ACS CAN New Jersey Assembly Budget Testimony

Date:        September 10, 2020

To:           Members, Assembly Budget Committee

From:       Michael Davoli, New York City and New Jersey Government Relations Director                    

Re: American Cancer Society Cancer Action Network Testimony Regarding the Fiscal Year 2021 Budget

The American Cancer Society Cancer Action Network (ACS CAN) is the nonprofit, nonpartisan advocacy affiliate of the American Cancer Society. Our mission is to support evidence-based policy and legislative solutions designed to eliminate cancer as a major health problem. With that objective in mind, we appreciate the opportunity to comment on Governor Murphy’s proposed budget as viewed “through the cancer lens”

As we all know, the Covid-19 pandemic has upended lives and the economy. But as this virus grips the nation, cancer is ever-present; 1 in 2 men and 1 in 3 women in the United States will be diagnosed with cancer in their lifetime. Cancer patients have long faced significant barriers to accessing care. Covid-19 has magnified these barriers, with 46% of cancer patients and survivors reporting a change in their ability to pay for care due to the pandemic, and 79% experiencing delays in active treatment. The pandemic has also shone a spotlight on health disparities across populations. Individuals from racial and ethnic minority groups are more likely to be uninsured, increasing the likelihood they will be diagnosed with advanced cancer. The 5-year relative survival rate is lower in Blacks than in Whites for every stage of diagnosis in the four most common cancer sites.

The American Cancer Society estimates that 53,340 new cases of cancer will be diagnosed in New Jersey and 15,710 cancer deaths will occur in the state in 2020, making it the second leading cause of death in the state. Below is a listing of the most prevalent cancers and their impact.

Cancer Burden in New Jersey

While policymakers are addressing acute needs related to COVID-19, cancer patients need changes that promote innovation, expand access, and drive towards health equity to relieve suffering during the pandemic and beyond. Eliminating cancer relies as much on public policy as it does on scientific discovery and innovation. To reinforce New Jersey’s commitment to the fight against cancer ACS CAN recommends the following be included in the 2020-2021 state budget.

• Budget Recommendation #1: Protecting all New Jerseyans from the predatory tactics of Big Tobacco and a lifetime of addiction by supporting the proposed $1.65 per pack cigarette tax increase, ending the sales of all flavored tobacco products and dedicating additional funding to New Jersey's tobacco control program.

The number one cancer killer is lung cancer. Smoking is responsible for 26.7% of cancer deaths in New Jersey,[2] while almost 12,000 people die each year from smoking- related diseases of all types, and 143,000 kids under 18 who are alive today will ultimately die from tobacco use if we do not act more urgently to intervene.[3] The 2014 U.S. Surgeon General report, The Health Consequences of Smoking – 50 Years of Progress, identified twelve cancers for which the “evidence was sufficient to infer a causal relationship” between smoking and the incidence of the disease.[4] The Surgeon General found that smoking caused a significant percent of cancers occurring in the lung, larynx, oral cavity and pharynx, esophagus, pancreas, bladder, kidney, uterine cervix, stomach, and acute myeloid leukemia. To reduce the overall number of cancer deaths and deaths from lung cancer in particular, New Jersey must act now to adopt stronger policies to reduce tobacco use.

Increasing the Cigarette Tax

Governor Murphy has included a $1.65 per pack cigarette tax increase in his fiscal year 2021 proposed budget. It has been 11 years since New Jersey has increased its cigarette tax and this proposal, if passed, will put us on par with states like New York and Connecticut. We estimate the proposed tax increase will reduce youth smoking by 17.2% and help 46,300 people who currently smoke to quit. Low-income adults, youth, and pregnant women are especially likely to quit or reduce their smoking with such a tax increase.

About two-thirds of smokers who quit reported that the increase in price helped them quit or not to start again. Lower smoking rates translate into fewer smoking-related cancers and premature deaths, reduced spending on smoking-related health problems, and more productive workers.

It’s estimated that if New Jersey raises its cigarette tax to $4.35 per pack that 23,700 youth under 18 will be kept from becoming adults who smoke, 18,700 premature smoking-related deaths will be prevented and over $100 million in new annual revenue will be generated while saving the state $1.44 billion in long-term health care costs from the declines in adult and youth smoking rates.

