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Limited Electronic Distribution Rights This PDF document was made available from www.rand.org as a public service of the RAND Corporation. 6 Jump down to document THE ARTS CHILD POLICY CIVIL JUSTICE EDUCATION ENERGY AND ENVIRONMENT HEALTH AND HEALTH CARE INTERNATIONAL AFFAIRS NATIONAL SECURITY POPULATION AND AGING PUBLIC SAFETY SCIENCE AND TECHNOLOGY SUBSTANCE ABUSE TERRORISM AND HOMELAND SECURITY TRANSPORTATION AND INFRASTRUCTURE WORKFORCE AND WORKPLACE The RAND Corporation is a nonprofit research organization providing objective analysis and effective solutions that address the challenges facing the public and private sectors around the world. Visit RAND at www.rand.org Explore RAND Health View document details For More Information Purchase this document Browse Books & Publications Make a charitable contribution Support RAND This product is part of the RAND Corporation technical report series. Reports may include research findings on a specific topic that is limited in scope; present discus- sions of the methodology employed in research; provide literature reviews, survey instruments, modeling exercises, guidelines for practitioners and research profes- sionals, and supporting documentation; or deliver preliminary findings. All RAND reports undergo rigorous peer review to ensure that they meet high standards for re- search quality and objectivity. Evaluation of the Arkansas Tobacco Settlement Program Progress During 2006 and 2007 Dana Schultz, Tamara Dubowitz, Susan Lovejoy, Shannah Tharp-Taylor, Hao Yu, John Engberg Prepared for the Arkansas Tobacco Settlement Commission HEALTH The RAND Corporation is a nonprofit research organization providing objective analysis and effective solutions that address the challenges facing the public and private sectors around the world. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. R ® is a registered trademark. © Copyright 2008 RAND Corporation All rights reserved. No part of this book may be reproduced in any form by any electronic or mechanical means (including photocopying, recording, or information storage and retrieval) without permission in writing from RAND. Published 2008 by the RAND Corporation 1776 Main Street, P.O. Box 2138, Santa Monica, CA 90407-2138 1200 South Hayes Street, Arlington, VA 22202-5050 4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213-2665 RAND URL: http://www.rand.org To order RAND documents or to obtain additional information, contact Distribution Services: Telephone: (310) 451-7002; Fax: (310) 451-6915; Email: order@rand.org The research described in this report was sponsored by the Arkansas Tobacco Settlement Commission under Contract No. 4500160544. The research was conducted in RAND Health, a division of the RAND Corporation. Library of Congress Cataloging-in-Publication Data Evaluation of the Arkansas Tobacco Settlement Program : progress during 2006 and 2007 /Dana Schultz [et al.]. p. cm. Includes bibliographical references. ISBN 978-0-8330-4626-0 (pbk. : alk. paper) 1. Smoking cessation—Government policy—Arkansas—Evaluation. 2. Tobacco industry—Health aspects—Arkansas. 3. Tobacco industry—Law and legislation—Arkansas. 4. Health promotion—Arkansas. 5. Arkansas Tobacco Settlement Commission—Evaluation. 6. Remedies (Law) I. Schultz, Dana (Dana J.) II. Arkansas Tobacco Settlement Commission. [DNLM: 1. Arkansas Tobacco Settlement Commission. 2. Smoking Cessation—methods. 3. Health Policy 4. Health Promotion—methods 5. Program Evaluation 6. Tobacco Industry—legislation & jurisprudence 7. Outcome Assessment (Health Care) 8. Tobacco Use Disorder—prevention & control 9. Smoking— prevention & control 10. Arkansas WM 290 E9192 2008] RA447.A7E932 2008 338.4'7616865061009767—dc22 2008051947 iii PREFACE The Tobacco Settlement Proceeds Act, a referendum passed by Arkansans in the November 2000 election, invests Arkansas’ share of the tobacco Master Settlement Agreement (MSA) funds in seven health-related programs. The Act also created the Arkansas Tobacco Settlement Commission (ATSC) to monitor and evaluate the performance of the funded programs. As part of its evaluation function, the ATSC contracted with the RAND Corporation in January 2003 to serve as an external evaluator. RAND is responsible for performing a comprehensive evaluation of the progress of the seven programs in fulfilling their missions, as well as the effects of the programs on smoking and other health-related outcomes. RAND submitted its first biennial report to the ATSC in July 2004, presenting evaluation results for the first biennium of the tobacco settlement program (Farley et al., 2005a). RAND submitted a subsequent interim report in June 2005 (Farley et al., 2005b) and a second biennial report in June 2006 (Farley et al., 2007). This document is the third official biennial report from the RAND evaluation. It documents continued activity and progress by the ATSC and the seven funded programs through December 2007, as well as trends in relevant health-related outcomes. First, the report summarizes the history and policy context of the tobacco settlement funding in Arkansas and discusses the ATSC’s activities and