Monday, November 16, 2009

Beware the Adverse Effects of Cigarette Taxes on Kids: Study Suggests Anti-Smoking Groups Should Re-Think Their Knee-Jerk Support for Tax Increases

A study published last year in the Archives of Pediatrics and Adolescent Medicine reports that the costs associated with smoking lead to food insecurity among children living in lower-income households with one or more smokers present (see: Cutler-Triggs C, Fryer GE, Miyoshi TJ, Weitzman M. Increased rates and severity of child and adult food insecurity in households with adult smokers. Archives of Pediatrics and Adolescent Medicine 2008; 162:1056-1062).

According to the study: "Food insecurity was more common and severe in children and adults in households with smokers. ... At multivariate analyses, smoking was independently associated with food insecurity and severe food insecurity in children (adjusted odds ratio, 2.0; 95% confidence interval, 1.5-2.7, and adjusted odds ratio, 3.1; 95% confidence interval, 1.4-6.9, respectively) and adults (adjusted odds ratio, 2.2; 95% confidence interval, 1.6-3.0, and adjusted odds ratio, 2.3; 95% confidence interval, 1.4-3.7, respectively). Conclusions: Living with adult smokers is an independent risk factor for adult and child food insecurity, associated with an approximate doubling of its rate and tripling of the rate of severe food insecurity."

The paper posits that the major reason for this finding is the high expense associated with cigarettes and the fact that spending on cigarettes makes it less possible to spend an adequate amount on food: "In the United States in 2005, an estimated $82 billion was spent to purchase cigarettes, with the average price of a pack of cigarettes being more than $4.38. Families with low income, in general, are more likely to experience food insecurity, spend less on food, and spend a larger percentage of available money on tobacco compared with more affluent families. In developing countries such as Bangladesh, China, and Bulgaria, tobacco expenditures crowd out expenditures for food, health care, and education. While the available data do not enable us to examine whether this is the mechanism behind the findings presented herein, it seems plausible."

The article goes on to explain the consequences of food insecurity for children: "Children who experience food insecurity are at higher risk for cognitive and psychosocial disability, poorer quality of life, and higher rates of suicidal ideation. They have lower scores on standardized academic tests, miss more days of school, and have more difficulty getting along with others. They also have poorer overall health, higher lead levels, increased rates of iron deficiency, and more emergency department use and hospitalizations."

The Rest of the Story

According to the Campaign for Tobacco-Free Kids, which has never met a cigarette tax increase proposal that it hasn't liked, these policy measures are a win, win, win solution that benefits everyone involved. The Campaign argues: "Increasing cigarette taxes is a WIN, WIN, WIN solution for governments — a health win that reduces smoking and saves lives; a financial win that raises revenue and reduces health care costs; and a political win that is popular with the public."

The present research suggests that the Campaign's reasoning is flawed, and that there may be substantial LOSERS from cigarette tax increases: namely, the children and families of smokers who do not quit smoking after a tax increase, and thus who spend more money on cigarettes and less on food, plunging their kids and families into more severe food insecurity with its associated adverse effects.

The Campaign's perspective has been too simplistic. It just isn't true that everyone wins with a cigarette tax increase. While those who cut down or quit smoking do benefit from the tax policy and will see health benefits, for those who do not quit or cut down, especially those of lower income, the policy will likely have significant adverse effects due to its exacerbation of existing food insecurity.

In an accompanying commentary, Dr. Frank Chaloupka notes: "Significant increases in cigarette and other tobacco product excise taxes are widely considered the single most effective policy option for reducing tobacco use. The findings of Cutler-Triggs and colleagues, however, might raise concerns about higher taxes worsening food insecurity in low-income smoking households as these households divert more of their incomes from spending on food to spending on cigarettes in response to the resulting higher cigarette prices."

It is time, I believe, that anti-smoking groups acknowledge these possibly adverse consequences of cigarette tax increases.

The way to ameliorate this problem is to allocate revenues from the tax increase specifically to smoking-related causes, including treatment for smoking-related diseases, and to earmark a substantial proportion of the revenues to benefit low income communities. With these features, a cigarette tax increase can still be an equitable policy.

But without allocating revenues for these specific purposes, cigarette tax increases are no longer equitable and to be sure, there are losers as well as winners. With the current state budget crises, many states are looking to cigarette tax increases to raise revenues and balance their budgets. Most anti-smoking groups are supporting these tax increases, even though the money raised will not be allocated to smoking-related programs and in many cases, will not be earmarked for low-income communities. These policies will have big losers, and for that reason, I believe anti-smoking groups must re-assess their knee-jerk support for such policies.

In an article regarding this research that was published last year on the Health News web site, Action on Smoking and Health offered its own suggestions for how to deal with the above problems.

Its first solution? Treat smoking around children as a form of child abuse and require doctors to report parents who smoke at home in the presence of their children.

Its second solution? Promote malpractice lawsuits against physicians who do not provide effective smoking cessation treatment (i.e., pharmaceuticals) for their smoking patients.

I have previously criticized each of these policy proposals:

Click here for my criticism of ASH's suggestion that smoking around children should be treated as a form of child abuse.

Click here for my criticism of ASH's suggestion that doctors who fail to prescribe pharmaceuticals for their smoking patients should be prosecuted for malpractice.

One final point about the Health News article: It makes the ridiculous assertion that: "exposure to second-hand smoke can cause nicotine withdrawal symptoms in non-smoking family members including sleep disturbances, anxiety, depression, and concentration difficulties." The levels of exposure to nicotine associated with secondhand smoke exposure are extremely low and I am not aware of any scientific evidence suggesting that these low levels are enough to produce nicotine dependence in nonsmokers.

It's not clear where the writer got this notion, but it certainly wouldn't surprise me if she got it from ASH or another anti-smoking group.

The rest of the story is that cigarette tax increases are not necessarily a win, win, win proposition. If not implemented properly and with attention to principles of equity, there can be substantial losers. If those losers turn out to be children who are forced into more severe food insecurity because of these policies, then anti-smoking groups stand responsible for those adverse consequences. Thus, these groups must end their uniform and thoughtless rhetoric and address these concerns directly. The days of knee-jerk support for any and all proposals to increase cigarette taxes - to fund any program under the sun - must end.

(Thanks to Ladyraj and Harry for the tips).

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