Misery in Missouri

How the Alliance of Big Tobacco and Missouri Politicians Keep Smoking-Induced Deaths at Unacceptable Levels

By Thomas Kruckemeyer

Executive Summary

2019 marks the 55th year since a definitive link was established by the U.S. Surgeon General between cigarette smoking and lung cancer. While the Federal and many state governments have taken strong actions to fight tobacco induced death/disease, in recent times, the Missouri state government has “distinguished” itself by doing almost nothing to protect its citizens from Tobacco-induced disease and death. Despite having one of the nation’s highest cigarette smoking rates along with high rates of tobacco induced death, nearly every key Missouri political leader has responded to this crisis by raking in tobacco interests campaign contributions and keeping the Missouri cigarette tax the lowest in the nation. It is a disgraceful situation.

Adult Smoking Rate- For the last ten years, the Missouri Adult Smoking rate averaged 22.8 percent ranking 8th highest in the nation. The national average state Adult Smoking rate in 2017 was 17.3 percent.

Lung Cancer Death Rate- In 2016, the Missouri Lung Cancer Death Rate was 48.0 (per 100,000) population. Which ranks as the 9th highest in the nation.

Heart Disease Death Rate- In 2016, the Missouri Heart Disease Death Rate was 192.1 (per 100,000) population. Which ranks as the 10th highest in the nation.

As the link between smoking and numerous fatal diseases is now unquestioned fact, one would think that smoking induced deaths would be on the decline. In Missouri, this is not the case.

The chart below displays smoking induced deaths in Missouri (See Table 1, Appendix). Clearly that Missouri has made little progress over the last 14 years.

Given the obvious need to address this problem, one would think that Missouri elected officials would take action by increasing the cigarette tax and by allocating significant funds from a successful lawsuit against tobacco companies to fund anti-smoking efforts. Sadly, this has not been the case.

2004/05 2006/07 2008/09 2010/11 2012/13 2014/15 2016/1710,000

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Smoking Induced

Missouri has not increased its cigarette tax since 1993 and at 17 cents per pack, it is the lowest in the nation and is less than 10 percent of the national state average; $1.76 per pack as of July 2019.

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State Cigarette Tax Rates 2019

(The above chart shows the top ten, middle ten, and bottom ten states and their current tax rate)

Since 2001, Missouri has received about $2.9 billion from the tobacco lawsuit, but has spent only $8.3 million (or about 0.3 percent) on tobacco control activities through FY 2018. Missouri elected officials choose to spend almost nothing to combat smoking induced disease and death.

Even if one is not concerned about preventing tobacco induced disease and death, there should at least be concern over the tremendous costs tobacco related disease impose on the state budget. The graph below shows smoking-induced Medicaid costs with tobacco tax dollars (See Table 3, Appendix).

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019$0.0

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Smoking Induced Medicaid Costs vs Tobacco Tax $$s

MO Tobacco Medicaid $$s MO CigTax

With cigarette tax revenues declining and Medicaid costs for treating tobacco caused illness rising, for Fiscal Year 2019 tobacco Medicaid costs exceed cigarette tax revenues by about $223 million; or a 4:1 ratio. Tobacco use is a net drain on the Missouri state budget.

One must wonder why this situation festers while our elected officials collectively do almost nothing about it. It can be shown empirically that nearly every important political leader in the state government accepts donations from tobacco companies and retailers. The chart below displays the top 17 Senators, all recipients of at least $10,000.

Official Position Tobacco Interests Contributions

Accepted

Mike Parson Governor $183,710Eric Schmitt Attorney General $73,425Mike Kehoe Lt. Governor $22,150Scott Fitzpatrick State Treasurer $10,300

Rep. Elijah Haahr Speaker of House $18,200Rep. John Wiemann Speaker Pro Tem $7,250Rep. Rob Vescovo Majority Floor Leader $6,600Rep. Sonya Anderson Majority Caucus Chair $5,650

Sen. Jamilah Nasheed State Senator $35,200Sen. Bob Onder State Senator $30,850Sen. Jeannie Riddle State Senator $16,950Sen. Gary Romine State Senator $16,700Sen. Dave Schatz State Senator (President Pro Tem) $15,700Sen. Paul Wieland State Senator $15,200Sen. Mike Cunningham State Senator $15,050Sen. Dan Hegeman State Senator $14,925Sen. Gina Walsh State Senator (Minority Leader) $14,750Sen. Wayne Wallingford State Senator (Asst. Majority

Leader)$13,450

Sen. Caleb Rowden State Senator (Majority Leader) $12,250Sen. Lincoln Hough State Senator $11,850Sen. Jason Holsman State Senator $11,700Sen. Mike Cierpiot State Senator $10,950Sen. Denny Hoskins State Senator $10,650Sen. John Rizzo State Senator $10,000Sen. Eric Burlison State Senator $10,000

It is notable that 33 of the 34 State Senators have accepted some tobacco campaign donations.

Missouri elected officials have the power and the fiduciary responsibility to fight tobacco induced disease and death and promote the public good; but (collectively) choose not to do so. It is a shameful story.

Introduction

In Missouri, as well as in 49 other states, health care access and health care costs are among the more important and most discussed public policy issues. Needless to say, there are many diverse factors driving health care costs. In 1964, the United States Surgeon General Luther Terry issued the first definitive report that established a strong correlation between cigarette smoking and lung cancer. Even though the tobacco industry and their allies have spent substantial amounts over the last 55 years in attempts to discredit the enormous amount of scientific research linking tobacco with illness and death, in 2019 there are no longer any credible public health officials nor organizations that dispute the lethal effects of tobacco use on human health. While many health problems are unavoidable and medical science has not determined strong cause/effect relationships for many types of disease, when it comes to tobacco use, this is not the case. Illness and death caused by tobacco is almost entirely preventable.

To be sure, thanks largely to publicly-funded programs run by the federal, state and local governments, the adult cigarette smoking rate has declined considerably since the 1960s.While many/most state governments have taken strong, proactive steps to reduce tobacco induced illness and death, Missouri stands out by virtue of the fact that the Missouri state government does almost nothing to attempt to ameliorate the deadly impact that tobacco use has within its borders.

Part A- Missouri: A National Leader in Tobacco Induced Disease and Death

Missouri Citizens Suffer and Die from at the Hands of the Tobacco Industry as Their Elected Officials Sit Idly By

Tobacco induced illness and death afflicts all states, but in Missouri the problem is almost spectacularly severe. Let us look at the some of the most compelling evidence.

