Press Releases Archive - Page 14 of 31

President’s Budget Would Hinder US Public Health Progress: Huge Cuts Proposed

The Nation’s Health
Kim Krisberg
May 2019

White House budget proposals are often more vision than reality. But they offer revealing insights into an administration’s values and priorities. Unfortunately, in the case of President Donald Trump’s new budget plan, many of those priorities are out of step with public health, proposing significant cuts to vital programs and agencies.

“In a time where life expectancy is falling, our leadership should be investing in better health, not cutting federal health budgets,” said APHA Executive Director Georges Benjamin, MD, in a news release. “This budget, put simply, kicks the can of worsening American health down the road.”

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Pharma Pushes Lawmakers to Reward Antibiotic Developers

April 29, 2019
National Journal

Antibiotic resistance has made common illnesses more difficult to treat and threatens to become a deadly killer in the decades to come. But even with this growing threat of “superbugs,” pharmaceutical companies have struggled financially to maintain research and development into new antibiotic treatments.

Public-health experts and drug companies are now calling on Congress to enact policies that would help manufacturers overcome financial hurdles to developing and marketing new antimicrobial products.

A United Nations report released Monday recommended intensifying the support for research and development of new antimicrobials. “Alarming levels of resistance” have been seen in countries of all income levels, and common diseases are “becoming untreatable,” according to the study.

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Trust for America’s Health Applauds Proposed Increases to Public Health Spending in House Appropriations Bill

May 1, 2019

Trust for America’s Health (TFAH) applauds the House Appropriations Committee and Chairwomen Nita Lowey and Rosa DeLauro for the draft FY2020 Labor, Health and Human Services, Education and Related Agencies (LHHS) spending bill, which would increase funding for the Centers for Disease Control and Prevention (CDC) and many programs that address the nation’s leading health threats.

Last week, TFAH released a report: The Impact of Chronic Underfunding of America’s Public Health System, which found that chronic underfunding of the nation’s public health system puts lives at risk. A list of TFAH’s top FY20 funding priorities can be found here.

TFAH’s President and CEO, John Auerbach, said:

“We are grateful to the leadership and staff of the Appropriations Committee and the Labor-HHS Subcommittee for demonstrating a substantive commitment to public health and prevention with the proposed funding levels. Public health officials are addressing an unprecedented range of health crises – the substance misuse and suicide epidemics, chronic diseases that contribute to rising healthcare costs and disability, public health emergencies and outbreaks – yet they are doing so with stagnant funding and outdated systems. The proposed bill would invest in public health infrastructure and proven programs that prevent illness and injury and improve emergency preparedness.

Public health doesn’t always get the headlines. But we have public health to thank for the safety and health of our communities. This bill only represents the first step in modernizing our public health system and we stand ready to work with Congress see this through.

We urge the Senate to prioritize public health with the same urgency and thoughtfulness the House has shown and we encourage both House and Senate leadership to work with the President to raise the budget caps so public health can tackle the nation’s urgent health challenges.“

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Trust for America’s Health is a nonprofit, nonpartisan organization that promotes optimal health for every person and community and makes the prevention of illness and injury a national priority.

New TFAH Report: Persistent Underfunding of America’s Public Health System Makes the Nation Vulnerable and Puts Lives at Risk

Funding for public health programs via the CDC budget decreased by 10 percent over the last decade while public health risks grew

(Washington DC – April 24, 2019) – Chronic underfunding of the nation’s public health infrastructure has left the nation vulnerable to serious health and safety risks, according to a new report released today by Trust for America’s Health.

The report, The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks, and Recommendations, 2019, examines federal, state, and local public health funding trends and recommends needed investments and policy actions to prioritize prevention and effectively address 21st century health threats.

The federal government, primarily through the U.S. Centers for Disease Control and Prevention (CDC), provides critical support for the nation’s public health infrastructure including by funding a substantial portion of state and local public health programs. But, between Fiscal Year (FY) 2010 – Fiscal Year 2019, the CDC’s budget fell by 10 percent when adjusted for inflation. Cuts to the CDC budget have direct impacts on state and local public health departments’ budgets. In 2018, 17 states and the District of Columbia cut their public health spending.

“Our country is grappling with unprecedented public health problems including the opioid crisis, the increasing number of Americans with chronic diseases, virulent infectious diseases and a growing number of weather-related emergencies,” said John Auerbach, President and CEO of Trust for America’s Health. “The CDC budget is simply not sufficient to address these demands.”