Those are lives worth fighting for. We ask the legislature to protect all New Jerseyans from the predatory tactics of Big Tobacco and a lifetime of addiction by supporting this proposed increase, ending the sales of all flavored tobacco products and dedicating additional funding to New Jersey's tobacco control program. Dedicating additional funds of the cigarette tax revenue to tobacco prevention and cessation programs will help amplify the benefits of the tax increase and further reduce suffering and death from tobacco-related disease.

Closing Tobacco Related Health Disparity Loopholes

The legislature has the opportunity to make clear their commitment to protecting New Jerseyans from falling prey to Big Tobacco by addressing flavored tobacco products left on the market. Nearly 6,100 New Jerseyans will be diagnosed with lung cancer in 2020.  Over 900,000 adults in New Jersey smoke and 2,500 kids become new daily smokers each year. By ending the sale of all flavored tobacco products, including menthol cigarettes, flavored cigars, hookah and smokeless tobacco. New Jersey will become a leader that other states look to when addressing tobacco issues.

Massachusetts recently passed legislation that restricts the sale of all flavors of all tobacco products, including menthol cigarettes, e-cigarettes, flavored cigars, hookah, and smokeless tobacco. Late last month California passed legislation that banned the sale of menthol cigarettes statewide. New Jerseyans deserve the same protection from an industry that shamelessly preys on high-risk groups including communities of color; those who identify as LGBTQ; people with lower income and education levels; and those in the disability community.

To be effective, comprehensive legislation that restricts the sale of all flavored tobacco products, including menthol cigarettes and flavored cigars must be enacted in New Jersey.

Investing in Tobacco Prevention and Cessation Programs

According to established standards and best practices for state tobacco control efforts,[5] New Jersey has never adequately financed its tobacco prevention and cessation program. In past years, state support for the program had been cut entirely. While the program was funded with approximately $7 million appropriation of revenue from the state’s tobacco tax revenue in fiscal year 2019, there is still work to be done. The approximately $7 million appropriation was a major step in the right direction, however the program will continue to operate at a greatly reduced impact until it is fully funded. As a direct result, New Jersey ranks near the bottom of the nation in funding tobacco control programs.[6]

Budget cuts in the last decade to New Jersey’s tobacco program have been amongst the deepest in the nation. The program’s state funding was completely eliminated in 2012, and the fiscal year 2018 budget saw a $500,000 restoration. In 2018, legislation was signed into law to dedicate one percent of the state’s cigarette and tobacco tax revenues to the implementation of a comprehensive tobacco control program. The amount appropriated from that law was approximately $7 million.

New Jersey’s inadequate funding of tobacco prevention and prevention and cessation programs is of particular concern because it pales in comparison to the huge amounts tobacco companies spend each year to market their deadly and addictive products, and the numbers are alarming. Tobacco companies spend an estimated $175.5 million a year advertising their deadly products in New Jersey.[7] New Jersey is no different than other states in the sense that ample revenue streams are already in place to provide life-saving tobacco control funding. In fact, New Jersey received approximately $700 million last year in tobacco tax revenue alone, but only a small fraction of that amount was specifically dedicated to comprehensive statewide programs that prevent and reduce future tobacco usage. This failure by the state to adequately fund tobacco prevention and cessation programs contributes to preventable chronic disease, suffering and death in New Jersey, and furthermore undermines the nation’s efforts to reduce tobacco use – still the leading cause of preventable death in the nation. Tobacco use furthermore takes a terrible toll on New Jersey’s finances, costing the state an estimated $4.06 billion in health care bills annually, including $1.17 billion in Medicaid payments alone.[8]

ACS CAN calls on the legislature to increase funding to tobacco control programs to $15 million annually as a first step towards fully funding the program at CDC’s recommended $103.3 million annually

The decline of smoking has not occurred among low-income populations

A lack of funding prevents the Tobacco Use Prevention and Cessation Program from reaching the most vulnerable populations with the highest rates of smoking. Educational attainment and income are factors associated with disparities in smoking prevalence. Those with less than a high school education now smoke at a rate more than five times that of an individual that has attained an undergraduate degree.