Adult Smoking Rate- For the last ten years, the Missouri Adult Smoking rate averaged 22.8 percent ranking 8th highest in the nation. The national average in 2017 was 17.3 percent.1

Thus, it should come as no great surprise that Missouri is also among the national leaders in smoking-induced deaths. (Data below is for the year 2016)

Lung Cancer Death Rate the Missouri Lung Cancer Death Rate is 48.0 per 100,000 population. Which ranks as the 9th highest in the nation. The national average is 38.5 per 100,000.2

Heart Disease Death Rate the Missouri Heart Disease Death Rate is 192.1 per 100,000 population. Which ranks as the 10th highest in the nation. The national average is 165.5 per 100,000.3

Chronic Obstructive Pulmonary Disease. (COPD) -the Missouri COPD Death Rate is 52.1 per 100,000 population. Which ranks as the 10th highest in the nation. The national average is 40.6 per 100,000.4

Cerebrovascular Disease/Stroke Death Rate- The Missouri CVD/Stroke Death Rate is 40.4 per 100,000 population. Which ranks as the 14th highest in the nation. The national average is 37.3 per 100,000.5

Based upon mortality data from the Missouri Department of Health & Senior Services along with data on Smoking Attributable Mortality supplied by the U.S. Centers for Disease Control, I have developed an estimate of Missouri deaths attributable to Lung and other Cancers, Heart Disease, COPD and Stroke. The estimate

1 www.cdc.gov/brfss/brfssprevalence/index.html2 www.gis.cdc.gov/Cancer/USCS/DataViz.html3 www.cdc.gov/nchs/deaths.htm4 National Vital Statistics Report, Volume 67, Number 5- Table I-165 Ibid

shows that for the years 2000 through 2017, the total is about 204,000. These are enough to fill Arrowhead Stadium almost three times. Note that this estimate is conservative. As noted, in addition to the aforementioned maladies, there are many other diseases associated with smoking that would surely increase this total.

One would think that given the fact that the risks of smoking have been well known for two generations, that deaths from smoking would be on the wane. Sad to report that this is not happening in Missouri. Using the 18-year data sample (2000 thru 2017), we find a decline in smoking induced deaths from Heart Disease and Stroke, but this is largely offset by increases in COPD deaths with Lung Cancer deaths being fairly constant. Overall, based on the cause of death categories that are available and are studied in this report, smoking induced deaths fell slightly for the 2000-2003 time frame, but have remained fairly constant over the last 14 years.6 (See Table One in Appendix for the Detailed Estimate)

Lung versus Breast Cancer- In recent years, substantial attention has been paid to the need to fight breast cancer. Let me be clear that I fully support any and all efforts to fight breast cancer. That said, it may interest readers of this report to know that in Missouri, nearly twice as many women die from LUNG CANCER as die from breast cancer. In the 21st Century (2000 thru 2017), 30,061 Missouri women died of lung cancer while 15,972 Missouri women died of breast cancer; a ratio of nearly 2:1 in favor of lung cancer. Furthermore, over this same period, female lung cancer deaths rose 6.5 percent while female breast cancer deaths declined 4.2 percent. Certainly, a decline in breast cancer deaths is a positive development. Nonetheless, given the fact that lung cancer is largely preventable, there seems to be little excuse for deaths from this disease to have increased in the current century.7 (See Table 2 in Appendix for the Detailed Estimate)

Tobacco and the Missouri Medicaid Program

When the topic of smoking and health and the proper role of government is discussed, ill-informed statements/opinions are often expressed. Among the most ill-informed and tiresome comments from tobacco proponents goes something like “the government really wants you to smoke because the government is addicted to the revenue that cigarette taxes raise”. In Missouri, such an assertion is absurd.

In FY 2019, the cigarette tax raised $72.9 million while the Other Tobacco Products tax yielded $21.9 million; for a total of $94.8 million. (the next section will discuss the Missouri cigarette tax in much more detail). Certainly the $72.9 million generated by the cigarette tax is useful revenue. Nonetheless, it comes nowhere close to covering the costs smoking imposes on the Medicaid program. Here are the numbers. The Campaign for Tobacco Free Kids has published an estimate based on a study by the Centers for Disease Control that shows that the Missouri Medicaid program spent $644.3 million (federal & state) in 2009 treating smoking induced illnesses. This is subject to adjustment to reflect 2019 spending by increasing it at the same rate as the Consumer Price Index for Medical Care (Midwest) for the intervening years. The results are as follows: Assuming that the state share of Medicaid expenditures is about 35 percent (vs 65 percent Federal), in 2019 the Missouri Medicaid program spent $295.8 million on smoking induced illness while collecting only $72.9 in taxes on cigarettes. This is about a 4:1 cost/benefit ratio. Thus, even if one is not concerned about the health havoc that smoking causes, there should be concern about how cigarette smoking is an on-going drain on the State Treasury.8 (See Appendix Table 3 for the complete estimate of smoking induced costs to the state Medicaid program.)

6 Deaths attributable to smoking in Missouri estimated by author from data at: healthapps.dhss.mo.gov/MoPhims/QueryBuilder?qbc=DM&q=1&m=1 and from:www.ncbi.nlm.nih.gov/books/NBK294316/table/ch12.t4/? report=objectonly7 Ibid8 Calculated from data provided by Tobacco Free Kids and the MO Office of Administration-Div. of Budget & Planning and the U.S. Bureau of Labor Statistics

There can be little doubt that smoking causes disease and death in Missouri well above the national averages. Furthermore, much of this is preventable. In addition, it is evident that despite the revenue cigarette excise taxes generate, the smoking induced costs to the Medicaid program far exceed these revenues, resulting in a net cost to the state budget.

Part B –Missouri Elected Officials Choose to do Almost Nothing About Tobacco Induced Disease and Death

The Missouri Cigarette Tax (or lack thereof)

The main tool for battling smoking related disease and death at the disposal of state Legislatures/Governors is the cigarette excise tax. Cigarette taxation can be of great help by:

1. Increasing the retail price of cigarettes which, in turn, discourages cigarette smoking particularly among teenagers who may lack the financial wherewithal to buy large numbers of cigarettes.