“At a time when the country’s health security threats are increasing, reducing spending to prevent and respond to these risks is dangerous and makes Americans less safe,” Auerbach said.

“CDC funding represents the majority of public health funding nationally and locally. When CDC funding is cut, state and local governments are often forced to reduce funding for critical programs including those to prevent chronic and infectious diseases, to protect environmental health and to provide vaccinations for children, among many others. These are programs Americans need and support. They shouldn’t be constantly on the chopping-block,” Auerbach said.

Among the Report’s Key Findings Are:

Over the past decade, the Centers for Disease Control and Prevention’s program funding—more than half of which goes to states, localities, and other nonfederal partners—decreased by 10 percent, after adjusting for inflation. At the same time, substance misuse has skyrocketed, the incidence of obesity and related health problems continue to climb, and the threat of weather-related emergencies is on the rise.
Federal funding cuts negatively affect state health departments as these funds are a primary source of state public health budgets. On average, federal funding comprises 48 percent of state public health budgets. Similarly, these spending cuts have serious consequences for local health departments given that federal and state allocations constitute a substantial portion of local health departments’ budgets.
Seventeen states and the District of Columbia cut their public health funding in FY 2018.
One-fifth of local health departments reported decreases in their FY 2017 budgets.
Multiple years of funding cuts contributed to more than 55,000 lost jobs at local health departments from 2008-17. These cuts undermine efforts to hire, train, and retain a strong public health workforce, which in turn limits governments’ ability to effectively protect and promote the health of their residents.
Cuts to public health funding often result in higher health care costs as preventable illnesses and injuries are major causes of hospitalization and other medical interventions.

The Report’s Topline Recommendations Include:

Increase federal investments in public health. To protect the health and safety of all the country’s residents we need more funding for public health programs, not less.
Provide sufficient, full-year funding for federal agencies to avoid interruptions in funding for critical health security programs.
Increase state and local investment in public health, prioritizing prevention and the social determinants of health.
Work across sectors to improve the effectiveness and efficiency of public health investments.
Ease coordination of funding from multiple sources.

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Trust for America’s Health is a nonprofit, nonpartisan organization that promotes optimal health for every person and community and makes the prevention of illness and injury a national priority.

Nearly 70 Organizations Call on Congress to Advance the Pandemic and All-Hazards Preparedness & Advancing Innovation Act

March 22, 2019

The Honorable Mitch McConnell Majority Leader U.S. Senate
The Honorable Charles Schumer Minority Leader U.S. Senate
The Honorable Nancy Pelosi Speaker U.S. House of Representatives
The Honorable Kevin McCarthy Minority Leader U.S. House of Representatives

On behalf of the undersigned organizations, representing public health, healthcare providers, emergency managers, environmental health, biotechnology innovators, and researchers, we are again writing to encourage you to advance the Pandemic and All-Hazards Preparedness & Advancing Innovation Act (PAHPAI, H.R. 269), which overwhelmingly passed the House of Representatives in January. A similar version passed the Senate Health Education, Labor & Pensions (HELP) Committee last year. The HELP and Energy & Commerce Committees have made tremendous, bipartisan progress on this important legislation, and it would be a setback for our national health security to further delay reauthorization. The disaster relief package being considered by Congress would be a logical vehicle for PAHPAI.

The recent wildfires, hurricanes and measles outbreaks have demonstrated that all sectors – public health, healthcare and private sector – play a critical role in saving lives during disasters and outbreaks. PAHPA is the backbone of our nation’s health security, providing the U.S. Department of Health and Human Services (HHS) with authorities for preparing the healthcare and public health systems for disasters and strengthening the medical countermeasures enterprise. The legislation addresses gaps we have seen in recent responses, such as the speed of funding for public health emergencies, development and deployment of medical countermeasures for significant threats and preparedness for children in disasters.

The time is now to move this legislation. We are particularly concerned that several authorities have expired as of 2018, including temporary reassignment of state and local personnel, the National Advisory Committee on Children and Disasters, limited antitrust exemption and other provisions critical to HHS contracting. We believe that time is of the essence in reauthorizing these important authorities.

