The War Against Tobacco Slows

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This post was written by Maggie Mahar and Niko Karvounis

2007 marked the first time in 50 years that less than 20% of Americans smoked.  This is the good news. The bad news is that, just as the battle against smoking has entered what may be its most critical, final phase, support for that battle has waned among policymakers—even though the problem is far from solved.

Tobacco use, especially cigarette smoking, continues to be the leading cause of preventable diseases in the United States. It is blamed for 435,000 premature deaths in this country each year, and it adds more than $75 billion to annual spending on health care, according to the federal Centers for Diseases Control and Prevention.

Consider the raw numbers: in 2007, an estimated 19.8% (43.4 million) of US adults were still smoking cigarettes; of these, 77.8% (33.8 million) smoked every day, and 22.2% (9.6 million) smoked some days.  That’s a lot of smoke.

Break down the demographics and you find stark patterns. Smokers are likely to have less education than other Americans: CDC research has found that adults who have a GED diploma (44.0%) and those with 9–11 years of education (33.3%) are most likely to use tobacco.  Americans with an undergraduate or graduate degree are least likely (11.4% and 6.2%, respectively). Poorer people also are more likely to smoke: 33% of U.S. adults living below the poverty level are smokers while only 23.5% of those living above that level still light up.

Given how expensive cigarettes are these days, these are striking statistics. Why do low-income people smoke? Medical research shows that being poor is extremely stressful. You have less control over your life and must cope with much more uncertainty: Will you be able to pay your rent? What will you do if you lose your job? Are your children safe walking home from school?  As anyone who has ever been addicted to tobacco knows, being anxious makes you reach for a cigarette.

Military veterans under the care of the Department of Veterans Affairs (VA) health care system are also more likely to smoke than other Americans. Indeed, a 2004 report titled “VA in the Vanguard: Building on Success in Smoking Cessation” points out that “the prevalence of smoking is approximately 43 percent higher” among these veterans than in the general population.  “Many Americans who may have never smoked prior to their military service began smoking while in the service,” the report observes.  In the past, “ ‘Smoke ‘em if you‘ve got ‘em’ was a common command, and in many cases was even encouraged as it was thought to help keep soldiers alert and awake—or to help them cope with the tedium of waiting while on watch and the stress of combat.”

Even today, the report notes, “while not having initiated smoking before the age of 18 years is typically a protective factor for being a nonsmoker, this is not true of men and women who serve in the military.” Serving in the military is a risk factor for smoking “even for those who did not start smoking prior to the age of 18.

“Smoking is the number-one health problem for vets,” says Dr. Steven Schroeder, former president of the Robert Wood Johnson Foundation, where he focused on smoking cessation.  “And reports are showing that many US soldiers serving in Iraq are turning to smoking to relieve their stress.”

The link between smoking and anxiety also helps explain why smoking is so strongly correlated with mental illness. According to the New England Journal of Medicine, “smoking rates have been reported to be over 80 percent among persons suffering from schizophrenia, 50 to 60 percent among persons suffering from depression, 55 to 80 percent among alcoholics, and 50 to 66 percent among those with [other] substance-abuse problems.”

The bottom line: as time goes on, smoking has become concentrated among groups of people who are suffering from anxiety and other problems that make quitting and responding to outreach and education efforts much more difficult. Indeed, the CDC notes that the proportion of daily smokers who made a stab at quitting fell from 47% in 1993 to 39.8% in 2007.

Medicare and Medicaid

Meanwhile, we’re not doing all we can to protect some of our most vulnerable citizens against premature death.

First, consider the role of doctors. By all accounts, helping someone quit smoking is much more of an art than it is a science, which makes primary care physicians (PCPs) and others who practice cognitive medicine key players in the process. At least 70 percent of smokers see a physician once a year, which means that PCPs often have the opportunity to talk to their patients about addiction.