2. Providing useful amounts of revenue that may be allocated to fund anti-smoking education and smoking cessation programs.

3. Generate revenues to help pay for the health care costs smoking imposes on publicly funded health care programs such as Medicaid.

4. Generate revenues to help fund a variety of other essential state government functions.

Over the last 40 years or so, the linkage between smoking and the onset of numerous deadly diseases has become an unassailable scientific FACT. In light of this, one would think that state governments would attempt to fight this by increasing cigarette taxes and allocating resources to reduce smoking and its deadly consequences. In most states this has taken place. There is one glaring exception and that would be Missouri. Those with some interest in this topic probably know that Missouri cigarette tax of 17 cents per pack is the lowest in the nation. What is less well known is that it has not always been this way.

As recently as 1985, the national average state cigarette tax stood at 16 cents per pack. The Missouri tax that year was 13 cents or 81% of the national average. The Missouri tax went to its current 17 cents in 1993. By then the national average had climbed to 28 cents; leaving Missouri at 61% of that amount. This began to change dramatically. By 2005, as shown in the graph below, the state national average climbed to 92 cents and then on to $1.79 in 2018. Missouri has remained at 17 cents since 1993 and is now less than 10% of the national state average.

1980 1985 1990 1993 1995 2000 2005 2010 2015 20180

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MO Cigarette Tax as a Percent of the National Average

This was quite a transformation.9 (The state averages cited in this paragraph/chart include the District of Columbia and U.S. territories.)

FUN FACT: The Federal government also levies a cigarette tax. It is currently $1.01 per pack. In 1982, the Federal cigarette tax was 8 cents per pack. In 1983, it was DOUBLED to 16 cents a pack. Do you remember the name of the President who signed the legislation that made this happen?

The Current Situation

In 2019, the most current data shows that the Missouri cigarette tax of 17 cents is the lowest in the nation. State cigarette taxes range from $4.35 per pack in New York and Connecticut down to 30 cents in Virginia. Next, in the basement, we find Missouri at 17 cents. The national state average is $1.76 per pack. Consider the cigarette tax rates in Missouri’s main border states along with those in the major tobacco producing states.

Missouri’s primary Border States and their cigarette tax rates:

Illinois $2.98 (Increased from $1.98 to $2.98 on July 1, 2019)

Iowa $1.36

Kansas $1.29

Arkansas $1.15

Major Tobacco Producing States and their cigarette tax rates:

Kentucky $1.10

Tennessee $0.62

S. Carolina $0.57

N. Carolina $0.45

9 www.tobaccofreekids.org/what-we-do/us/state-tobacco-taxes/fact-sheets

Georgia $0.37

Virginia $0.30

Not only is Missouri the lowest in the nation, but it holds this distinction by a substantial margin versus for all but a few states.10

The Real Missouri Cigarette tax is at an All Time Low - It is a popular myth that taxes only increase. While tax hikes of varying types certainly occur, it is notable that the Missouri cigarette tax (adjusted for inflation) is, in fact, at an all-time LOW. The Missouri cigarette tax was first levied in 1956 at a rate of 2 cents per pack. Over the 63 subsequent years, it has increased to 17 cents. However, if one were to calculate what it would be in constant 1956 dollars, one would find that in 2018 that it is 1.8 cents per pack, or the all-time LOW. (See Table 4 in Appendix for the table displaying this calculation.)

This Yoke is Light - When cigarette tax increases are proposed/discussed, those who oppose this are fond of asserting that it is unfair to single out a certain group (smokers) for special taxation. All taxes, of course, when establishing a tax base must specify something to tax. Nonetheless, this argument seems to have some traction. Therefore, one might reasonably wonder just how much of the Missouri State budget is supported by cigarette/tobacco taxes. Wonder no longer.

At the turn of the century (State Fiscal Year (FY) 2000), the Missouri cigarette tax yielded $103.6 million. This provided 0.96% of the state operating budget even when excluding Federal funds. By FY 2019, cigarette tax collections totaled $72.9 million or 0.382% of the state operating budget; or less than four-tenths of one percent. (The state also levies a tax on non-cigarette tobacco products that yielded $21.9 million in FY 19. Including this in the tobacco tax revenue total, the overall tobacco contribution to the FY 19 state budget rises to 0.496%) By any reasonable standard, the cigarette smoking public in Missouri is receiving very favorable tax treatment. (See Table 5 in Appendix for the table displaying the calculations.)

The above demonstrates that the Missouri cigarette tax is a relatively small contributor to the state budget. Therefore, one might reasonably wonder just how much additional revenue the state could generate if it were to adopt the cigarette tax rates found in other states. In the Appendix, you will find a table that contains estimates of how much additional revenue Missouri would generate if it were to adopt the cigarette tax rate currently levied in each of the other 49 states. Note that these calculations adjust for the fact that cigarette sales would be inversely affected by a higher retail price that would likely result from a higher tax. Highlights/lowlights include:

At The Top Tax Rate MO Tax Rate Increase in MO Revenue at Other State Rate

Connecticut $4.35 $0.17 $1,404.2 millionNew York $4.35 $0.17 $1,404.2 million

Main Border States

Illinois $2.98 $0.17 $1,042.3 millionIowa $1.36 $0.17 $490.7 millionKansas $1.29 $0.17 $463.8 millionArkansas $1.15 $0.17 $409.3 million

Tobacco Growing

Kentucky $1.10 $0.17 $389.6 millionTennessee $0.62 $0.17 $194.0 million

10 Ibid

N. Carolina $0.45 $0.17 $122.0 millionGeorgia $0.37 $0.17 $87.5 millionVirginia $0.30 $0.17 $57.1 million

The salient take away here is that Missouri could raise the tax by 13 cents, still be tied for lowest in the nation and generate about $57 million. It could emulate tobacco growing Kentucky and raise $389.6 from their tax rate of $1.10. How about going to roughly the national average? Utah & Montana are at $1.70. At their rate(s), Missouri would pick up an additional $617.6 million. (See Table 6 in Appendix for the table displaying the calculations.)

Missouri Elected Officials Are Responsible for Keeping the Tax Rate at this Low Point - It is evident that the Missouri cigarette tax at 17 cents leaves a lot of money “on the table” relative to the other states; true even for the primary tobacco growing states. Astute readers may acknowledge this obvious fact, but wonder if the so-called Hancock amendment in the Missouri Constitution would permit a substantial or any increase in the Missouri cigarette tax? The answer to this question is an almost unqualified YES. A little history is in order.