its responses to recommendations by RAND in the earlier evaluation reports. Then it evaluates the progress of each of the funded programs, including assessing progress in achieving long-range goals established by the programs in 2005 and tracking the program’s process indicators. The report also updates trends in outcome measures developed to monitor the effects of the funded programs on smoking and other health-related outcomes. Finally, it provides both program-specific and statewide recommendations for future program activities and funding. The contents of this report will be of interest to national and state policymakers, health care researchers and providers, and others concerned with the effect of the tobacco settlement funds on the health of Arkansans. This work was sponsored by the Arkansas Tobacco Settlement Commission, for which Aaron Black serves as project officer. The work was carried out within RAND Health. RAND Health is a division of the RAND Corporation. Abstracts of all RAND Health publications and full text of many research documents can be found at the RAND Health Web site at http://www.rand.org/health/. v CONTENTS PREFACE iii CONTENTS v FIGURES vii TABLES ix SUMMARY xiii ACKNOWLEDGMENTS xxvii ACRONYMS xxix Chapter 1. Introduction and Background 1 Chapter 2. The ATSC Policy Context in 2006–2007 9 Chapter 3. Tobacco Prevention and Cessation Program 17 Chapter 4. Fay W. Boozman College of Public Health 37 Chapter 5. Delta AHEC 49 Chapter 6. Arkansas Aging Initiative 63 Chapter 7. Minority Health Initiative 79 Chapter 8. Arkansas Biosciences Institute 95 Chapter 9. Medicaid Expansion Program 111 Chapter 10. Evaluation of Smoking-Related Outcomes 125 Chapter 11. Evaluation of Non–Smoking Outcomes 149 Chapter 12 Synthesis and Recommendations 167 Appendix A. Initiated Act 1 of 2000: The Tobacco Settlement Proceeds Act 177 Appendix B. RAND Evaluation of the Arkansas Tobacco Settlement Program Evaluation Methods 199 REFERENCES 209 vii FIGURES Figure 1.1 Flow of Master Settlement Funds Received by Arkansas, As Defined in the Initiated Act 4 Figure 1.2 Logic Model for Evaluation of the Arkansas Tobacco Settlement Program 7 Figure 2.1 Tobacco Prevention and Cessation Spending per Capita 10 Figure 2.2 Cigarette Taxes in Arkansas and Neighboring States 11 Figure 4.1 Enrolled COPH Students by Race/Ethnicity 40 Figure 4.2 Percentage of Spending from Tobacco Settlement Funds and Other Funds, by Fiscal Year 47 Figure 5.1 Percentage of Delta AHEC Budget from Tobacco Settlement Funds and Other Funds, by Fiscal Year 61 Figure 8.1 ABI Funding, 2004–2007 99 Figure 9.1 Percentage of Enrollees in Expanded Medicaid Pregnancy Benefits Who Used at Least One Service, CY 2006–2007 113 Figure 9.2 Percentage of Enrollees in the AR Seniors Program Who Used at Least One Service, by Month, CY 2006-2007 116 Figure 9.3 Spending by the Medicaid Expansion Programs, Sum of Tobacco Settlement Funds and Federal Matching Funds, by Program, by Fiscal Year 123 Figure 10.1 Conceptual Model of Behavioral Responses for Smoking Cessation 127 Figure 10.2 Percentage of Adults Age 18 and Over in Arkansas Who Smoke, 1996 Through 2007 130 Figure 10.3 Percentage of Adults Age 18 and Over in Arkansas Who Smoke, Adjusted for Changes in Survey Sample Demographic Characteristics 130 Figure 10.4 Percentage of Women Age 18 and Over in Arkansas Who Smoke, Adjusted for Changes in Survey Sample Demographic Characteristics 131 Figure 10.5 Percentage of Men Age 18 and Over in Arkansas Who Smoke, Adjusted for Changes in Survey Sample Demographic Characteristics 132 Figure 10.6 Percentage of Adults Age 18 and Over in Arkansas and in Neighboring States Who Smoke, Adjusted for Changes in Survey Sample Demographic Characteristics 133 Figure 10.7 Number of Packs of Cigarettes Sold per Arkansan, Age Fifteen and Older, 1998– 2007 135 Figure 10.8 Percentage of Pregnant Women in Arkansas Who Smoke, 1995 Through 2007 136 Figure 10.9 Adjusted Smoking Prevalence Rates Among Pregnant Women in Arkansas, Adjusted for Demographic Changes, 1995 Through 2007 137 Figure 10.10 Adjusted Prevalence of Smokers for Young Adults, Ages 18-25, in Arkansas, Adjusted for Demographic Changes, 1996 Through 2007 139 viii Figure 10.11 Adjusted Prevalence of Smokers for Pregnant Teens in Arkansas, Adjusted for Demographic Changes, Ages 14 Through 19, 1995 Through 2007 140 Figure 10.12 Unadjusted Prevalence of Smoking Among High School Students in Arkansas, 1995 Through 2007 140 Figure 10.13 Adjusted Prevalence of Smokers for Young Adults, Ages 18-25, in Arkansas and Neighboring States, Adjusted for Demographic Changes, 1995 Through 2006 141 Figure 10.14 Violation Rates for Selling Tobacco Products to Minors, FFY 2001 Through FFY 2008 142 Figure 10.15 Cumulative Spending per Capita for the ADH Tobacco Prevention and Education Program Community Grants, School Grants, and Sponsorship Awards, January 2001–June 2008 145 Figure 10.16 Short-Term Health Indicators, Baseline Trends and Current Deviations 147 Figure 11.1 Fraction of Elderly with at Least One Avoidable Hospitalization for Preventable and Acute Conditions, Comparison of Counties 155 Figure 11.2 Use of Adequate Prenatal Care Visits, for Counties with High and Low Percentages of People Eligible for Expanded Medicaid Benefits, 1995 Through 2007. 