Best practice for smoking cessation is built around a highly interactive interventional model called the “5 A’s”:  “Asking about tobacco use at every visit, Advising patients to quit, Assessing their readiness to do so, Assisting with the formation of a quit plan, and Arranging follow-up visits. The 5 A’s take time, but unfortunately counseling is undervalued by a reimbursement schedule that pays little for “cognitive” care (talking to and listening to patients.)

Medicare covers no more than 8 counseling sessions over the course of a year—four “intermediate” sessions that last just 3 to 10 minutes, and four “intensive” sessions, defined as any sessions lasting longer than 10 minutes. Meanwhile, the fees Medicare pays for this type of counseling are so small that most providers cannot afford to spend more than 11 or 12 minutes in an “intensive” session. Further, Medicare generally does not reimburse for products like nicotine patches.

Medicaid is similarly unimpressive in its coverage. Currently, 38 state Medicaid programs cover at least some smoking cessation treatments for beneficiaries, but only one state (Oregon) covers all of the medication and counseling recommended by the US Public Health Service.  Worse, two-thirds of states require some type of patient cost-sharing for medication like nicotine patches, which can dissuade reluctant—or low-income—patients from following through on  their treatments.

A recent CNN story profiles  Gerald Dimmitt, a 65-year old smoker who went to pick up Chantix, a smoking cessation drug, from his local pharmacy—but left without the drug, in outrage over his steep co-pay of $139 for a two-week supply. “If smoking is so dangerous … why then do they want to charge $139 to make me stop?” Dimmitt asks. It’s a good question. Since so many smokers are people with lower levels of education and lower incomes, high-co-pays can be a powerful deterrent to quitting.

Meanwhile, these days, most primary care physicians don’t even bother with tobacco control. A 2006 Robert Woods Johnson survey of 1,120 primary care physicians found that only 10 percent of physicians referred patients to programs or experts to help them quit smoking. This is troubling: as Dr. Steven Schroeder noted in a 2005 JAMA article, “helping smokers quit may be the most important thing that [a physician could do]” since “tobacco use remains the single most preventable cause of death” in the nation.

Reduced State Support

Of course, primary care physicians are famously over-worked and underpaid; if we want them to add another service to their schedule, we should give them some support.  This is where state-sponsored resources—such as quit lines and cessation clinics— should come into play. Unfortunately, while there is some smoking prevention and cessation infrastructure in every state, the big picture is pretty bleak.

The CDC recommends that state per capita annual expenditure on tobacco control programs (e.g. research, advocacy, cessation programs, and education) fall somewhere between $9.23 and $18.03, depending on the population of a state and the prevalence of smoking within its borders. But according to a recent report from the advocacy group Tobacco-Free Kids (TFK), in FY 2009, “no state is funding tobacco prevention programs at levels recommended by the CDC” and “only nine states are funding tobacco prevention at even half the CDC’s recommended amount” (Alaska, Delaware, Wyoming, Hawaii, Montana, Maine, Vermont, South Dakota and Colorado).  At the aggregate level, the CDC reports that in 2007 state “investments in comprehensive, state-based tobacco prevention and control programs…totaled $595 million, approximately 325-times less than the smoking-attributable costs.”

Slowly but surely, states have been getting out of the tobacco control business. A recent report from the American Lung Association found that overall funding for state tobacco control programs declined by 28 percent between fiscal years 2002 and 2005, a slow-down that has serious public health repercussions. A 2005 study published in the American Journal of Public Health (AJPH) concluded that if states spent just the minimum amount recommended by the CDC, youth smoking rates would be 3 percent to 14 percent lower nationwide; a 2008 AJPH study found that if states spent just the minimum amount recommended by the CDC between 1995 and 2003, there would be been between 2.2 million and 7.1 million fewer smokers in the US today.