Adult Prevalence of Smoking by Education, 2017[9]

Adult Prevalence of Smoking by Income, 2017[10]

According to the latest Census, nearly 10% of New Jersey households have incomes below $15,000. Individuals with lower socioeconomic status and lower educational attainment live throughout the state. In urban, rural and suburban areas of New Jersey, individuals with lower socioeconomic status struggle not only with extremely tight finances, but with the financial and health consequences of this powerful addiction as well. Tobacco use and all its consequences disproportionately large share of their household income on tobacco-related products. Yet they receive little help from the state when they want to quit smoking.

Ranges Exist Between Counties

The northern New Jersey region has significantly lower rates of overall cancer incidence and mortality, a difference that is partially due to lower rater of lung cancer incidence and mortality. Men living in the counties of Atlantic, Camden, Cape May, Cumberland, Gloucester and Ocean have lung cancer incidence and mortality rates that exceed the state average. By contrast, men living in the counties of Bergen, Hunterdon, Middlesex, Morris, Somerset and Union have rates of lung cancer incidence and mortality that are lower than the state average.[11] Women residing in Atlantic, Camden, Cape May, Gloucester, Monmouth and Ocean had lung cancer incidence and mortality rates that exceed the state average. Women living in the countries of Bergen, Essex, Hudson, Hunterdon, Mercer, Middlesex, Morris, Passaic, Somerset and Union had lung cancer incidence and mortality rates that are below the state average.[12]

Because we know that 80% or more of lung cancer deaths are caused by smoking, it is not surprising to find that the smoking rate in the northern New Jersey region has been lower than in the southern region of the state for some time.[13] Given the overwhelming scientific connection between lung cancer and smoking rates, we examined smoking rates by county. As you can see below, the counties’ smoking rates tend to reflect the differences in both lung cancer incidence and mortality rates. Clearly, tobacco control measures must focus on these counties with the above average smoking rates. As seen below, those counties are more likely to be found in the southern half of the state.

Percentage of Adults Who Reported Current Cigarette Smoking by County of Residence, Adults Aged 18 and Older, 2016[14]

Tobacco Use and Covid-19

While there’s no direct evidence yet showing that a history of smoking makes a person more likely to get Covid-19, there is evidence that smoking increases the risk of other types of viral lung infections. This increase in risk stems from changes in a person’s immune system, as well as damage to the cells lining the airways in the lungs. According to the World Health Organization, being a current or former cigarette smoker may increase your risk of severe illness from Covid-19.[15] Smoking impairs lung function, making it harder for the body to fight off coronaviruses and other respiratory diseases.[16] Furthermore, available research suggests that smokers are at higher risk of developing severe Covid-19 outcomes and death.

Investing in Tobacco Prevention and Cessation Programs Saves Money and Lives

A well-funded tobacco control program will not only produce long-term savings but can have an immediate benefit. While we commend the fiscal year 2020 allocation of approximately $7 million in funding for comprehensive state tobacco control, ACS CAN believes that if we do not take steps to provide additional state funds for tobacco prevention and control in the future, there will continue to be a detrimental impact on the prevention of cancer and will ultimately result in more people dying prematurely from tobacco-related illnesses including cancer.

For every dollar spent on tobacco prevention, states can reduce tobacco-related health care expenditures and hospitalizations. California saw a $55 to $1 return on investment between 1989 and 2008[17]. Tobacco control programs in Massachusetts and elsewhere have been proven to reduce youth smoking and help people who currently use tobacco to quit.

Florida has provided robust and sustained funding for its program for over a decade. In 2007, Florida launched the Tobacco-Free Florida program, which was based on CDC best practices. The program uses community-based efforts, hard-hitting media campaigns and help for tobacco users who are trying to quit. Florida voters approved a constitutional amendment in 2006 requiring the state to spend 15% of its tobacco settlement funds on tobacco prevention. In 2017, Florida spent $67.8 million on tobacco prevention and cessation programs. In 2015, Florida reported that its high school smoking rate fell to 6.9%, a 75% decline since 1998.[18] In 2019, Florida reported that its high school smoking rate fell even further to 2.1%.

A study in the American Journal of Public Health found that for every dollar spent by Washington State’s tobacco prevention and control program between 2000 and 2009, more than five dollars were saved by reducing hospitalizations for heart disease, stroke, respiratory disease and cancer caused by tobacco use[19]. Over the 10-year period, the program prevented nearly 36,000 hospitalizations, saving $1.5 billion compared to $260 million spent on the program. The 5-to-1 return on investment is conservative because the cost savings only reflect the savings from prevented hospitalizations. The researchers indicate that the total savings could be more than double if factors like physician visits, pharmaceutical costs and rehabilitation costs were included.