In 1980, Missouri voters approved a Constitutional Amendment (Article X – Sections 16 through 24) whose main goal was to establish a limit as to how much revenue the state could collect/spend each year. The limit is linked to the growth in the state economy as measured by state personal income. While state revenues exceeded the limit in the late 1990s, those days are long gone. For Fiscal Year (FY) 2017, the State Auditor reports that Total State Revenues as defined by the amendment were $4,209.1 million below the “Refund Threshold”. For the last five FYs (2013 thru 2017) the average amount below the refund threshold was $3,978.7 million. Obviously, this feature of the Hancock Amendment is not a constraint on the Missouri Legislature/Governor with respect to raising the cigarette tax or most any other state tax.11

In 1996, voters amended the Hancock amendment to include Section 18(e). The basic purpose of this is to prevent the Legislature/Governor from imposing a major tax increase without direct voter approval. For FY 2019, the Office of Administration estimates that this limit will be $105 million.12 This limit is based on overall growth in the state budget and is likely to increase in future years. The point of knowing this is contrary to what you may have heard, the Legislature/Governor has the legal authority to substantially increase the state cigarette tax WITHOUT VOTER APPROVAL. An increase of 23 cents would generate about $100 million in new revenues and not violate any aspect of the Hancock amendment. This could be done in future years on an annual or recurring basis until a suitable level of cigarette taxation is attained.

The Master Settlement Agreement

It is clear that Missouri elected officials choose to generate relatively small amounts of revenue from the direct taxation of cigarettes and other tobacco products. There are, however, those who contend that tobacco control could or should be funded by funds received as a result of the Master Settlement Agreement (MSA). Again, some history is in order.

In the mid - 1990s, Missouri joined 46 other states in a lawsuit against the major tobacco companies for the purpose of recovering costs associated with treating tobacco induced illnesses. In 1998, a verdict was reached that entitled Missouri and other states to collect damages over a 25 year time frame. After additional legal wrangling, Missouri achieved “State Specific Finality” and the revenues began to accrue in FY 2001. From FY 2001 through FY 2019, Missouri has spent $2,896.9 million from revenues generated by the MSA. This averages out to about $152.5 million per year. In the context of the state operating budget, this is meaningful revenue. Given the toll that smoking takes on public health, as well as the costs that are imposed on government funded health care programs, one would think that a sizable allocation of these proceeds would go

11 www.app.auditor.mo.gov/Repository/Press/201803629167812 https://oa.mo.gov/sites/default/files/FY_2020_Executive_Budget_Final.pdf

towards “Tobacco Prevention, Education and Cessation”, or in fewer words, anti-smoking activities. One would be wrong. Over the 18 year period for which we have complete data, Missouri has spent about $8.4 million of MSA money on anti-smoking efforts or about 0.3 percent of amount spent.

To be sure, the nearly $2.9 billion has gone to help fund many worthy activities. Surely, the “Medicaid” allocation has helped defray some tobacco related costs. Nonetheless, the fact that Missouri has spent almost none of the MSA proceeds to explicitly fight the scourge of tobacco induced disease and death in Missouri should be a source of embarrassment to the elected officials who have allowed this to happen. But wait, there’s more!

The Small Tobacco Company Loophole

The MSA has complexities that have, in turn, led to uncertainty as to the expected revenue stream for the state. The 1998 agreement divided the tobacco companies into two categories generally designated:

Participating Manufacturers (PMs) – The major tobacco companies

Non-Participating Manufacturers (NPMs) - Smaller tobacco companies

The so-called NPMs either did not sign the MSA or were not in existence at the time, but did agree to set aside monies in an escrow account to have funds available should a state or states prevail in a future lawsuit. In addition, the payments made by the NPMs were also designed to prevent them from having a substantial cost advantage over the PMs and using the cost advantage to gain market share by selling cigarettes at a discount. It was left to the states to “diligently enforce” the agreement as it affected the NPMs. States not diligently enforcing the provisions affecting the NPMs were subject to losing a portion of the MSA payments from the PMs to the extent that they lost market share to the NPMs as a result of a having a significant cost advantage in the post- MSA environment. Unfortunately, over the intervening years, the Missouri General Assembly has failed to enact the needed legislative measures that would place the smaller tobacco companies on an equal footing with the larger companies.

The legal and legislative dispute(s) are complex. Nonetheless, the result of this has been the creation of two primary NPMs which have concentrated their business in Missouri. They are Cheyenne International of Grover, N. Carolina and Xcaliber International of Pryor, Oklahoma. Both companies contribute substantial sums to many Missouri elected officials, presumably to protect the favorable treatment they receive in Missouri. 13

In sum, the MSA has provided Missouri and other states with substantial resources that could have been used to ameliorate the rates of disease and death caused by smoking. In addition, it is evident that due to inaction from our Legislature, Missouri has failed to maximize the financial benefits that are available. A resolution of the “NPM Loophole” would increase revenues from the MSA accruing to Missouri. While estimating the amount of revenues available from closing this loophole has proven to be difficult, the annual total would certainly be substantial. This is clear neglect on the part of our elected officials and the behavior exhibited here is inexcusable.

Historical MSA Spending Allocations

Expenditure Categories Total MSA Spending Percent of TotalFY 2001 thru FY 2018 Thru FY 2018

Transfers to Gen. Revenue $1,002,712,863 36.5Medicaid $1,281,331,840 46.7

MO Senior RX Coverage $159,099,256 5.8Non-Medicaid Health Care $44,361,315 1.6

13 www.followthemoney.org/tools/legislative-overview?j=MO&+y=2019

Early Childhood Education $222,244,482 8.1Tobacco Control Programs $8,394,820 0.3

Life Science Research $27,444,071 1.0Miscellaneous $793,459 0.0

Total Spending Thru FY 2018 $2,746,382,106 100.0

FY 2019 Total Spending $150,549736

Grand Total Thru FY 2019 $2,896,931,842

Source: Data provided by the Missouri Office of Administration-Division of Budget & Planning

Additional Missouri State Budget Failings

In addition to the lack of tobacco control funding from the cigarette tax and the MSA cited above, Missouri devotes very limited resources to regulating tobacco and alcohol retailing. The Missouri Department of Public Safety has a Division of Alcohol and Tobacco Control. This Division is charged with enforcing the collection of alcohol and tobacco excise taxes, ensuring that retailers selling alcohol and tobacco are properly licensed and that laws prohibiting under-age sales of these products are enforced. It seems apparent that the resources allocated to these functions are sparse. In FY 2018, just over $1.6 million of state money was allocated to this Division which helped pay for 28 “full time equivalent” employees. To be sure, these numbers have risen in recent years. That said, given the state’s population in 2017 was 6,113,532, these resources seem inadequate for the task assigned. Note that their duties include both alcohol and tobacco control duty. It would be reasonable to assume that many retailers may be less than diligent in their efforts to restrict cigarette sales to under-age customers. (See Table 7 in Appendix for DPS-ATC funding levels in recent years.)