What’s going on here? The short answer is that states are spending the money meant for tobacco control on other things. Most of the funds that states are supposed to use to pay for anti-smoking measu
res comes from the landmark 1998 Master Settlement Agreement with tobacco companies, in which the companies agreed to pay states $206 billion over 25 years. In theory, this money was supposed go toward paying for smoking-related sicknesses and anti-tobacco programs. Sadly, TFK reports that, “in the last 10 years, states have spent just 3.2 percent of their total tobacco-generated revenue on tobacco prevention and cessation programs. From Fiscal Year 2000 to…Fiscal Year 2009, the states have received $203.5 billion in tobacco revenue – $79.2 billion from the tobacco settlement and $124.3 billion from tobacco taxes. During this time, the states have allocated $6.5 billion to tobacco prevention and cessation programs”—even though the CDC recommends  spending about five times as much in order to adequately fund tobacco control programs.

The problem is that no formal guidelines were ever set for state spending of tobacco funds, which means states often spend the money in other areas—primarily to patch the holes in their budgets. In November, NPR reported that “nearly half [of] states…securitized their settlements [over the past few years]— meaning they sold off the future payments for a lump sum to pay down debt or balance budgets.” Other states, like Ohio, use the money to fund economic stimulus packages.

Not all expenditures are so noble, however. ABC News reports that, “among other things, tobacco-settlement money has been put toward a North Carolina museum on tobacco farming and a veterinary center in Kentucky for diagnosing illnesses in thoroughbreds. Some $100 million is helping make aircraft parts in Kinston, N.C. And more than $80 million is being used to bring broadband service to rural Virginia.”

The irony of all this is that in the long run, funding smoking cessation efforts actually helps states save money. A 2008 PLoS Medicine study found that between 1989 and 2004, California’s tobacco control program was associated with $86 billion less in health care spending than would have been expected without the program. Savings grew progressively over time, and by 2004 they reached 7.3% of the state’s total health care  bill.

What Are the Options? 

Nevertheless, as the economy sinks into a deep recession, it will become more and more difficult to convince states that paying for tobacco control should remain a spending priority. Budget shortfalls are inevitable, which means that state legislatures and governors will have to juggle a variety of different crises. Further, the fact that the majority of smokers are poorer, and less well educated than most means that they belong to a group that political leaders all-too-often ignore (even if they are Vets). With smoking relatively rare among the well-educated upper-middle class, tobacco control may seem less important to many legislators.

There is some good news, however. If states want to improve public health and reduce smoking-related illnesses, they do have a very cheap, relatively painless option: public smoking bans. These laws, which have become increasingly popular and are currently in place in 35 states and D.C., have shown to work.

A new CDC study of the Parkview Medical Center in Pueblo, Colorado found that, “three years after a comprehensive ban on smoking in public places, hospital admissions for myocardial infarctions [heart attacks] had declined 41% from pre-ban levels” in the city. Researchers attribute the drop to "reduced second-hand smoke exposure among nonsmokers and reduced smoking, with the former making the larger contribution." In other words, fewer people smoked or breathed in smoke, so fewer people suffered heart attacks.

The same thing is happening all over the world: cities in Ireland, Scotland, and Italy with public smoking bans all saw rates of cardiac hospitalizations fall by 11% to 17% in the first year after prohibition. Fewer sick people means less spending on critical care and hospital admissions. This is an important point: though our health care system does a relatively poor job of helping people quit smoking, it spends a lot of money on the illnesses that smokers contract, such as heart attacks. Every year, Medicaid spends about $31 billion on smoking-related illnesses; Medicare shells out $27.4 billion. All in all, the CDC puts the average annual smoking-attributable health-care expenditures between 2001 and 2004 at approximately $96 billion. Tack on lost productivity costs of $97 billion—because smokers take smoke breaks and miss more days of work due to illness than other people—and the total economic burden of smoking is approximately $193 billion per year. 

