In the Spring 2009, issue of the Harvard Public Health Review entitled “Stealth Tobacco”, there was an article about the response of the tobacco industry to the increasingly heavy regulation and prohibition of cigarettes. The industry has been very resourceful in marketing tobacco in forms and packages that are designed to reduce the public opposition to the sale and use of tobacco products.
Tobacco marketers have figured out that the public is more ready to prohibit tobacco ingested through smoking processes because of the second-hand smoke issue. As a result, they have aggressively marketed smokeless tobaccos that are chewed, either in traditional chewing tobacco products or in more innovative products that package nicotine in lozenges, mints, and other orally-ingested forms.
Although these tobacco products do not pose the public health risks to those in the vicinity of the tobacco user that cigarettes, cigars, or pipes pose, they have all of the same negative consequences for the user, including the same addictive properties we associate with smoked cigarettes.
As I have said many times, I do not oppose a mature adult’s freedom to smoke or otherwise ingest tobacco, but I believe more strongly that these alternative forms of tobacco ingestion should be heavily taxed, that sales to children under 21 should be prohibited, and that health insurance plans should not only be permitted to charge tobacco users more for their health coverage, but should be required to do so.
The federal government, which has talked a lot about the need for health care reform to address prevention and wellness issues, has a golden opportunity to take a strong stand on this issue, and adjust Medicare, Medicaid, VA, and DOD participant co-payments or premiums to discourage tobacco consumption, and to direct states receiving federal funds for Medicaid and SCHIP programs to do the same.
The federal government has recently increased the excise tax on cigarettes from $.39 to $1.01 a pack. It needs to make sure that it heavily taxes all forms of tobacco ingestion, and that states bring tobacco taxes up to a minimum level. By way of comparison, New Jersey has the highest tax on cigarettes, $2.58 a pack, while South Carolina is at $.07 per pack.
I am sympathetic to the argument that an excise tax on tobacco is highly regressive, as is any other sales tax. I also recognize that we are dealing with addictive behaviors. Therefore, I would require both the federal government and the states to use all the increased revenues from these taxes for smoking cessation programs, not to reduce budget deficits. Over time, the lower-income population would find that its discretionary income would rise because it would not be spending scarce funds on tobacco products, and would see a broader improvement in health and quality of life.
I would adjust Medicare and Medicaid payments to reward physicians and other providers that are actively promoting smoking cessation as part of their primary care interactions with patients, and to reward broad integrated care organizations that are attacking this issue aggressively. Tobacco cessation counseling is a high-level skill and requires a highly-customized and individualized approach to each person who is being counseled. We need to make sure that the financial benefits of undertaking this activity are given to those who do it.
Finally, I favor the regulation of the marketing and sale of tobacco products by the FDA, because, over time, that regulation will be able to curtail the sale of tobacco products to minors. Pitney Bowes was in the cigarette tax collection business until the early 1980′s, and I learned from those in that business that the technology to track individual tobacco product sales is available and affordable.
I applaud companies like Wegmans, the Rochester New York-based retail grocery chain, which has decided to stop selling cigarettes and other tobacco products in its stores. I would like to see the major pharmacy retailers do the same, even though tobacco products are among their most profitable retail products.