Monday, April 26, 2010

Action on Smoking and Health Argues for Insurance Surcharges for Smokers, but Not Obese People, Because Smokers are a Lower Income, Marginalized Group

ASH's Position is an Example of Classism in the Anti-Smoking Movement

Action on Smoking and Health (ASH) has proposed that smokers be forced to pay surcharges on their health insurance premiums in order to provide needed revenue for health care reform. In attempting to make the case for why smokers should face this surcharge while obese individuals should not, ASH argues that such a proposal would elicit less outrage if applied to smokers than obese people, because smokers are a marginalized, lower social class group that has less political clout.

ASH argues as follows: "Fewer than 20% of adults are smokers, and only about 13% smoke daily, while about 33% of adults are obese, and another 33% are classified as overweight. Thus the number potentially affected by a smoker surcharge is far smaller, and, because smokers are concentrated largely in the lower socioeconomic classes, they are less likely to be able to effectively object. A surcharge on the obese would arouse objections from a much larger segment of the population, including many people with considerable influence."

The Rest of the Story

Believe it or not, I'm not making this up. This is ASH's real argument for applying the surcharge to smokers, but not obese individuals.

This demonstrates that to ASH, this truly is class warfare. It is not about health or reducing health care costs; instead, it is about declaring war on a particular social class that ASH apparently abhors.

In public health, economic, and public policy terms, the fact that there are more obese and overweight individuals than smokers would argue for promoting a surcharge based on overweight as a priority, since it would result in a greater overall improvement in health and a greater amount of revenue for health care reform. ASH has distorted public health logic by arguing that the policy should apply to a much smaller group because that group is of a lower social class and thus, easier to control.

While I have been arguing for some time that the modern-day anti-smoking movement operates as a form of class warfare, rather than as a pure endeavor to improve the public's health, this is perhaps the first time that the movement has explicitly admitted that it is engaged in class warfare, and that its intent is to control and punish marginalized populations.

ASH is explicitly arguing that the degree of marginalization of a population should be a consideration (a positive one) in whether or not to regulate the behavior of a group of people. The more marginalized the group, the more appropriate it is to regulate their behavior, according to ASH's argument here. Such an argument is inherently classist. Marginalization should not be a factor in public health regulation, and it certainly shouldn't increase our propensity to regulate. If anything, it should caution us against actions that may increasingly marginalize that population, leading to adverse effects on them and their families.

The argument that punitive-type laws should be targeted towards those who have the least political power is also a classist position. When society needs money to pay for needed services, that revenue should be extracted from the most politically marginalized subgroup, according to ASH's argument.

ASH's' support for isolated insurance surcharges on smokers is but one example of classism in the anti-smoking movement. Another example is the efforts of ASH and other groups to isolate exposing children to secondhand smoke as the sole risk-increasing parental health behavior that would be classified as child abuse. The apparent attempt by at least some anti-smoking groups and advocates to intervene in the home and coerce parents to adopt a certain health behavior (not smoking around their kids), in the absence of evidence that this behavior necessarily leads to severe and immediate harm, is not only troubling because of its implications for parental autonomy and individual privacy rights, but also because it represents prejudice and discrimination based on social class.

Essentially, what such a policy says is that we as the more privileged, better educated class of citizens (nonsmokers) are going to tell a less privileged and less educated class of citizens (smokers) how to live their lives and how to raise their children within the privacy of their own homes.

Education is the strongest predictor of smoking status. So intervening to regulate smoking in the home is essentially an intervention that is going to punish less educated and less well off people for engaging in an unhealthy behavior. But because this is an isolated call for intrusion into the home (we are not calling for regulation of other health behaviors on the part of parents that affect their children), it has the appearance of being a class issue, rather than a true public health issue.

I don't see anyone calling for fines on parents who feed their children steak four nights a week, even though this is arguably doing health damage and increasing their risk for a number of chronic diseases. I don't see a call for criminalization of parents who don't put enough sunscreen on their children when they send them out to the country club swimming pool for the afternoon.

If anti-smoking groups really want to do something to help children who are exposed to secondhand smoke in the home, then how about offering free smoking cessation services to parents who want to quit smoking? How about using cigarette taxes to help these smokers, to benefit them directly, rather than call for taxes on smokers to fund completely unrelated programs that do not benefit the people who need the resources the most?

Classifying smoking around kids as child abuse, criminalizing this behavior, or outlawing it does nothing to address the social class disparities inherent in the public health problem of smoking. In fact, it exacerbates the very problem that we should be aiming to solve.

The war on tobacco-related morbidity and mortality should be just that: a war against tobacco products and the health harm that they cause. It should not be a war against what anti-smoking activists apparently view as a lower social class.

As a start, the increased degree of marginalization of a social group should never be used as a criterion to argue for the appropriateness of a proposed discriminatory public policy.

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