But public smoking bans don’t do much to teach individuals about the danger of smoking in their home or amongst friends.  Granted, there is an argument to be made no-smoking laws dramatically changes the social acceptability of smoking, which might have important psychological effects on peoples’ habits. Nevertheless bans on smoking are very different from programs designed to help smokers kick the habit. Bans turn smokers into social pariah, much the way losing “war on drugs” has become a “war on addicts” which labels them criminals. In each case the addict needs society’s help: our goal should be to convert the customers. Without customers, the business of selling poisons would no longer be profitable.
Unfortunately, it is very, very difficult to help those addicted to drugs like heroin. By contrast, with a combination of free pharmacologic products like nicotine patches and counseling, we have learned how to help many smokers. 

Research has shown that smoking cessation programs, when they include counseling, have long-term success rates of 15 to 35 percent, says Dr. Michael Fiore, a University of Wisconsin professor of medicine who is also chairman of the federal Public Health Service’s guidelines panel on smoking cessation. Last, year Kaiser Permanente reported that 52% of patients who participated in its “Healthy Lifestyles” smoking cessation program were tobacco free six months later.

And research shows that even if smokers relapse the first time, smoking cessation programs often firm up their resolve to try again—and eventually, succeed.

Today’s smokers are among society’s most vulnerable citizens. They deserve help. And if you are not swayed by the moral argument, consider the numbers we’ve discussed. Tobacco is the leading cause of premature death in the U.S.  Total cost to society, in the form of added health care costs and lost productivity: $193 billion a year. If we were going to do one thing to improve the nation’s health and rein in health care spending, this would be it.

Yet somehow, all anyone wants to talk about is obesity. Granted, it, too, is a national health problem—but why are we so interested in obesity while turning our backs on smokers? Is it because we have “red-lined” tobacco as a problem for “them”—the poor, the mentally ill, and, oh yes, the veterans who have fought our wars—but not “
us”—the educated, informed, and affluent?

Health reformers, let’s band together, and push for robust smoking cessation coverage under Medicaid and Medicare; better reimbursements  for doctors who try to help patients quit smoking; and revitalized state commitments to fund tobacco control. Outlawing smoking in public places is fine, but we can and should do more. 

31 thoughts on “The War Against Tobacco Slows”

  1. One thing that’s rarely acknowledged about smoking or obesity is this: as much as there is increased public health spending on people who smoke and are obese, if they live 7-10 years less on average, think of the savings to Social Security and Medicare…

  2. I believe that smoking decreases the lifetime costs of medical care. I also believe that it especially decreases the cost of medical care born by the government. When you add in the effects on Social Security and the effect of taxes on cigarettes, smoking is financially overwhelmingly beneficial for the goverment.
    Consider this, smokers live approx 7 years less than non-smokers. It is not necessarily cheaper to die from a non-smoking related disease than it is to die from a smoking related disease. I will admit that smokers probably lose more days from work and incur more costs during their working years than non-smokers, but that is mostly on private insurers and is probably more than made up for the illnesses non-smokers get 7 years later (when medical care costs have gone up a good 30%).
    What about the longer time that non-smokers spend in nursing homes at the end of their lives. What about the increase in costs from diabetes from the generally heavier non-smokers?
    This issue was looked at in depth in an article in the New York Times magazine more than 5 years ago. The conclusion – smoking saves money.
    I am a physician and I have councelled many patients to stop smoking. Furthermore, I do not like smoke and am happy that none of my children smoke. But the idea that stopping smoking will save money is baloney. Also, while I believe that everyone should have good information, and be helped to quit if they want to, I do not believe in the “Nanny State”.
    “Smoke ’em if you got ’em”