157 Figure 11.3 Ratio of Medicaid to Other Hospital Stays by Length of Stays for Stays of Six Days or Less 159 Figure 11.4 Ratio of Medicaid to Other Hospital Stays by Length of Stays for Stays of Nineteen Days or More 160 Figure 11.5 Percentage of Elderly with at Least One Avoidable Hospitalization for Preventable and Acute Conditions, by Counties with High and Low Poverty Rates 161 [...]... effects of the programs on smoking and other outcomes Finally, Chapter 12 synthesizes the evaluation findings and offers recommendations for program improvement and future spending of the tobacco settlement funds THE MASTER SETTLEMENT AGREEMENT The MSA settled all legal matters alleged by the participating states against the participating tobacco companies, placed conditions on the actions of the tobacco. .. the Arkansas Tobacco Settlement Commission (ATSC) and gave it the responsibility for monitoring and evaluating the performance of the funded programs As part of its evaluation function, the ATSC contracted with the RAND Corporation to serve as the external evaluator RAND was charged with performing a comprehensive evaluation of the progress of the programs in fulfilling their missions, as well as the. .. in program direction and the overall maturation of the program over time Many of the programs have increased their technical capacity to the point where they can now fully track the effects of the programs and determine quality deficiencies and what to do about them With more advanced data collection and analysis capabilities, the programs are better positioned to take the next step with their evaluation. .. states over the next 25 years Arkansas is unique in the commitment made by both elected officials and the general public to invest its share of the tobacco settlement funds in health-related programs The Arkansas Tobacco Settlement Proceeds Act of 2000 (referred to hereafter as the Initiated Act), a referendum passed by the voters in the November 2000 election, specifies that the Arkansas tobacco funds... background information about the MSA, the basic orientation and content of the Initiated Act, and the methods used in the RAND evaluation Chapter 2 addresses the policy context within which the tobacco settlement program operates, including activities and progress of the ATSC Chapters 3 through 9 present evaluation results related to the activities and progress of each of the seven funded programs Chapters 10... and to oversee the distribution of the funds as specified in the Act The fund structure and distribution of funding shares by program are displayed graphically in Figure 1.1 The MSA disbursements are deposited into the Tobacco Settlement Cash Holding Fund, from which funds are to be distributed to other funds The other funds consist of the Tobacco Settlement Debt 3 Service Fund, the Arkansas Healthy... in Arkansas All of the programs have now achieved their initiation and short-term goals as specified by the Initiated Act For the long term, all but one of the programs had accomplished or were on schedule to accomplish the programmatic goals developed to measure progress toward long-term outcomes Our analysis of smoking behavior in Arkansas provides evidence of the continued effectiveness of the tobacco. .. in the Initiated Act to dedicate the tobacco settlement funds to support healthrelated programming To do justice to the health-related services, education, and research these programs are now delivering, they must be given the continued support and time they need to fulfill their mission of helping Arkansas to significantly improve the health of its residents In addition, the programs must take the. .. achieved them In 2005, the ATSC formally approved the programs’ long-term goals, and it has continued to monitor their progress toward those goals RAND has worked with each of the programs to establish two means of assessing progress toward these longer-term goals First, each program has a set of specific programmatic goals that define the programs’ vision for their future scope of activities The programmatic... enrollees and providers about the availability of the Medicaid Expansion Programs ƒ Allocate funds to educate newly enrolled and current enrollees in the Pregnant Women’s Expansion program and the AR-Seniors program regarding the services they are eligible to receive under their respective programs ƒ Develop partnerships with some of the other tobacco settlement programs or other state or local organizations . 12 Synthesis and Recommendations 167 Appendix A. Initiated Act 1 of 2000: The Tobacco Settlement Proceeds Act 177 Appendix B. RAND Evaluation of the Arkansas Tobacco Settlement Program Evaluation. researchers and providers, and others concerned with the effect of the tobacco settlement funds on the health of Arkansans. This work was sponsored by the Arkansas Tobacco Settlement Commission, for. performing a comprehensive evaluation of the progress of the seven programs in fulfilling their missions, as well as the effects of the programs on smoking and other health-related outcomes.