• Tobacco Control Recommendation #1: Increase in the state’s cigarette tax by $1.65 per pack to raise the rate to $4.35 per pack, matching the rates in New York and Connecticut, as well as the pursuit of tax parity between other tobacco products, including e-cigarettes. Evidence shows that increases in cigarette taxes must be significant to have a public health impact, creating a deterrent to using the products, and the generation of additional revenue from these products should be used to bring the state funding for the tobacco control program into closer alignment with the CDC recommended amount, beyond the 1% dedication.
• Tobacco Control Recommendation #2: End the sale of all flavored tobacco. Flavored tobacco products are used by the tobacco industry to lure kids into a lifetime of addiction. 143,000 kids who are alive now in New Jersey will die prematurely as a result of smoking. More than 80% of kids who use tobacco start with a flavored product. In this country, 54% of teens who smoke use menthol cigarettes. For African-American teens who smoke, that figure rises to 70%.  Big Tobacco has shamelessly targeted communities of color, the LGBT community and low socioeconomic neighborhoods with predatory marketing of menthol products for decades. Now is the time to protect all kids from a lifetime of addiction by enacting comprehensive legislation to end the sale of all flavored tobacco products, including but not limited to menthol cigarettes, flavored cigars, hookah, and smokeless tobacco.
• Tobacco Control Recommendation #3: At a minimum, maintain the proposed $7.2 million funding of revenue from tobacco sales for tobacco control and prevention initiatives, in accordance with the 2017 legislation that was passed that dedicates 1% of the revenue for this purpose. The recent Surgeon General’s report[20] found that while significant progress has been made in reducing smoking over the last several decades, there is still much more work to be done in reducing death and disease from tobacco use. New Jersey must continue to at the very least, fulfill its promise to use 1% of tobacco revenues for programs to help tobacco users quit and to keep children from starting. The Centers for Disease Control and Prevention’s (CDC) updated Best Practices document[21] provides a blueprint for state tobacco control programs based on the latest evidence. According to the CDC’s report, new research has identified strategies for states to have more impact with less cost – making it more important than ever to meet the recommended funding levels. We feel strongly that the state should, at a minimum, continue to dedicate at least 1% of its cigarette tax revenue to tobacco prevention and cessation programs for FY 2021.
• Tobacco Control Recommendation #4: Increase funding to tobacco control programs to $15 million annually as a first step towards fully funding the program at CDC’s recommended $103.3 million annually. The additional funding should be used for the following:
• Target more resources to adult cessation. Achieving near-term reductions in tobacco use rates, and the incidence of tobacco-caused disease, will best be accomplished by encouraging adults who use tobacco to quit and providing resources to help them succeed. Only by motivating people who use tobacco to attempt to quit and providing the encouragement, resources, and support to make those attempts successful will near-term smoking rates decline, disease rates decline, premature death rates decline, and economic saving accrue. Most people who use tobacco want to quit and encouraging and assisting adult cessation is a cost-effective tobacco control strategy.

• Continue to grow community-level interventions, especially in disadvantaged urban neighborhoods and rural areas. To change social norms, a program must be well integrated into the community. Program personnel must understand, and preferably, live within the communities in which they work. Maintaining and further increasing the level of community engagement and activity that supports efforts to reduce tobacco use is critical.
• Increase funding for anti-smoking media messages. As quickly as possible, the New Jersey tobacco control program should continue the work that has been done and further increase its media budget and target messages to those hard-to-reach populations who are targeted by tobacco industry advertising, such as the poor and non-English speakers, that the program has difficulty reaching.
• Further develop and implement strategies for reaching those with mental health conditions or addiction disorders. The smoking rate among people with a history of mental health conditions and addiction in New Jersey is an astounding 35.6%.[22] Increasingly tobacco use is concentrated in this population, and if the problem is not addressed now, the burden of tobacco use will increasingly fall on those battling other serious conditions and mental health threats.

Budget Recommendation #2: Find cures and new therapies by maintaining the $2 million in funding for the NJ State Commission on Cancer Research (NJCCR).