  3. I agree completely with Legacy Flyer’s comments, especially the notion that smokers incur lower healthcare costs over a lifetime than non-smokers. I would like to add a couple of additional thoughts.
    In my own case, doctors have urged me, literally for decades, to get more fiber into my diet in order to mitigate some digestive system issues that I’ve had. Even though I fully understand their advice and appreciate that I might live somewhat longer if I followed it, the problem is that most foods that are high in fiber I just plain don’t like and I would also have to reduce consumption of other foods that I genuinely enjoy. I’ve increased my fiber intake some but to nowhere near the recommended level. Even if it ultimately means that I die a couple of years sooner than otherwise, I’ve made a conscious choice that I’m comfortable with.
    For smokers in the lower socioeconomic groups, it could well be that they understand that smoking is not good for them and that they are probably shortening their life span by continuing to smoke, but they also find it relaxing and enjoyable. All the counseling in the world probably won’t change that. I don’t think the issue is underfunding or that the better off among us don’t care about poor people, but that many, if not most, smokers are making an implicit (or even explicit) choice that works for them. If they stop smoking and are able to live another few years in grinding poverty with all the associated stress, they may not think it’s worth it if it means they have to give up the “benefits” that smoking gives them.
    More generally, I get a little impatient when I keep hearing that this or that government initiative is underfunded. Indeed, I’ve never heard of a government initiative, program or agency that advocates contend is adequately funded. Money is a constraining resource as I’ve said many times. If we don’t want people to smoke, maybe we should put the resources into improving education in order to reduce the number of people living in poverty over the long term.

  4. How does it feel to be in the cross-hairs of a discussion that is premised on the idea that lengthening life increases health care costs? By this logic, nothing you do to extend life and improve health saves money. This argument was also on the front page of the Washington Post Outlook section on Sunday, and is embraced by Peter Orszag, the soon-to-be OMB chief, in his report. What’s your response? That’s a worthy paper for a think tank.

  5. Merril,
    It is surprising that the idea that lengthening life does NOT increase health care costs has ever had any proponents.
    Another side of this discussion was also featured in an article in the New York Times several weeks ago. In England, a preliminary decision had been made not to cover the costs of some expensive drug that may increase the life of someone with a terminal malignancy by a couple of weeks. An English committee had made the decision that the expense was simply not justified. Of course, this caused a tremendous degree of controversy – as perhaps it should.
    Many people engage in a form of magical thinking with respect to health care costs:
    If we can only cover everyone with the latest treatments, costs will go down – wrong.
    An electronic medical record will save billions – wrong.
    New treatments for deadly diseases save money – mostly wrong, people merely go on to die later from another, possibly more expensive disease.
    The only intelligent approach that I have ever seen to the financially wise use of healthcare dollars came out of Oregon years ago and was abandoned because it was so unpopular.
    Just wanted to shine a ray of sunshine onto this discussion

  6. Everyone–
    Thanks for your comments.
    Somehow, the comment I wrote yesterday was lost, so let me repeat it:
    when talking about health care savings, I don’t put premature death in the “plus” column.
    To me, health care savings involves saving money while improving health (better care and reduced spending actually go hand in hand.)
    Yesterdcay I susggested that if we, as a society, considered premature death a form of health care savings, then it would make sense to euthanize all weak or sickly citizens at about age seven, eliminating their future health care bills from the system.
    Merrill has it exactly right: this “discussion is premised on the idea that lengthening life increases health care costs .. . By this logic, nothing you do to extend life and improve health saves money.”
    We should stop trying to treat cancer, heart disease, etc. Just let everyone die of the first disease that hits them.
    We’d save a bundle in Social Security . . .
    (Merrill — can you send me link to WaPo piece?)
    And Barry– the fact is that all domestic programs in the U.S. are underfunded.
    How can you tell? Count the number of desperately poor people in teh U.S.–the homeless, the malnourishsed children, the mentally ill people wandering hte streets, families living in apartments infested with vermin. . .”
    I know some people say “the poor will always be with us.” Those people
    should try going to Europe–Sweden, Denmark, France . . .not to mention Japan.
    Those countriess fund their domestic government programs.
    We use that moeny to blow up other countires–and their citizens– with some of our poorer and least well educated citizens thrown in for good measure. (And if friendly fire doesn’t get them, the cigarettes they learn to smoke while in the service will.)

