Turning Point's underlying philosophy rests on the linkage of public health agencies and their partners across sectors of a community (Turning Point description, available at http://www.turningpointprogram.org). An important feature of partnering is to facilitate the leveraging of resources to support public health infrastructure improvements. In addition to the products of Turning Point partnerships (eg, state Public Health Improvement Plans), the process of partnering itself may be seen as a form of leveraging resources. 1 The articles in this special issue of JPHMP, as well as our own extensive interviews with more than 100 Turning Point participants during 2002-2004, offer evidence that both the process and products of Turning Point partnerships have enabled states to leverage financial resources to further their public health agendas.
Both Nebraska and Maine, for example, appear better prepared to address statewide needs due to their allocation of tobacco settlement funds for development of viable local public health systems. 2,3 Likewise, New Hampshire's successful bid to apply federal emergency preparedness/bioterrorism (EP/BT) funding to build local public health capacity 4 illustrates how the collaborative processes inherent to Turning Point may place participating states in a better position to apply for and receive federal and state funding for local public health priorities. 5
These examples of the leveraging of tobacco settlement and EP/BT funds exemplify how the process and products of Turning Point partnerships have helped states access and allocate funds for improving public health infrastructure in ways that broadly address priority public health issues. As compared to categorical funding directed toward specific health problems, such as prevention or treatment of infectious or chronic diseases, funding for public health infrastructure improvement generally fails to mobilize widespread advocacy. Moreover, the rare instances of available noncategorical funds for public health-related issues often trigger internecine battles among constituency groups. The experiences of Nebraska and Maine described in this issue are, therefore, of particular interest due to the highly politicized environment involving the state allocation of tobacco settlement funds. 6
The Use of Tobacco Settlement Funds
In 1998, the state attorneys general in 46 states, the District of Columbia, and 5 US territories agreed to settle the largest public health class action lawsuit in this country. Known as the Master Settlement Agreement (MSA), several tobacco companies operating in the United States agreed to pay states a projected $206 billion over the first 25 years to compensate for Medicaid and other health care costs associated with smoking. 7 In exchange for settlement of all legal claims against the tobacco companies, states receive annual funding from this suit in proportion to their historic spending for tobacco-related Medicaid health care costs. The remaining 4 states (Florida, Minnesota, Mississippi, and Texas) reached separate agreements with the tobacco companies for an additional $40 billion and other concessions.
Although the MSA included several other requirements for actions by the tobacco companies regarding marketing, advertising, lobbying, public education, and document disclosure, the settlement contained no specifications as to how states should allocate their settlement funds. Since receiving their first payments in 2000, states have spent settlement dollars in a variety of ways other than for tobacco control, including offsetting state budget shortfalls, tax relief, health services, supporting physical infrastructure, education and social services, supplementing rainy day/reserve funds, and providing debt service on securitized settlement funds. By one accounting, tobacco-use prevention programs across the United States received only 3% of the total share of settlement funds in 2003. 8
Many tobacco control advocates and other public health researchers and leaders have expressed disappointment over how states have employed their tobacco settlement funds. 9-11 Most argue that, in keeping with the intent of the settlement, at least a proportion of these funds should be spent on comprehensive tobacco control efforts that have proven to be effective. 6 The Centers for Disease Control and Prevention (CDC) has enumerated funding recommendations for state tobacco control programs. 12 In fiscal year (FY) 2005, only 3 states (Maine, Delaware, and Mississippi) met CDC's minimal recommendations for annual tobacco control funding, and 5 states (Michigan, Missouri, South Carolina, Tennessee, and New Hampshire) and the District of Columbia allocated no funding for tobacco control from either MSA funds or tobacco tax revenues. 13
The Use of Tobacco Settlement Funds by Turning Point States
Like other states, Turning Point states have also chosen to use their MSA funds in a variety of ways other than tobacco control. Our analysis of 2003 MSA spending allocations, employing data from the US General Accounting Office 14 suggests that a slightly higher percentage of tobacco settlement funds was allocated for tobacco control efforts across the 20 Turning Point States that participated in the MSA (5.8% of funds) than across the 26 non-Turning Point MSA states (4.6% of funds) (see Figure 1). This small difference in percentage allocation allowed for almost 20% higher per capita spending on tobacco control in Turning Point states ($2.13 per capita) than non-Turning Point states ($1.79 per capita) during FY 2003.
