Agraphia Medical Tragicomedy


A Tax For Cigarettes

I saw a cardiac patient today; 3 stents, COPD, peripheral vascular disease... the whole 9 yards. While asking him my standard social history questions (smoke, drink, do any street drugs?) he hung his head low.

"Yeah, my doc tells me I gotta quit, but I can't get down to less than a pack a day."

It's something I hear all the time. I've talked to smokers who are crack and heroin addicts - they say that the nicotine urge is worse than any other addiction they've fought.

For better or for worse, patients seem to focus on the lung cancer aspect of smoking. I suspect it's due to a particularly effective ad campaign in the past few decades, but the truth is, smoking is far worse with regards to other diseases. Tobacco, whether chewed, smoked, or snu'ed causes a huge variety of vascular diseases.

I figure it should be easy enough to calculate the cost of a pack of cigarettes. Ask a random sampling of ER patients how much they smoke per day (we measure tobacco use in pack-years, i.e. the number of packs per day they've smoked times the number of years). Get permission to access their healthcare records, and calculate the differential in healthcare costs between smokers and non-smokers.

Take that differential, divide it by pack, and add it as a healthcare tax.  I support people's right to make bad choices; I also support their right to pay for those choices.

Your thoughts?

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  1. They’ve done this analysis. Smokers (because they die younger and pay butt loads of taxes on their cigarettes) currently more than pay for themselves. Actually, it would be “bad” for the solvency of the healthcare system if they quit because they would live longer and not subsidize other patients.

    I agree that smoking is repulsive and we should do anything we can (within reason) to get people to quit, however they are not to blame for the skyrocketing costs to the healthcare system.

  2. Speak of the devil! I knew you were one of the people who fell off my blogroll.

    Honestly, I’ve never looked it up. Have we already figured this out? Do packs of cigarettes already contribute to the system equivalent to the disease they put in?

  3. Yeah, they actually contribute more to the system than the disease they put in. We should really be trying to get people to smoke if it’s all about saving $$ / paying for healthcare. Trying to find you a citation, but there are so many and I have too much work to do.

  4. Not sure that pack-price ultimately acts as a disincentive or does more than raise revenue for the govt. Australia recently legislated to introduce plain-packaging – all packs will be required to bear graphic photos of gangrenous feet or mouth cancer and nothing else. Will be interesting to see if this works. A good friend of mine blogged about this on the Lancet Student website:

  5. I’ve been a lurker for awhile, but this topic is really one that gets me. As a nursing student, I’ve been taught a lot, but the two main themes are being fat and smoking will kill you. It’s amazing to see people kill them selves, willingly. I agree, a better solution has to be in place to not only deter people from smoking, but for paying for their health care. Lord knows how many of them are going to pay my salary.

  6. Had a remarkably similar conversation about this yesterday. In Ireland they tried to do something along what you are saying, increase the price of cigarettes until they were too expensive for people to buy, and then they would quit. But all it did was create a black market for cigarettes. As a government, we can’t MAKE people not do something if they want to do it. They tried that with alcohol back in the 30’s and look what happened.

    IMO, if this is going to work, they need to make things OTHER than cigarettes expensive. Like renewing your drivers license (random example). You would need to take a nicotine (and other drug test) to get your license each year. Positive tests cost $100 more to get a license each year.

  7. ER Jedi — The problem with that is that people would just stop getting their licenses renewed and drive uninsured. They would be unable to get car insurance, thus raising premiums for non-smokers. Everything has a cost….

  8. Honestly, even if my pt’s who get past the pack a day mark, many stop at around four cigarettes per day. Something about the halflife of nicotene.

    OMDG: frankly, I’m not convinced by the whole “smokers cost less than healthy old people” argument. That’s only true until pharma figures out how to market really expensive COPD drugs (see: roflumilast) and turns big profits by incrementally prolonging the lives of smokers. Also, screening CT is well on its way to becoming standard of care for smokers. In the long run, there’s just no way that maintaining the prevalence of severe, chronic illness is cheaper than primary prevention (although I agree secondary/tertiary prevention may be a whole different ballgame).

  9. @OMDG I’ve read similar studies (one from the NIH in the UK comes to mind) that concluded smoking had an ultimately positive impact on health care cost. The reasoning was that people paid into the system and withdrew large amounts in health care dollars, but for a shorter amount of time. It sounded morbid at first, but it’s not something that I find all that surprising. I’ve also seen similar arguments made that preventative medicine, while a lofty goal, would actually exacerbate the problem. Interesting thoughts.

  10. MSO — I’ve made this argument myself before about preventive care. It’s not that I don’t think we should be promoting it, but people think it’s going to be this huge panacea for the spiraling costs of healthcare. I just don’t think that’s going to happen. Furthermore, depending things like access to care, etc. it could end up that the people who take advantage of gov’t subsidized preventive care are the people who are already getting it and paying for it, resulting in a net cost for the gov’t. Nobody knows if this will happen, but given how hard it can be to get in to see a doctor and the high levels of mistrust of the medical system among people who currently don’t see doctors, don’t think the scenario is completely implausible.