With the rock bottom cigarette tax and the propensity to use MSA proceeds for purposes other than anti-smoking efforts, one would still hope the Missouri Department of Health & Senior Services (DHSS) would be granted some reasonable level of funding from some funding source to fight tobacco induced disease. Unfortunately, this is not the case. In FY 2012, the MO-DHSS expended $2,171,910 on tobacco control of which about 98 percent was Federal money. By FY 2018, this total fell to $1,532,652 of which about 94 percent was Federal. In essence, the MO-DHSS spends almost no state money on tobacco control, despite the obvious need. Certainly, there are many demands on the state budget and there have been years that saw little or no overall state revenue growth. Nonetheless, the failure to fund anything more than token tobacco control efforts by our elected officials is simply a disgrace. (See Table 7 in Appendix for DHSS tobacco control funding levels in recent years.)

Electronic Cigarettes and Vaping

As recently as state fiscal year 2010, Missouri cigarette tax collections totaled $91.2 million. For FY 2019, this total fell to about $72.9 million, or a decline of about 20 percent. While there are no “official” reasons for this, it would be reasonable to assume that much of this can be attributed to the growing use of so-called E-cigarettes/vaping; particularly among teenagers and young adults. The common denominator for these products is that nearly all contain nicotine; the addictive chemical found in traditional cigarettes. The public health community generally agrees that research into the effects of this phenomenon (both short and long term), is needed. It seems that little good is likely to come from nicotine addiction along with inhaling numerous other potentially harmful chemicals. Furthermore, common sense suggests that those who develop an addiction to nicotine, are more likely to become smokers of traditional cigarettes with all their deadly consequences. Lastly, E-cigarettes are not subject to any explicit excise tax in Missouri, further eroding the meager tax revenue that traditional cigarette smoking in Missouri generates. Certainly, dealing with E-Cig/Vaping growth must be part of an overall solution to this problem.

Part C: Tobacco and Missouri Elected Officials – A Love Story

Previous sections of this report have, in essence, established that Missouri public health suffers greatly as a result of smoking rates well above national averages and that our elected officials have abdicated their responsibility and CHOOSE to do almost nothing about it.

The apparent alliance between tobacco interests and Missouri elected officials seems straightforward. Could it be that continued inaction on increasing the cigarette tax and allocating adequate funds to anti-smoking efforts can be traced to the fact that in 2019, 33 of 34 State Senators, the most prominent members of the House

Leadership as well as our most prominent statewide elected officials accept campaign contributions from tobacco interests? Before looking at the numbers, a few words about the data are in order.14

1.The source of all campaign contribution data is a website called www.followthe money.org

2. The totals shown cover the Missouri Senate that served in the 2019 session. The totals purport to cover the entire career of the Senators and other elected officials listed.

3. The data for each Senator and other elected officials was compiled by the author for this report. Every reasonable effort has been made to report it as accurately as possible.

4. The numbers shown here are probably conservative. This is because many campaign contributors are listed only by initials or acronyms. This, in turn, makes it difficult or impossible to know what business they are in and if they are part of the tobacco industry, in some way. The same holds true for individual donations. There is no way to determine the motives of individual contributors. Finally, substantial monies flow through Political Action Committees and many contributions are listed as “Undocumented”. There is no definitive way to know the extent to which tobacco interests are a part of these. The office holders, however, are almost certainly aware of who is assisting them financially.

Wet My Beak

Before looking at the donations accepted by our elected officials, let us look at the major sources of tobacco interests funding.15

Tobacco Campaign Contributor Total Donations Donations for 2018/2019

Reynolds American $122,324,230 (for 30 years) $155,775Altria $79,514,547 (for 28 years) $224,375

Cheyenne International $4,500,062 (for 10 years) $570,800X-caliber $4,259,376 (for 12 years) $265,124

MO Petroleum Marketers $795,624 (for 24 years) $244,694Casey’s General Stores $685,825 (for 22 years) $54,725

Dirt Cheap Inc $241,319 (for 17 years) $41,900Total of Above $122,320,983 $1,557,393

Let us turn to the individual donations and look at these numbers.

Official Position Tobacco Interests ContributionsAccepted

Mike Parson Governor $183,710Eric Schmitt Attorney General $73,425Mike Kehoe Lt. Governor $22,150Scott Fitzpatrick State Treasurer $10,300

Rep. Elijah Haahr Speaker of House $18,200Rep. John Wiemann Speaker Pro Tem $7,250Rep. Rob Vescovo Majority Floor Leader $6,600Rep. Sonya Anderson

Majority Caucus Chair $5,650

14 www.followthemoney.org/tools/legislative-overview?j=MO&+y=201915 Ibid

As the table above shows, the Senators who took part in the 2019 session accepted an estimated $352,000 from tobacco companies and retailers. Leading the way was Sen. Jamilah Nasheed with $35,200 in contributions. Exactly 17 Senators (or half the total) made the $10,000 or above club. Only Sen. Brian Williams took $0 from tobacco interests as defined here.

Accepting tobacco money is bi-partisan. Republicans with 70% of the Senate seats garnered 73% of the money. Meantime, the Democrats with 30% of the seats took 27% of the loot.

While tobacco contributions to each of the 163 House members has not been completely compiled, it is noted that the key members of the House of Representatives leadership share the Senate’s affinity for tobacco money. In addition, our statewide elected officials also share in the tobacco interests' considerable largesse. Below please find a table that displays key information by Missouri Senate District.