We commend the work of the committed Senators, Representatives and their staff who have devoted considerable thought to this legislation. Our organizations are committed to our nation’s health security, and we remain ready to assist in order to see this legislation enacted into law as soon as possible.

Sincerely,

AABB (formerly known as American Association of Blood Banks)
AFSCME
Alliance for Biosecurity
American Academy of Pediatrics
American Association of Poison Control Centers
American Association on Health and Disability
American Hospital Association
American Public Health Association
American Society for Microbiology
America’s Blood Centers
Asian & Pacific Islander American Health Forum
Association for Professionals in Infection Control and Epidemiology
Association of American Medical Colleges
Association of American Veterinary Medical Colleges
Association of Maternal & Child Health Programs
Association of Public Health Laboratories
Association of Schools and Programs of Public Health
Association of State and Territorial Health Officials
Barnesville Hospital
Berger Health System
Big Cities Health Coalition
Biotechnology Innovation Organization (BIO)
California Life Sciences Association
Central Ohio Trauma System
Child Care Aware of America
Colorado Association of Local Public Health Officials
Commissioned Officers Association of the U.S. Public Health Service, Inc. (COA)
Coshocton Regional Medical Center
Council of State and Territorial Epidemiologists
Entomological Society of America
Fayette County Memorial Hospital
Federation of American Hospitals
Future of Life Institute
Genesis Community Ambulance
Global Health Technologies Coalition
Health Industry Distributors Association
Health Resources in Action
Healthcare Distribution Alliance
Healthcare Leadership Council
Healthcare Ready
Hogg Foundation for Mental Health
Hospital Council of Northwest Ohio
Infectious Diseases Society of America
International Association of Emergency Managers
Johns Hopkins Center for Health Security
Los Angeles County Department of Public Health
Louisiana Public Health Institute
March of Dimes
Mount Carmel Health System
National Association of Counties
National Association of County and City Health Officials
National Association of Federal Veterinarians
National Association of Pediatric Nurse Practitioners
National Association of State Emergency Medical Services Officials
National Center for Disaster Preparedness, Columbia University
National Emergency Management Association National Network of Public Health Institutes
NEHA
Oklahoma City-County Health Department
One Health Commission
One Health Initiative Autonomous pro bono Team
Suburban Hospital Alliance of New York State
The Antimicrobials Working Group (Amplyx Pharmaceuticals, Aridis Pharmaceuticals, Cidara Therapeutics Inc., ContraFect Corporation, Entasis Therapeutics Inc., Iterum Therapeutics Ltd., Melinta Therapeutics Inc., Motif Bio plc, Nabriva Therapeutics US Inc., Paratek Pharmaceuticals Inc., Qpex Biopharma Inc., SCYNEXIS Inc., Summit Therapeutics plc andVenatoRx Pharmaceuticals Inc.)
The Society for Healthcare Epidemiology of America
Trauma Center Association of America
Trust for America’s Health
UCSF Benioff Children’s Hospitals
Virginia Hospital & Healthcare Association

President’s Proposed FY20 Budget Will Harm the Nation’s Public Health

Washington, D.C., March 11, 2019 – Statement from John Auerbach, president and CEO, Trust for America’s Health (TFAH).

Auerbach on the President’s Budget Proposal:

“The President’s proposed budget – which includes a 12 percent cut to the Department of Health and Human Services (HHS) budget and an approximate 10 percent cut to the CDC – would be harmful to the nation’s public health and safety. States and communities are grappling with increasing healthcare costs, rises in premature deaths due to chronic disease, substance misuse and suicide, and an increased threat of weather-related emergencies. These realities have created unprecedented demands on our already under-resourced public health infrastructure. Now is the time to strategically increase investments in public health programs and infrastructure, not cut them.”

Auerbach on the consequences of spending caps:

“This proposed budget shows the potential consequences if Congress fails to raise spending caps this year. Health agencies and programs are a continuum. If we decrease investments in prevention and detection of diseases, we can expect higher costs for treatment and response. We urge Congress to reject the proposed budget and work toward a spending package that invests in America’s health.”

Auerbach on diverted resources:

“We are also deeply concerned by the recent report that HHS has diverted an additional $385 million from other programs to increase shelter capacity for unaccompanied migrant children. These programs can’t afford any further diversions. The $14 million being taken from the Centers for Disease Control and Prevention (CDC), for example, is more than the agency’s budget for activities around climate change, unintentional injuries, or healthcare associated infections.”