Despite the lack of overall difference in tobacco settlement allocations between Turning Point and non-Turning Point states, the use of tobacco settlement funds in Nebraska and Maine offer examples of how public health infrastructure improvements may provide the medium to support local tobacco control efforts. The successful allocation of MSA funds toward the improvement of local public health infrastructure has been attributed to the products and processes of Turning Point partnerships in both Maine and Nebraska.
When MSA funds became available, Maine Board of Health officials, who had been partners in the collaborative processes of the Turning Point initiative, were guided in their decision making regarding use of settlement dollars largely by the Turning Point focus on building public health capacity. 2 This emphasis on statewide capacity building led to a geographically broad dispersal of tobacco settlement funds, so that every region in Maine now has a funded Healthy Maine Partnership that addresses tobacco control, nutrition, and physical activity programming. According to participants in the process, the climate set by Turning Point helped direct the flow of tobacco settlement dollars in Maine to improve local tobacco control and other health programming. 15,16
Similarly, the Nebraska Public Health Improvement Plan (PHIP)-developed as a result of the Turning Point planning processes-emphasized infrastructure improvement as a primary priority. Wide distribution of the PHIP and other related Turning Point partnership activities are credited with helping to educate legislators regarding state public health issues and, ultimately, with their decisions to allocate a portion of Nebraska's tobacco settlement dollars toward improving local public health infrastructure. 17 Under Legislative Bill 692, about $6 million of the state's annual MSA funding is allocated toward improvement of public health infrastructure.
In addition to the efforts in Maine and Nebraska to initiate public health infrastructure changes using tobacco settlement funds, interviews with participants in the 21 funded Turning Point states indicate that at least two other Turning Point states, Louisiana and New Hampshire, are looking to MSA funds to help sustain public health infrastructure changes begun with Robert Wood Johnson Foundation funding. 16 Moreover, both Maine and Nebraska indicate that these new local public health infrastructures are well positioned to access other federal funds, such as EP/BT training or substance abuse prevention dollars. A variety of strategies are being implemented to sustain elements of the Turning Point initiative. 18 Sustaining or expanding public health infrastructure changes by leveraging MSA funds is innovative and deserves ongoing attention.
A Win for All?
The direct funding of tobacco control efforts through Healthy Maine Partnerships and other aspects of the Maine's comprehensive tobacco control program has had well-documented effects on various tobacco-related outcomes, including significant reductions in smoking rates among high school students. 11 Although the allocation of tobacco settlement funds for purposes other than tobacco control in Nebraska remains contentious, 19 it is perhaps the case that the emphasis on direct funding for tobacco control from MSA dollars underestimates the role of public health infrastructure changes in support of tobacco control efforts. Despite the precipitous drop in statewide funding for tobacco control in Nebraska, from $7 million in FY 2003 to about $405,000 in FY 2004, 19 state and local tobacco control advocates celebrated the June 28, 2004, passage of a strong, comprehensive smokefree workplace ordinance in Lincoln, the state's largest city (Ordinance available at http://www.lincoln.ne.gov/city/council/smoke.htm). It is likely that, absent the significant involvement of local advocates led by the Lincoln-Lancaster County Health Department, this ordinance would have been substantially weaker. 19
It has long been the contention of tobacco control advocates that advocacy for strong local policies is more effective than efforts at the state or federal levels. 20 And, other effective tobacco prevention and education activities typically require a strong local presence. 12 Thus, efforts by Turning Point states to build local public health capacity through use of tobacco settlement funds may have an indirect, positive effect on tobacco control by providing opportunities for public health staff to work in partnership with community constituencies and to ensure infrastructure to maintain and monitor success. In turn, the emphasis on a broader public health agenda supported by a diverse constituency may increase the likelihood that new resources for local public health priorities, including funds to prevent and treat tobacco-related diseases, may be more readily acquired.
In summary, the articles contained in this issue and our own interview findings demonstrate that Turning Point partnerships and products have helped states leverage funds from various sources to address public health priorities. 18 Furthermore, the use of tobacco settlement funding to develop local public health infrastructure may have both a direct and indirect impact on tobacco prevention and control. This approach to supporting public health infrastructure improvement deserves careful attention by the public health community.
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