Sen. Tobacco Induced Adult Tobacco Annual BudgetDistrict Senator Deaths 2000-

2017Smoking Campaign Impact

Rate Contributions (millions $$)

5 Nasheed 6,274 26.25 $35,200 -$6.572 Onder 4,049 17.54 $30,850 -$4.18

10 Riddle 5,902 24.84 $16,950 -$6.173 Romine 7,019 28.30 $16,700 -$7.45

26 Schatz 6,218 19.34 $15,700 -$7.1522 Wieland 5,417 27.03 $15,200 -$5.2533 Cunningham 7,171 25.11 $15,050 -$7.9812 Hegeman 6,852 21.29 $14,925 -$7.8813 Walsh 5,842 15.57 $14,750 -$6.9727 Wallingford 7,086 27.02 $13,450 -$7.6719 Rowden 3,619 18.71 $12,250 -$3.4530 Hough 5,554 19.31 $11,850 -$6.197 Holsman 4,988 22.74 $11,700 -$5.048 Cierpiot 4,988 22.74 $10,950 -$5.04

21 Hoskins 6,599 25.92 $10,650 -$7.0711 Rizzo 4,992 22.74 $10,000 -$5.0520 Burlison 4,876 18.72 $10,000 -$5.276 Bernskoetter 6,092 19.55 $8,500 -$6.951 Sifton 6,100 15.57 $8,100 -$7.35

28 Crawford 7,838 24.83 $7,700 -$8.979 Curls 4,993 22.74 $7,500 -$5.05

34 Luetkemeyer 5,601 26.69 $7,420 -$5.5525 Libla 8,890 30.12 $6,850 -$9.9915 Koenig 6,074 15.57 $6,475 -$7.3118 O’Laughlin 7,431 24.04 $6,200 -$8.4629 Sater 7,129 25.72 $6,200 -$7.8617 Arthur 4,402 19.47 $4,600 -$4.5131 Emery 6,347 24.70 $4,400 -$6.8223 Eigel 4,012 17.54 $3,500 -$4.1332 White 7,198 23.17 $3,250 -$8.2116 Brown 6,254 26.56 $2,600 -$6.5124 Schupp 6,169 15.57 $1,500 -$7.454 May 6,192 26.25 $1,000 -$6.45

14 Williams 5,834 15.57 $0 -$6.96

Total 204,000 $351,790 -$222.9

The ranking is based on the amount of “Campaign Contributions Accepted by the Senators from Tobacco Interests”. Also displayed are the number of tobacco-induced deaths for 2000 through 2017, as well as the “Adult Smoking Rate”, and the current annual impact on the state budget. This is, in turn, defined as cigarette taxes collected less the state funded costs to the Medicaid program. This table teaches us much. Again highlights/lowlights include:

1. Save for Senator Brian Williams, every Senator currently serving accepts money from tobacco interests. It is acknowledged that the funds accepted by Senators May, Schupp and Brown were minimal.

2. There is a strong positive correlation between smoking rates and tobacco induced deaths.

3. In all cases, cigarette taxes attributable to each Senate District fall well short of covering the smoking induced state Medicaid costs for that district. Cigarette smoking imposes a huge net cost on the state budget.

The horrible consequences of smoking are well known. Thus, it is remarkable that in Missouri, (a state with no significant stake in the tobacco/cigarette industry) the acceptance of tobacco money is nearly unanimous amongst our Statewide office holders, Senators and key House members. It is also an unmitigated disgrace.

To be sure, there is no way to precisely know the extent to which tobacco industry campaign donations influence legislative action or lack thereof on this issue. That said, given Missouri’s disgraceful record with respect to tobacco control combined with the near universal acceptance of tobacco money in the State Senate, House leadership and the statewide officials, one might reasonably conclude that tobacco money is a dominant influence.

This is problem that the Legislature has created. More importantly, it is a problem that the Legislature has almost complete power to solve. The Legislature/Governor have the power to:

1. Increase the cigarette tax by at least 20 cents per pack per year. This would generate about $85 million per year and this revenue would fall well below the so-called Hancock II limit.

2. Impose a tax on E-cigarettes predicated on their nicotine content.

3. Allocate a reasonable share of MSA proceeds to anti-smoking programs. The Centers for Disease Control recommends that a state the size of Missouri should spend $72.9 million per year on “best practices” tobacco control programs. As noted above, Missouri spends almost nothing.

4. End the “loophole” that allows smaller tobacco companies (NPMs) to avoid paying their fair share.

5. Expand Medicaid as allowed for by the Affordable Care Act. Additional revenues from a higher cigarette tax would be ample to cover any funding shortfalls that may occur.

Summary-Major Points Include:

- Deaths in Missouri from Smoking Induced Illness are Well Above National Averages- In addition to the needless suffering, Smoking-Induced Illness/Death is a Net Cost to the State

Medicaid Program- The Missouri Cigarette Tax is easily to lowest in the nation and the State spends almost nothing to

fight smoking induced disease and death- The Missouri Legislature/Governor have the power to change this. Unfortunately, almost all of the

most important Missouri elected officials accept tobacco interests campaign contributions and apparently choose to do almost nothing about this.

About The Author- Thomas Kruckemeyer:- Holds a Masters Degree in Economics from the University of Missouri-St. Louis (1977) and a

Masters Degree in Political Science from the University of Missouri-Columbia (1990)- Served as Chief Economist for the Missouri-Office of Administration/Division of Budget & Planning

from 1978-2004- Served as Chief Economist for the Missouri Budget Project from 2005 – 2018- Currently is the Senior Economic Fellow with the Missouri Budget Project

Please Note That This Report Represents the Views of Thomas Kruckemeyer and is not in any way affiliated with the Missouri Budget Project

The author would like to thank everyone who assisted him in producing this report with special thanks to Dr. Charles Kofron.