TFAH urges Congress and the Administration to work to raise the budget caps and enact appropriations bills that reflect the health needs of our population. Our specific concerns about the proposed budget include:

An approximate 10 percent reduction to CDC’s overall program budget. The budget request proposes about $750 million in spending cuts to CDC’s program level, compared with FY19.

Proposed CDC program cuts include:

Cuts to programs to prevent chronic conditions down by approximately 20 percent – including programs to address obesity, diabetes, cancer, heart disease and stroke. These diseases are the leading causes of death and healthcare costs in the U.S.; decreasing our investment in their prevention would be short-sighted.
Cuts to programs to protect health from environmental threats such as lead poisoning and asthma made worse by air quality – down approximately 25 percent.
Cuts to programs to prevent birth defects down by approximately 28 percent.
Inadequate funding to prevent substance misuse and suicide – Deaths from alcohol, drugs and suicide are at an all-time high,¹ yet the budget proposes cuts or level funding for many substance misuse and suicide prevention activities at the Substance Abuse and Mental Health Services Administration and CDC.

The creation of a comprehensive HIV strategy.

Trust for America’s Health applauds the bold goal to end the U.S. HIV epidemic by 2030, but an increased investment in the domestic response to HIV should not come at the expense of efforts to combat other infectious diseases, chronic diseases or environmental threats. At the same time, administrative and legal changes to the ACA and Medicaid are likely to reduce HIV patient access to care.

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1. Trust for America’s Health and Well Being Trust. Pain in the Nation Update: While Deaths from Alcohol, Drugs, and Suicide Slowed Slightly in 2017, Rates Are Still at Historic Highs, March 5, 2019. https://www.tfah.org/report-details/pain-in-the-nation-update-while-deaths-from-alcohol-drugs-and-suicide-slowed-slightly-in-2017-rates-are-still-at-historic-highs/

U.S. deaths from alcohol, drugs and suicide hit highest level since record-keeping began

March 5, 2019
By Jayne O’Donnell
USA Today

“The number of deaths from alcohol, drugs and suicide in 2017 hit the highest level since federal data collection started in 1999, according to an analysis of Centers for Disease Control and Prevention data by two public health nonprofits.”

View full story here.

Number of Americans Dying Due to Alcohol, Drugs, and Suicide is at an All-time High

Synthetic Opioid Deaths Rose 45 Percent Between 2016 And 2017,
Have Increased 10-fold In The Last Five Years

(Washington, DC and Oakland, CA – March 5, 2019) – More than 150,000 Americans—the most ever—died from alcohol and drug-induced fatalities and suicide in 2017 – more than twice as many as in 1999 – according to a new analysis released today by Trust for America’s Health (TFAH) and Well Being Trust (WBT).

The TFAH and WBT analysis of Centers for Disease Control and Prevention data found that between 2016 and 2017, the national rate for deaths due to alcohol, drugs, and suicide increased 6 percent from 43.9 to 46.6 deaths per 100,000. While the increase is lower than the prior two years, it is higher than the 4 percent average annual increase since 1999.

According to the analysis, the number of Americans dying due to substance misuse and suicide is at an all-time high.

Synthetic opioids continue to drive increases in deaths

Synthetic opioid deaths rose 45 percent between 2016 and 2017 and have increased 10-fold in the last five years. Americans are now dying at a faster rate from overdoses involving synthetic opioids than they did from all drugs in 1999.

Two decades ago, fentanyl and synthetic opioids were associated with less than 1,000 annual deaths nationwide. In 2017, more than 1,000 Americans died from synthetic-opioid overdoes every two weeks.

In 2017, synthetic-opioid deaths were highest among males, Blacks, Whites, adults ages 18-54 and those living in urban areas. Synthetic-opioid deaths were concentrated in Northeastern and Midwestern states.

Suicide deaths growing at fastest pace in years

Deaths from suicides also rose faster between 2016 and 2017 than in previous years, increasing four percent from 13.9 to 14.5 deaths per 100,000. The 2017 increase was the largest since the data collection began in 1999. For the previous decade, between 2008 and2017, suicide rates increased an average of 2 percent per year, a 22 percent total increase.