  7. I think we also need to understand that when it comes to smoking, rather than obesity, it affects more then just the smoker. It is one thing to mandate people with laws to not smoke in public, however, we can not put people in jail for smoking in front of their children at home. There is a domino effect that is present with this addition that incures more healthcare costs.

  8. Carl–
    You are right, second-hand smoke is also a factor, and a reason why helping smokers quit is also a matter of public health.
    I’m not at all sure that second hand smoke hurts us if we are on the street, but certainly an infant or young child at home with a heavy smoker–or a waitress or barteneder working in a smokey restaurant are likely to suffer some damage.

  9. Maggie:
    Premature death is a form of savings.
    No one wants, sanely, to die prematurely, but saving money on ineffective medical procedures to lenghthen life a short time is a savings.
    I am not a fan of death.
    I side with Woody Allen when he said “I don’t oppose dying, I just don’t want to be around when it happens.”
    My prior point about providing a smaller death benefit in lieu of costly, ineffective, covered medical benefits gives the patient and his family an option, a viable option, in my opinion.
    The fellow can go out a hero.
    Personally, I would love to have that option, and may even put that in my living will.
    Don Levit

  10. Maggie,
    I obviously don’t have any problem with interventions, like smoking cessation, that can help people to quit smoking and live more years of good quality life. What I have a problem with is claiming that such efforts save the healthcare system money when they often don’t, at least on a lifetime medical cost basis. For those who have lived beyond a normal lifespan and have a very low quality of life, I’m not very enthusiastic about employing a “full court press” to prolong death at high cost. I would like to know more about how the Europeans and Canadians handle these situations.
    What we should really be aiming for is not necessarily maximizing lifespan but rather healthspan or years of high, or at least good, quality of life. In a perfect world, aside from healthcare costs related to labor and delivery, childhood immunizations and cost-effective preventive care, it would be great if virtually all remaining healthcare costs occurred right at the end of life. That is, we all live in near perfect health and when we reach the end of our lives, the body expires reasonably quickly. Short of that fantasy, if we could ever develop a cure for Alzheimer’s and dementia, perhaps through stem cell research, or at least significantly postpone the time when those diseases become debilitating, that would be huge.

  11. Maggie,
    Actually, what you said was that stopping smoking would save money. “it (smoking) adds more than $75 billion to annual spending on health care”. It is this statement that I and other objected to.
    None of us has ever said: “We should stop trying to treat cancer, heart disease, etc. Just let everyone die of the first disease that hits them.” That was a “strawman” you built so you could knock it down.
    I think all of us agree that we would like to have the best possible health care at a price that we can afford.
    Since the amount of money that can be spent on health care is virtually unlimited and grows each year as new (and generally expensive) drugs and treatments are discovered, it is important for us to look carefully at what the “bang for the buck” is with various treatments.
    This issue ties in nicely with the prior article about Oncology and the (over)use of treatments that don’t offer any significant increase in quality lifespan.
    Furthermore, the methods that the government is using to stop smoking have become increasingly coercive. This coercive strategy is based on one faulty and one questionable premise. The faulty premise is that stopping smoking will save money. The questionable/over rated premise (in my opinion)is that second hand smoke is a significant issue to those who don’t live with a smoker.
    I am not a smoker, don’t like to breath others smoke, and am glad my wife and children are not smokers. I have councelled quite a few patients to stop smoking as well. However, we live in a free country with others who are obese, abuse alchol, drive SUVs, ride motorcycles without helmets, etc. etc. In a free country, I believe we are allowed to “pick our own poison”.