Contact the Author:

Thomas Kruckemeyer421 Belair

Jefferson City, MO 65109-0707573-636-2581

dtkruck@embarqmail.com

Appendix

Table 1

SAM=Smoking Attributable Mortality

Year 2000/01 2002/03 2004/05 2006/07 2008/09 2010/11 2012/13 2014/15 2016/17 % Change

2017/ 2000

Lung Cancer 7,461 7,547 7,905 7,778 7,769 7,718 7,958 7,827 7,397 -0.86

SAM 87.05 6,495 6,570 6,881 6,771 6,763 6,719 6,927 6,813 6,439 -0.86

Other Cancers 7,968 8,343 8,277 8,473 8,585 8,835 9,118 9,385 9,523 19.52

SAM 20.17 1,607 1,683 1,669 1,709 1,732 1,782 1,839 1,893 1,921 19.52

Coronary Heart Disease 23,891 22,659 20,729 19,813 19,236 18,072 17,233 16,800 16,341 -31.60

SAM 32.3 7,717 7,319 6,695 6,400 6,213 5,837 5,566 5,426 5,278 -31.60

COPD 9,972 10,151 9,946 9,878 11,123 10,746 11,430 12,124 12,593 26.28

SAM 61.7 6,153 6,263 6,137 6,095 6,863 6,630 7,052 7,481 7,770 26.28

Stroke/ CV Disease 8,921 8,656 7,932 7,515 7,127 6,690 6,569 6,756 6,922 -22.41

SAM 16.25 1,450 1,407 1,289 1,221 1,158 1,087 1,067 1,098 1,125 -22.41

Smoking Induced Deaths 23,421 23,241 22,672 22,195 22,729 22,055 22,453 22,711 22,533 -3.79

Sources of Data: MO -Dept. ofHealth & U.S. Centers forDisease ControlCalculated by Author

Table 2

Missouri MissouriFemale Female

Deaths from Deaths fromYear Lung Cancer Breast Cancer Ratio

2000 1,546 903 1.712001 1,507 910 1.662002 1,557 887 1.762003 1,574 913 1.722004 1,649 891 1.852005 1,589 971 1.642006 1,695 907 1.872007 1,665 877 1.902008 1,680 913 1.842009 1,699 857 1.982010 1,742 869 2.002011 1,693 890 1.902012 1,763 852 2.072013 1,769 856 2.072014 1,812 877 2.072015 1,772 863 2.052016 1,702 871 1.952017 1,647 865 1.90

Total 30,061 15,972 1.88

% Change2017/2000 6.53 -4.21

Source: Missouri Dept.of Health &Senior ServicesWebsite

Table 3

MO Overall Medicaid Tobacco Cost Total Cost CPI State of MO MO MO Tobacco MO

In 2009 As Per TFK Report $644.3Medicare

MWShare (35%) CigTax Ratio Year Medicaid $$s CigTax

2010 $666.1 1.03382 $233.1 $91.2 2.56 2010 $233.1 $91.2

2011 $686.9 1.031254 $240.4 $90.0 2.67 2011 $240.4 $90.0

2012 $714.2 1.039763 $250.0 $88.6 2.82 2012 $250.0 $88.6

2013 $735.8 1.030163 $257.5 $88.2 2.92 2013 $257.5 $88.2

2014 $757.9 1.03009 $265.3 $82.3 3.22 2014 $265.3 $82.3

2015 $776.4 1.024466 $271.8 $81.7 3.33 2015 $271.8 $81.7

2016 $807.3 1.03971 $282.5 $83.7 3.38 2016 $282.5 $83.7

2017 $824.5 1.021386 $288.6 $79.9 3.61 2017 $288.6 $79.9

2018 $832.5 1.00961 $291.4 $75.9 3.84 2018 $291.4 $75.9

2019est $845.1 1.0152 $295.8 $72.9 4.06 2019 $295.8 $72.9

Table 4

Nominal RealConsumer Missouri Missouri

YEAR Price Index Cigarette Tax Cigarette Tax(cts. Per Pack) (cts. Per Pack)

(1956 $$$)

1955 26.8 1956 27.2 2 2.001957 28.1 2 1.941958 28.9 2 1.881959 29.1 2 1.871960 29.6 2 1.841961 29.9 4 3.641962 30.2 4 3.601963 30.6 4 3.561964 31.0 4 3.511965 31.5 4 3.451966 32.4 4 3.361967 33.4 4 3.261968 34.8 4 3.131969 36.7 9 6.671970 38.8 9 6.311971 40.5 9 6.041972 41.8 9 5.861973 44.4 9 5.511974 49.3 9 4.971975 53.8 9 4.551976 56.9 9 4.301977 60.6 9 4.041978 65.2 9 3.751979 72.6 9 3.371980 82.4 9 2.971981 90.9 9 2.691982 96.5 9 2.541983 99.6 13 3.551984 103.9 13 3.401985 107.6 13 3.291986 109.6 13 3.231987 113.6 13 3.111988 118.3 13 2.991989 124.0 13 2.851990 130.7 13 2.711991 136.2 13 2.601992 140.3 13 2.521993 144.5 13 2.451994 148.2 17 3.121995 152.4 17 3.03

1996 156.9 17 2.951997 160.5 17 2.881998 163.0 17 2.841999 166.6 17 2.782000 172.2 17 2.692001 177.1 17 2.612002 179.9 17 2.572003 184.0 17 2.512004 188.9 17 2.452005 195.3 17 2.372006 201.6 17 2.292007 207.3 17 2.232008 215.3 17 2.152009 214.5 17 2.162010 218.1 17 2.122011 224.9 17 2.062012 229.6 17 2.012013 233.0 17 1.982014 236.7 17 1.952015 237.0 17 1.952016 240.0 17 1.932017 245.1 17 1.892018 251.1 17 1.84

Source: Calculated by Author with data from the U.S. Bureau of Labor Statistics

Table 5

FiscalMO

CigaretteMO

OtherMO

Total MO OperatingCigarette

TaxTobacco

Tax % Change

Year TaxTobacco

TaxTobacco

Tax Budget% of State

% of State

% Change % Change

MO OTP Tax

Less: Federal Budget BudgetMO

CigTaxMO OTP

Tax& MO

CigTax(millions

$$)(millions

$$)(millions

$$) (millions $$)