The highest rates of suicide continue to occur among Whites, males and people living in rural areas. Increases in suicide were geographically widespread but increases were proportionally greater among certain demographic groups including young people (particularly children and adolescents), Blacks and Latinos. Between 2016 and 2017, suicide death rates for children and adolescents increased by 16 percent from 2.1 deaths per 100,000 to 2.4 per 100,000.

“It is important to see hope in the slowing of rates—but it’s not nearly enough. We should not be satisfied at all. Too many of us are dying from preventable causes, and each time we make progress—like with prescription opioids—new problems—like synthetic opioids—appear,” said Benjamin F. Miller, Chief Strategy Officer, WBT. “Tackling such a complex problem is not about adding up small changes – but really about transformation at a systems level.”

Age and Gender Differences

The 2017 rate of death by alcohol, drugs, and suicide among all adults ages 35-54 was 72.4 deaths per 100,000, for all males it was 68.2 per 100,000, for all females it was 25.7 deaths per 100,000.

Regional Differences

While most states saw increases in deaths due to alcohol, drugs and suicide, the trends are worst in certain states:

West Virginia had the highest rate of death from alcohol, drugs, and suicide in the nation (91 deaths per 100,000).
New Mexico was second with 77 deaths per 100,000.
Ohio was third with 69.4 deaths per 100,000.
Alaska (67.6 per 100,000) and New Hampshire (66.0 per 100,000) were fourth and fifth respectively.

Overall, 43 states and the District of Columbia had higher rates of deaths from alcohol, drugs and suicide between 2016 and 2017. Five states—Massachusetts, Oklahoma, Rhode Island, Utah, and Wyoming—had lower rates.

“We need a comprehensive approach with attention to the upstream root causes – like childhood trauma, poverty and discrimination —and the downstream life-saving efforts – like overdose reversal and access to treatment—and everything in between,” said John Auerbach, President and CEO of the Trust for America’s Health. “A focus on only one or two approaches won’t work with complex and widespread epidemics like these. As a nation, we need to better understand and to systematically address the factors that drive these devastating deaths of despair.”

The TFAH/WBT brief recommends several policy actions to prevent deaths from alcohol, drugs, and suicide, including:

Increasing funding and support for programs that reduce risk factors and promote resilience in children, families and communities. Exposure to trauma and adverse experiences at young ages increase the potential for substance misuse and suicide. Programs that reduce community violence, address poverty and discrimination, create safe, supportive schools and quality learning experiences and promote access to secure housing and employment opportunities all reduce adverse experiences and build resilience.
Providing more resources to programs that promote harm reduction and access to treatment for individuals with substance use disorders including access to mental health services covered by insurance on par with coverage for physical health care. Increased access to programs for communities and population groups at the highest risk for substance misuse and suicide are particularly critical.
Supporting policies that limit access to the lethal means of suicide by promoting safe storage of medications and firearms and encouraging responsible opioid prescribing practices.

The TFAH/WBT Pain in the Nation publication series was launched in 2017 and examines substance misuse and suicide trends and evidence-based policies and programs in an effort to promote a comprehensive approach to solving the nation’s deaths of despair crisis. The report series is designed to focus attention on the need for national resilience strategy.

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Trust for America’s Health is a nonprofit, nonpartisan organization that promotes optimal health for every person and community and makes the prevention of illness and injury a national priority.

Well Being Trust is a national foundation dedicated to advancing the mental, social, and spiritual health of the nation. Created to include participation from organizations across sectors and perspectives, Well Being Trust is committed to innovating and addressing the most critical mental health challenges facing America, and to transforming individual and community well-being. www.wellbeingtrust.org. Twitter: @WellBeingTrust

States Can Improve Residents’ Health and Reduce Healthcare Spending by Adopting Policies Outside of the Healthcare Sector, New Report Shows

February 21, 2019

Policies that can improve health and save money include: Pre-K and school nutrition programs, syringe access, tobacco and alcohol taxes, paid family leave, the Earned Income Tax Credit and rapid rehousing.

(Washington, DC) — States can improve their residents’ health and well-being, and lower healthcare costs, by implementing a range of policies in sectors beyond healthcare, according to a new report, Promoting Health and Cost Control: How States Can Improve Community Health and Well-being through Policy Change, released today by Trust for America’s Health (TFAH).

