, for instance. The chairman of the Ohio House Finance Committee, Jay Hottinger, says lawmakers had to decide what was the greater good.

State Representative JAY HOTTINGER (Republican, Ohio): Obviously, it was a huge infusion of cash, and I don't think anyone could justify the entire enormous amount being spent on smoking cessation. I just don't think that that was a logical conclusion anyone could arrive at, so a substantial amount of our money did go towards school building construction.

ELLIOT: And most recently, for an economic stimulus package. While the attorneys general intended for the money to pay for tobacco control, it's the state legislatures that have the authority to appropriate funds.

Despite the disputes over how to spend the money, the settlement has resulted in more programs and lower smoking rates. Youth smoking is down from 36 percent a decade ago to 20 percent today. Adult rates have dropped from just under 25 percent to just under 20. But in Washington state, they're down to 16-and-a-half percent. Now, the focus here is on the hardest core smokers, among them, immigrants.

(Soundbite of singing)

ELLIOT: At this Buddhist temple in Tacoma, the state is funding Vietnamese community leaders to take on a culture where smoking is a social ritual.

Mr. PHUC NGUYEN: My name is Phuc Nguyen(ph). I'm a smoker myself before, and back in my youth, smoking in Vietnam is the norm. And so, if you're not smoking, you're not a man.

ELLIOT: Studies show smoking rates among Vietnamese men in the U.S. to be as high as 40 percent. After smoking for 29 years, Phuc Nguyen quit and is now working with local activists to reach other members of the temple. He says the message has to be subtle.

Mr. NGUYEN: If you say don't smoke because it's an unhealthy habit, blah, blah, blah, people don't listen to me, but when you give them specific example - OK, you have to see the doctor more. You have to buy more medicine. And also, your pocket will be empty soon. You have to think that you spend like $200 a month, just blow it away.

ELLIOT: Paul Ziemann of the King County Health Department says officials used to fear anti-smoking talk would drive the hardest-to-reach populations away from other critical services. That philosophy has changed.

Mr. ZIEMANN: It's not that that population is less interested in quitting smoking. I just think we've done a poor job at getting the message out before, and we're trying to catch up now.

ELLIOT: He says tobacco companies have certainly gotten their message to immigrant communities.

Mr. ZIEMANN: What's more American than Marlboro, you know?

ELLIOT: Debbie Elliot, NPR News.

BLOCK: Tomorrow, Debbie reports on what the tobacco settlement has meant for the Marlboro man and other icons of cigarette advertising.

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