  11. I teach high school (US) and teach about the effects of tobacco on the body, not only the cancer, but that just about every other disease is magnified if you smoke-cardiovascular, respiratory (not just cancer), etc etc. The response from the students (who already smoke or chew or rub)? I don’t care. I’d rather die young. It doesn’t matter.
    I never hear-it won’t affect me.
    What I can’t get them to understand that they will NOT die young, most likely, but live a life on oxygen, with COPD, unable to do most anything physical, etc etc.
    I might as well talk to a brick wall for all that it happens.
    You can tax the butts (pun there) 100% and people will drive across state lines and get the lower taxed ones (happens in my state). People will do what ever it takes to get their fix.
    You cannot legislate, tax or take away anything that people want. They will vote with their feet.
    It would be nice to have a magic wand that we could wave, wouldn’t it!
    Finally, I suspect (but have not studied) that cessation of smoking etc. would lower health care costs in the US.

  12. I think that taxing cigarettes would just cause a downward spiral. It would start with cigarettes but knowing the government and their love for taxes soon there would be a tax on everything deemed “unhealthy” pop, junk food, alcohol, cigarettes etc. I am not saying I support these habits, I’m just saying it may have negative effects in the long run.

    • If I told you that the reason diabetes, obesity and heart disease have skyrocketed in America is our access to cheap calories and refined sugars, would you still be be upset if they were taxed more?

      Put another way: McDonalds only costs $0.99 for a hamburger. However, on the back end the added cost of diabetes, hypertension, and hyperlipidemia is unbelievably high and is bankrupting the country…

  13. I’m a soon- to- be college graduate with a degree in healthcare administration and this is actually something we extensively discussed in both hca finance and our senior seminar class with regards to the new reform bill.

    I, for one, support the tax fully. Like you say, people have the right to smoke and drink or tan, but it puts a bigger burden on an already strained system and these choices should not hinder another person’s use of the system, someone who has taken at least acceptable care of themselves and require care for something out of their control.

    Raising the tax initially won’t make a huge dent on the number of smokers because people will still pay, but over time, it should at least relieve a miniscule amount of strain on the system; and let’s be positive, a little is better than nothing.

    I’ve been an avid reader for a while now, and just couldn’t help but to respond to this post.

  14. I’m an American living in the UK, where it’s widely acknowledged that cigarette taxes more than cover the costs of a smoker’s health problems – to a degree, smokers fund the NHS. I think this is a good thing. I’m unsure how it would work in the states, though – despite Obama’s best efforts, there is no national health system in the US and there won’t be. I suppose there’s Medicare/Medicaid, but that’s not the same. Or would the tax be distributed among the various insurance companies?

    I do think the so-called “sin tax” is a good idea, particularly when everyone in society has to pay for the health care. I love the NHS, and think it’s fantastic. It’s great that it exists, and, by-and-large, it does a very good job.

  15. Also I am speaking from the stance of the Canadian health care system where the tax pays for everyones health care anyways. Not that our health care is any better (I waited 15 hours to get stitches in a deep wound that nearly hit my carotid artery) but taxes do cover a lot of our technology and probably the cost of a smokers health issues.

  16. I can’t speak to the validity of the “smokers more than pay for themselves,” argument, but I know in my state, Arkansas, that a sin tax on cigarettes is what funds our trauma system. The reason it’s so particularly effective as a funding mechanism is because cigarettes are inelastic, in economic terms. That means that we can jack the price up and people will pay whatever, mainly because they’re so ridiculously addictive, even if it means going without things like they’re anti-hypertensives, which obviously would contribute to their overall well being.

    In the face of being unable to stop smokers by taxing them our state has gone ahead and put some institutional level interventions in place. Health Behavior & Health Education folks tell us that we have to target multiple levels to effect change, not just one. So we tax the individual for their cigarette use, but we also do things like make it illegal to smoke on the campuses of schools and hospitals, which are criminal offenses. There are additional hurdles. Of course, and I’m biased here because it’s one of my colleges, Arkansas is one of the states that threw its tobacco settlement money into cessation and establishing a school of public health.

  17. I agree that smokers should pay a tax considering they live in the 21st centsury and have been informed of the risk for years. High risk drivers have to pay more for car insurance. Smoking and various cancers have led us to onclude more of a cause/effect relationship instead of a vague correlation. Yeah, they should pay for their choices – not me.

  18. i have read some very one eyed views on this site,,now i shall put the other side of the story to you all,,i am a smoker of some 50 years of smoking.
    led into smoking by peer pressure,and govt permitted advertising at 14 years of age,when the govt wanted the taxes from cigarettes.
    i have tried all methods available to quit,l to no avail.
    the govt tax on cigarettes takes 70% of my fortnightly (pension) income.
    i am treated like a leper if i smoke in public,and people constantly nag me to quit,so i am becoming a recluse and confining myself to my home.
    if this govt is serious about public health,it should ban carbon monoxide gases
    being produced from vehicles which is far more deadly to humans than passive smoking,,it all comes back to govt revenue,,so please try to be fair.

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