2000 $103.6 $8.6 $112.2 $10,826.2 0.957% 1.036%

2001 $99.4 $8.7 $108.1 $11,783.5 0.844% 0.917% -4.05 1.16 -3.65

2002 $97.3 $9.5 $106.8 $12,540.0 0.776% 0.852% -2.11 9.20 -1.20

2003 $97.9 $10.2 $108.1 $11,304.4 0.866% 0.956% 0.62 7.37 1.22

2004 $98.8 $10.8 $109.6 $12,341.5 0.801% 0.888% 0.92 5.88 1.39

2005 $99.2 $11.0 $110.2 $13,104.0 0.757% 0.841% 0.40 1.85 0.55

2006 $99.9 $11.4 $111.3 $13,340.0 0.749% 0.834% 0.71 3.64 1.00

2007 $97.0 $11.9 $108.9 $14,560.0 0.666% 0.748% -2.90 4.39 -2.16

2008 $97.2 $12.2 $109.4 $14,999.4 0.648% 0.729% 0.21 2.52 0.46

2009 $94.8 $13.1 $107.9 $15,845.2 0.598% 0.681% -2.47 7.38 -1.37

2010 $91.2 $15.0 $106.2 $14,989.2 0.608% 0.709% -3.80 14.50 -1.58

2011 $90.0 $15.6 $105.6 $15,113.1 0.596% 0.699% -1.32 4.00 -0.56

2012 $88.6 $16.3 $104.9 $15,690.4 0.565% 0.669% -1.56 4.49 -0.66

2013 $88.2 $16.9 $105.1 $15,633.7 0.564% 0.672% -0.45 3.68 0.19

2014 $82.3 $17.2 $99.5 $15,904.5 0.517% 0.626% -6.69 1.78 -5.33

2015 $81.7 $17.7 $99.4 $16,456.3 0.496% 0.604% -0.73 2.91 -0.10

2016 $83.7 $19.4 $103.1 $16,782.1 0.499% 0.614% 2.45 9.60 3.72

2017 $79.9 $20.5 $100.4 $17,082.4 0.468% 0.588% -4.54 5.67 -2.62

2018 $75.9 $21.5 $97.4 $17,423.6 0.436% 0.559% -5.01 4.88 -2.99

2019 $72.9 $21.9 $94.8 $19,104.7 0.382% 0.496% -3.95 1.86 -2.67

Source: MO Executive Budget Books & MO Office of Administration

Table 6

State State Cigarette Tax Difference vs Missouri (17cts) Missouri Net Gain at New RateNew York 4.350 4.18 $1,404,198,992Connecticut 4.350 4.18 $1,404,198,992Rhode Island 4.250 4.08 $1,381,028,571Massachusetts 3.510 3.34 $1,193,687,933Hawaii 3.200 3.03 $1,106,892,101Vermont 3.080 2.91 $1,071,975,529Minnesota 3.040 2.87 $1,060,173,176Washington 3.025 2.855 $1,055,726,218Illinois 2.980 2.81 $1,042,316,370California 2.870 2.7 $1,009,101,176New Jersey 2.700 2.53 $956,552,605Pennsylvania 2.600 2.43 $924,951,933Wisconsin 2.520 2.35 $899,303,529Delaware 2.100 1.93 $759,284,706Oklahoma 2.030 1.86 $735,072,000Alaska 2.000 1.83 $724,618,487Arizona 2.000 1.83 $724,618,487Maine 2.000 1.83 $724,618,487Maryland 2.000 1.83 $724,618,487Michigan 2.000 1.83 $724,618,487New Mexico 2.000 1.83 $724,618,487Nevada 1.800 1.63 $653,753,277New Hampshire 1.780 1.61 $646,554,353Utah 1.700 1.53 $617,554,286Montana 1.700 1.53 $617,554,286Ohio 1.600 1.43 $580,844,370S. Dakota 1.530 1.36 $554,843,429Texas 1.410 1.24 $509,687,933Iowa 1.360 1.19 $490,656,000Florida 1.339 1.169 $482,624,499Oregon 1.330 1.16 $479,175,529Kansas 1.290 1.12 $463,796,706West Virginia 1.200 1.03 $428,895,462Arkansas 1.150 0.98 $409,327,059Kentucky 1.100 0.93 $389,630,924Louisiana 1.080 0.91 $381,716,706Indiana 0.995 0.825 $347,853,277Colorado 0.840 0.67 $285,152,000Mississippi 0.680 0.51 $219,140,571Alabama 0.675 0.505 $217,056,639Nebraska 0.640 0.47 $202,433,345Tennessee 0.620 0.45 $194,049,076Wyoming 0.600 0.43 $185,644,370Idaho 0.570 0.4 $172,998,992S. Carolina 0.570 0.4 $172,998,992N. Carolina 0.450 0.28 $121,957,647N. Dakota 0.440 0.27 $117,670,992Georgia 0.370 0.2 $87,521,345Virginia 0.300 0.13 $57,121,345Missouri 0.170 0 $0Blue = MO Border States & Tobacco Growing States

Source: by Author based on Cigarette Tax Rates in:www.tobaccofreekids.org/what-we-do/us/state-tobacco-taxes/fact-sheets

Table 7

Grid OneMO-Division of Alcohol &

Tobacco Control Fiscal Year Fiscal Year Fiscal Year Fiscal Year Fiscal Year Fiscal Year Fiscal YearExpenditures FY

2012-FY 2018 2012 2013 2014 2015 2016 2017 2018

General Revenue $895,282 $852,470 $804,418 $782,447 $765,124 $0 $0

Federal Funds $115,526 $111,198 $88,202 $50,644 $60,828 $63,168 $24,272

Other State Funds $130,719 $135,874 $113,003 $108,551 $108,909 $1,545,650 $1,632,656

State Subtotal $1,026,001 $988,344 $917,421 $890,998 $874,033 $1,545,650 $1,632,656

Total $1,141,527 $1,099,542 $1,005,623 $941,642 $934,861 $1,608,818 $1,655,928

Full Time Equivalent Employees 21 20 19 17 17 21 28

Grid TwoMO-DHSS

Expenditures for Tobacco Control Fiscal Year Fiscal Year Fiscal Year Fiscal Year Fiscal Year Fiscal Year Fiscal YearExpenditures FY

2012-FY 2018 2012 2013 2014 2015 2016 2017 2018

General Revenue $52,624 $70,262 $88,843 $38,895 $106,866 $71,282 $98,877

Federal Funds $2,119,286 $1,794,478 $1,555,737 $1,687,290 $2,096,415 $1,788,578 $1,433,775

Other State Funds $0 $0 $0 $0 $0 $0 $0

State Subtotal $52,624 $70,262 $88,843 $38,895 $106,866 $71,282 $98,877

Total $2,224,534 $1,935,002 $1,733,423 $1,765,080 $2,310,147 $1,931,142 $1,631,529

Source: http://oa.mo.gov/sites/default/files/FY_2020_Executive _Budget_Final.pdf