Dec. 3 (UPI) -- Twenty years after 46 states and the District of Columbia reached a historic settlement with four major tobacco companies, the United States has seen an unprecedented drop in adult smoking. But advocates say the billions paid to states are not always being targeted for smoking cessation.
The 1998 agreement established a fund in which tobacco companies -- Philip Morris, R.J. Reynolds, Brown & Williamson and Lorillard, as well as industry trade associations -- pay states billions annually for smoking-related healthcare costs, impose permanent restrictions on tobacco marketing and contribute $1.5 billion to an entity dedicated to counter-advertising and public education.
Partly due to the agreement, smoking in the United States is at its lowest level since 1951, and per capita use has not been so low since the 1930s, even though the U.S. population has doubled in the last seven decades, according to the National Association of Attorneys General.
John Schachter, spokesman for the Campaign for Tobacco-Free Kids, said there have been many missed opportunities because states have repurposed their tobacco funds.
"We've made incredible progress over the last 20 years bringing down smoking rates for adults and youth," Schachter told UPI. "There's still a lot of work to be done. In light of the billions of dollars the tobacco settlement yielded, it would be great if more of the states used it for tobacco prevention and cessation.
"We only have a few states that devote remotely close to the money needed for those programs. We could really have the first tobacco-free generation if states spent more money on top of other policies that we've supported."
The Campaign for Tobacco-Free Kids said the annual payments will have netted states $246 billion by 2023. But most states have consistently fallen far short of using that money to implement recommendations made by the U.S. Centers for Disease Control and Prevention.
For fiscal 2018, states provided just 22 percent of the recommended funding to such prevention and cessation efforts.
"Despite having evidence that tobacco-control efforts and programs save lives, in the past 20 years, states have by and large failed to fund tobacco prevention and cessation programs at the levels needed to drive down smoking rates," Deb Brown, chief mission officer of the American Lung Association, told UPI.
"Fortunately, the [tobacco companies'] annual payments to states do not have an end date, and so our state leaders still have the opportunity to do the right thing."
Many states have placed the tobacco settlement funds into their general treasury, making the money available for anything -- from filling budget holes to supporting other programs. The American Lung Association said North and South Carolina, for example, used some of their funds to support tobacco farmers and producers.
Brown said of the $27.5 billion states collected this year, less than 3 percent -- roughly $721.6 million -- will be spent on programs to help smokers stop and prevent kids from picking up the habit. She said Alaska is the only one that's funded its tobacco prevention program at CDC-recommended levels this year.
Joel London, a spokesman for the CDC's Office of Smoking and Health, said the agency has learned a lot over the past two decades what measures are effective.
"We used several lessons that we've learned from several states that were at forefront of the movement and had promising success early on," London said of CDC efforts to document best practices in smoking cessation programs.
"We now have several decades of experience and science showing what works to reduce tobacco use among youth and adults. We've seen great progress, often not as quickly as we prefer, but we've seen progress nonetheless."
He added that electronic cigarettes, which are popular among young adults, have changed the dynamic in the battle against tobacco.
"E-cigarette companies can legally promote these products by using techniques that are prohibited for cigarettes by the master settlement agreement, including television and radio ads, billboards, outdoor signage and sponsorships," London said.
He said e-cigarettes must also be included in prevention and cessation programs -- pointing out that they've been the most popular tobacco product among U.S. youth since 2014 -- and experts saw a 78 percent increase in e-cigarette use among high school students from 2017 to 2018.
Regarding efforts that can still be made, Schachter pointed to California voters passing a measure last month that adds $2 to cigarette taxes -- and a public service campaign in Florida. He said states could also raise the legal smoking age to 21. In most states, it's 18. He also said only half of states have smoke-free environment laws that define places where people can smoke.
"The bad news is that tobacco use remains the leading cause of preventable disease and death in the United States, and we still have 34 million current adult cigarette smokers," London said. "The good news is that we know what works ... including proven interventions such as tobacco product price increases, comprehensive smoke-free laws, hard-hitting mass media campaigns and access to cessation resources.
"If we were to fully invest in and implement comprehensive tobacco control programs that advance these proven strategies, we could significantly reduce the staggering toll that tobacco use has on society."