Since 1983, NJCCR has funded promising cancer research in New Jersey. NJCCR promotes significant and original research in New Jersey into causes, prevention, treatment and palliation of cancer and serves as a resource to providers and consumers of cancer services. Throughout its 30-year history, the NJCCR has awarded over $40 million to over 800 peer reviewed cancer research grants and student fellowships. NJCCR is the only statewide institution that provides peer reviewed scientific cancer research grants to all eligible institutions in New Jersey, and this merit-based system has a strong track record of funding the best new scientists who engage in ground-breaking basic research. Last year’s final adopted budget included a $2 million appropriation for this program. The Governor’s proposed FY 2021 budget maintains this appropriation at the same level.

The merits of cancer research are undeniable, and the benefits are vast. An independent study of NJCCR grant recipients show that these researchers leverage $10 in federal funding for each $1 of NJCCR funding. All eligible institutions in New Jersey can apply for cancer research funding grants. In the past, grants have been awarded to researchers at Rutgers Cancer Institute of NJ, Rutgers School of Biomedical and Health Sciences, Rutgers School of Dental Medicine, Princeton, Rider, and Rowan Universities.

With the $2 million in funding, the Commission will be able to fund 16 cancer research fellowships to scientists conducting basic cancer research in New Jersey this year. Additionally, the Commission will be able to award five bridge grants, providing funding to promising and productive New Jersey investigators who faced short term interruption in funding for research projects focused on cancer prevention, diagnosis, treatment and survivorship.

Researchers funded by an NJCCR grant have discovered life-saving scientific breakthroughs, including the recent discovery by Princeton and Cancer Institute of NJ researchers of the gene, Metadherin, a gene critical to breast cancer metastasis.

New Jersey’s cancer research enterprise extends beyond the laboratory and campus: NJCCR research and funding augments NJ’s reputation as the world’s medicine chest. The state has one of the highest concentrations of pharmaceutical and biotechnology firms in the nation: a $25 billion industry. The ability of the pharmaceutical industry to tap NJ’s cancer research talent and scientific breakthroughs bolsters their strength and in turn the NJ economy.

Recommendation: Maintain the program’s base appropriation of $2 million and add to it the revenues generated by the current taxpayer filer and license fee programs.

Budget Recommendation #3: Identifying cancers early, maintain the Governor’s proposal to fund the New Jersey Cancer Education and Early Detection Screening Program (NJCEED).

NJ CEED offers a critically important service to men and women who lack health insurance – free cancer screening for breast, cervical, colorectal and prostate cancer. Detected early, these cancers are more easily treated. Failing to have these cancers detected early can lead to deadly consequences.

Program services are provided through 21 contracted lead agencies; each county in NJ has at least one lead agency[23]. Cancer screening saves lives. Detecting cancer early increases the chances of successful treatment, improves survival rates, and saves New Jersey overall on medical costs. For example, research shows that the earlier breast cancer is treated and detected, the better the survival rate. When breast cancer is diagnosed at an early stage while still confined to the breast, the 5-year survival rate is 99%.

Published research on the success of the National Breast and Cervical Cancer Early Detection Program, which partially funds and guides the state screening program, demonstrates a substantial impact on reducing mortality from breast cancer in medically uninsured, low income women. These evidence-based findings justify the state’s investment in NJCEED and the early detection of cancer.

NJCEED has never been more important to the health of New Jerseyans. Since the Covid-19 pandemic began, over 120,000 New Jerseyans have lost their employer-based health insurance. NJCEED is critical to ensuring that these New Jerseyans get the screening that they need.

Recommendation: Total combined state and federal support for this important program is currently approximately $12 million. New Jersey should maintain the current level of funding for the NJCEED program so the lead agencies can adequately serve their existing patients and outreach to the eligible population to the extent possible. We recommend that state funding for this program be maintained at $3.5 million.

Conclusion

ACS CAN’s mission is to support evidence-based policy and legislative solutions designed to eliminate cancer as a major health problem. With that objective in mind, we appreciate the Legislature’s commitment to the fight against cancer. With your support of the above-mentioned budget priorities in 2020-2021 you can reduce New Jersey’s cancer rate; help identify cancers at their earliest- and often most treatable- stage and ensure that cancer patients are adequately supported from the public policy standpoint as they battle this devastating disease.

While COVID-19 may have stopped many things in our lives, cancer hasn’t stopped. So, neither have we. We look forward to standing by your side in the fight against cancer.