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| DR GREG DWORKIN |
BY GREG DWORKIN { MEDICAL GRADUATE }
It's hard in public health not to have critics if you actually try and do something, and in that sense, public health is no different than politics (except public health folks do it without a constituency.) Nonetheless, I am hopeful that this cursory visit to policy-land helps to put into focus that
- HHS and CDC policy is to decrease cigarette smoking
- One of the tools to do this is tobacco taxes and
- a lot of powerful constituencies (including, but not limited to, tobacco states, tobacco companies, libertarians and many smokers) don't like that.
When SCHIP (Children's Health Insurance Program) was passed with tobacco
Objective: increase the combined cigarette excise tax to at least $2 per pack.
Objective: increase the combined cigarette excise tax to at least $2 per pack.
Tax funding, we had some vociferous rguments about the merits and demerits of regressive Taxes to fund public health.
A new Morbidity and Mortality Weekly Report (MMWR) from CDC has a nice round-up of some data and points out that to the Federal Government, it is a set goal to increase cigarette taxes . If it's policy, let's get it out on the table and look at it.
Some definitions and baseline stuff, before we get into it. By "Combined cigatette excise Tax", we mean "combined federal and average state cigarette excise tax", which varies from state to state. In fact, if you are tobacco producing state, chances are your taxes are lower.
As of April 1, 2009, 28 states in all had achieved the HP2010 objective of $2.00 per pack when the state cigarette excise tax was combined with the federal excise tax.
So what's this HP2010 stuff? That's something called Healthy People 2010, a program from the Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services (HHS). More:
Healthy People 2010, a broad-based collaborative effort among Federal, State, and Territorial governments, as well as hundreds of private, public, and nonprofit organizations, has set national disease prevention and health promotion objectives to be achieved by the end of this decade (www.healthypeople.gov). The effort has two overarching goals: to increase the quality and years of healthy life and to eliminate health disparities. Healthy People 2010 features 467 science-based objectives and 10 Leading Health Indicators, which use a smaller set of objectives to track progress toward meeting Healthy People 2010 goals.
One of those 10 leading health indicators is tobacco use. And guess what? It is federal health policy to try and reduce tobacco smoking. Why? Because smoking is not good for you : Smoking is injurious to health for you !?
Cigarette smoking and exposure to secondhand smoke result in approximately 443,000 premature deaths, 5.1 million of potential life lost, and $97 billion in productivity losses in the United States each year (3). Comprehensive tobacco control program and policy recommendations have been provided to the public health community with the goal of reducing tobacco use and secondhand smoke exposure so that
they are no longer a significant public health problem in the United States (4,5).
How to do this?
CDC and the Institute of Medicine (IOM) recommend that comprehensive tobacco control programs be implemented fully in every state and territory to accelerate the reduction in smoking prevalence among all U.S. citizens and decrease the public health burden of smoking-related disease (4,5). Although tax increases are an evidence-based policy intervention that will reduce smoking prevalence independently, excise tax increases are more effective and have greater public health impact when combined with other evidence-based components of comprehensive tobacco control programs (5).
Hence, tobacco taxes are not only on the table, they are deliberately on the table, at least if you're not a Southern state. Do note that they are not meant to do the job in a vacuum, hence the "other evidence-based components of comprehensive tobacco control programs".1
But, wait a minute. Doesn't that proportionally hit the lower income demographics? After all, they also smoke more.
So, cigarette taxes are meant to have an "elastic" response. Raise them here and see the effect go down there. If there were no such response, it'd be thought of as "inelastic" (economists have a more formal definition, which I am not adhering to.) But does it work?
A 10% increase in the real price of cigarettes is estimated to reduce consumption by nearly 4% (6). The Task Force on Community Preventive Services recommends price increases through excise taxes as an effective policy intervention to prevent smoking initiation by adolescents and young adults, reduce cigarette consumption, and increase the number of smokers who quit (6). The 2000 report of the U.S. Surgeon General, Reducing Tobacco Use, concluded that raising tobacco excise taxes is one of the most effective tobacco prevention and control strategies (2). Specifically, it found that increasing the price of tobacco products would decrease the prevalence of tobacco use, particularly among youths and young adults, and that tobacco excise tax increases would lead to substantial long-term improvements in health (2). Tax revenues also might support the prevention and treatment components of comprehensive state tobacco control programs (2).