The new report analyzes state action on 13 policies outside the healthcare sector that have a long-term impact on health and an evidence base showing their effectiveness. They include: tobacco and alcohol taxes, syringe access programs, universal pre-K and rapid rehousing laws, among others. The wide policy lens of the report, which covers numerous sectors, including taxation, employment, education, housing and transportation, underscores the many economic and social factors beyond medical care that influence health.

In the context of the longest decline in life expectancy since World War I, and, insufficient resources dedicated to preventing health problems before they arise, this new report serves as an urgent call to state policymakers to take concrete steps to improve residents’ health. The report was made possible by financial support from the Robert Wood Johnson Foundation and Kaiser Permanente.

“In the current environment, states have an even more vital role to play in promoting the health and well-being of their residents,” said John Auerbach, President and CEO of Trust for America’s Health. “Our goal in creating this report is to provide state public health officials and policymakers the evidence and business case for the adoption of policies that have been shown to improve community health.”

Policies Analyzed in the Report	Number of States with the Policy
Universal Pre-K program*	10 (incl. DC)
School breakfast program	31 (incl. DC)
School lunch program	20
School competitive foods (snacks and drinks)	28 (incl. DC)
Syringe access programs	27 (incl. DC)
Smoke-free laws**	29 (incl. DC)
Tobacco taxes***	51 (incl. DC)
Alcohol taxes***	51 (incl. DC)
Complete streets	30 (incl. DC)
Housing rehabilitation loan and grant programs****	40 (incl. DC)
Rapid re-housing laws	9 (incl. DC)
Earned income tax credit	30 (incl. DC)
Paid sick leave	12 (incl. DC)
Paid family leave	7 (incl. DC)
Fair hiring protections (ban the box)	34 (incl. DC)

The economic benefits of these policies can be substantial. For example:

Pre-K education programs can generate $4.63 in benefits to participants, taxpayers, and others in society for every $1 spent on such programs.
Expanding syringe exchange programs could return $7.58 for every $1 invested in the long run, by lowering HIV rates and reducing treatment costs. There is no evidence such programs lead to higher drug use.
Rapid re-housing programs, which focus on getting homeless individuals into stable housing before addressing other challenges, can reduce hospital admissions and jail bookings. One pilot study found that such an approach saved more than $36,000 in treatment costs per person over the course of a year, nearly twice what the program cost.

“While the healthcare sector plays an important role in providing health services when someone gets sick, many of the factors that keep people healthy are outside the healthcare system and involve where people live, work, play and learn,” said Adam Lustig, Manager of the Promoting Health and Cost Control in States initiative and one of the report authors. “This report gives state policymakers a menu of evidence-based policies that have been shown to improve individual and community health.”

“I encourage all state policymakers to read this important report. Doing so will give them access to proven solutions to the challenge of run-away healthcare spending yet so little improvement in health outcomes. To improve Americans’ health, we have to think beyond the healthcare sector and about the many factors that impact health,” said Anand Parekh, MD, MPH, Chief Medical Advisor, Bipartisan Policy Center and a member of the Promoting Health and Cost Control in States Advisory Board.

To create the report, TFAH reviewed approximately 1,500 evidence-based programs and strategies. The 13 policies ultimately included in the report all:

Have a strong health impact and economic evidence of that impact, such as cost avoidance or reduction.
Focus on prevention at the population health level, i.e., are designed to prevent illness or injury at the community level rather than the individual level.
Focus on primary prevention, preventing an injury or illness rather than treating it.
Can be implemented by state legislative action.

The findings show dramatic variability in how states approach these health-promoting policies. For instance, all 50 states plus DC institute tobacco and alcohol taxes. But only nine states and DC have laws in place to encourage universal pre-K programs, which have been shown to set children up for better health later in life. Universal pre-K programs are state funded programs that support pre-K for nearly 50 percent or more of the state’s 4-year-olds. Only six states and DC support paid family leave, even though data show such policies support maternal and child health, and, can save employers money in the long run.

“Action is imperative,” said Auerbach. “As a nation, we spend trillions of dollars a year on healthcare and yet Americans are getting less healthy. The solution is two-fold: direct more spending to prevention efforts and address the social determinants of health instead of their impact after someone is sick.”

Notes:
*states that support state-funded pre-K to nearly 50% or more of the state’s 4-year-olds.
**comprehensive smoke-free as per the American Lung Association
*** rates vary, and higher taxes are generally more effective
**** many states fund such programs in the absence of statewide legislation

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