Commissioner Calls Smoking Public Health Enemy No. 1 and Asks Drug Firms for Ammunition
"When I first talked to the mayor's office about this job, I said smoking would be my No. 1 concern," said Dr. Frieden, who spent the last five years working in India to control tuberculosis with the World Health Organization. "And if he didn't care about that, I wasn't interested."
Now, both the new CDC Director and Mike Bloomberg's agressive anti-smoking policy are not without critics. Here's a recent blog by (occasional pen pal) Philip Alcabes on the topic:
Still, it’s hard to applaud Frieden for his work during his tenure as commissioner here in NY. Perhaps he couldn’t stand in the way of the moral juggernaut driven by mayor Mike Bloomberg. Or maybe Frieden’s medical focus makes him share some of Bloomberg’s fervid disdain for the nasty bits of urban life — the smoking, the quick noshes, the hook-ups — even if not the bluenose moralism. What can’t be denied is that Dr. Frieden and Mayor Bloomberg together promoted the myth that bad health is purely a matter of bad behavior.
The myth was an alarming break with the reality of the real causes of poor health, but it played well. There was the ban on smoking in bars, the ban on serving trans fats, the constant hectoring about what we eat and how much of it, and the finger wagging about AIDS "complacency"and our failure to use condoms. There were the restaurant closings on account of violating the health code (that was after the City’s health department had been embarrassed by media reports of rats in a number of food establishments). Those were aspects of the stagecraft that has characterized the Bloomberg reign in NYC, but none of them had much impact on the city’s health.
The myth was an alarming break with the reality of the real causes of poor health, but it played well. There was the ban on smoking in bars, the ban on serving trans fats, the constant hectoring about what we eat and how much of it, and the finger wagging about AIDS "complacency"and our failure to use condoms. There were the restaurant closings on account of violating the health code (that was after the City’s health department had been embarrassed by media reports of rats in a number of food establishments). Those were aspects of the stagecraft that has characterized the Bloomberg reign in NYC, but none of them had much impact on the city’s health.
Well, being overweight isn't good for you, either. Oddly enough, it's a risk factor for hospitalization for swine flu (but that's another story for another day.) What Alcabes was getting at is the interplay between cheaper education, more affordable housing and other community aspects of public health (having a job would better your health in a variety of ways, including being able to afford food.) And whether that's public health or really social policy, it all matters. It especially matters because (Alcabes, correspondence) some smoking behavior is self-medication. Addiction and self-medication are not easily dealt with sans social and medical services to replace that which is removed.
So, while we have merely scratched the surface, and whereas there's plenty to argue about here, keep in mind that Healthy People 2010 priorities are driving policy. That's something you need to know. Oh, and by the way, one of the policy goals is access to health care. Wouldn't that be nice to achieve as well?
So, while we have merely scratched the surface, and whereas there's plenty to argue about here, keep in mind that Healthy People 2010 priorities are driving policy. That's something you need to know. Oh, and by the way, one of the policy goals is access to health care. Wouldn't that be nice to achieve as well?
Note from MMWR: The federal tax of $50.33 for cigarettes is levied per 1,000 cigarettes. When calculated per pack of 20 cigarettes, this is $1.0066 per pack. For this study, this fractional tax is referred to as $1.01 per pack.
Among other things, some examples of "other evidence-based components of comprehensive tobacco control programs" are outlined below:
Senator Dodd Statement on the Mark-Up of the Family Smoking Prevention and Tobacco Control Act.
{ It will give FDA the authority to prevent the sale and marketing of tobacco to children, to require changes to cigarettes to make them less harmful and protect the public health, and to prevent tobacco companies from using misleading marketing practices to encourage tobacco use. }