  12. Barry, Legacy Flyer and Don–
    Smoking is the number one cause of premature death in this country.
    Barry– Before a smoker dies he does not enjoy high quality life. Often he has a bad cough; he is short of breath; he may suffer from angina.
    We’re not close to a cure for Alzheimer’s. We do know how to help people stop smoking. Smoking cessation clinics did not require a lot of expensive technology. In terms of “bang for the buck” this is, as Dr. Steve Schroeder points out, “the most important thing we can do” to improve healthspan.
    Schroeder points out that we pay a lot more attention to acute care for upper-middle-class people than preventive care for low-income people–smoking cessation falls into the latter category.
    Legacy Flyer–
    Please go back and look at Merrill Goozner’s comment.
    He hit the nail on the head.
    When people stop smoking we Do Save the health care dollars that we would have had to spend treating their cough, their congestive heart failure, their lung diseae etc.
    What you and others are talking about is the fact that because the reformed smoked lives longer, net, net we don’t save money. And, as Merrill points out, that puts you in the Absurd position of arguing “that lengthening life increases health care costs . . . By this logic, nothing you do to extend life and improve health saves money.”
    This is why I gave you an absurd example–to underline how untenable your position is.
    Vert simply –premature death does not belong in the “healthcare savings” column.
    Don–
    I think you should put that provision in your living will. And try to make it an airtight living will.
    Then do a little reading about how many people change their minds when actually facing death and desperately want ot live as long as possible.
    What if they hold you to your living will?

  13. Maggie and Niko,
    Your’e right on the money about the current tobacco situation. The uneven coverage (where it exists) currently given to tobacco cessation programs is not helping smokers who want to quit (and 70 percent saay they do) take advantage of the techniques that can double or triple their chances of succeeding.
    A group of leaders from the business, labor, healthcare and governmnent comnmunities is pushing for a stronger, more consistent approach to making smoking cessation more accessible. A national working group of these organizations met in November and produced a “Call for ACTTION” (Access to Cessation Treatment for Tobacco In Our Nation) that outlines a strategy for strengthening cessation efforts. You can check it out at http://acttiontoquit.com/ .

  14. You said: “When people stop smoking we Do Save the health care dollars that we would have had to spend treating their cough, their congestive heart failure, their lung disease etc.”
    But we then have to spend other money to treat their diabetes, Alzheimers, colon cancer, etc. There is no net savings – an important point for a Government struggling to find a way to pay for future health care costs.
    “What you and others are talking about is the fact that because the reformed smoked lives longer, net, net we don’t save money. And, as Merrill points out, that puts you in the Absurd position of arguing “that lengthening life increases health care costs . . . By this logic, nothing you do to extend life and improve health saves money.”
    Of course it is POSSIBLE to “extend life, improve health and save money”. But this is not the way that things usually happen unless you live a healthy life until age 90, then get hit by a truck.
    What you think is absurd – that lengthening life increases health care costs over a persons lifetime – is in fact generally historically true and not only in the US.
    Just look at the average lifespan of someone in 2009 versus 1959. We live longer and we spend a LOT more on health care.
    What killed people at age 85 in 2008 was generally the same thing that killed them at age 80 in 1979. They have lived longer and more money was spent on their health care. It is good that they have lived longer, it is also more expensive.
    Rather than quibble about this rather obvious point we should focus on extending the period of high quality life, rather than the period people are merely alive. We also need to focus on what treatments yield the highest number of quality years of life per dollar spent.

  15. Prevention Matters and Legacy Flyer:
    Prevention Matters–
    Thanks for the link. I’d
    be interested in getting an update from you if the Obama administration reacts (as I hope they will) to your Call for Action. You can reach me at mahar@tcf.org
    Legacy Flyer–You write: “the point we should focus on extending the period of high quality life.”
    I couldn’t agree more. I would add only that smoking cessation clinics would help do just that.

  16. I take issue with the idea that “nonsmokers”, by living longer, cost more in health care.
    This assumes that there actually is such a thing as a nonsmoker, and that is a very rare bird indeed–certainly in the US.
    Given the history of tobacco use here, virtually everyone in the US is or has been either an active or a passive smoker. If you can find statistics based on the health care costs of people who have never been exposed to secondhand smoke and have never smoked themselves, then please use that data in your comparison of lifetime health care costs. For everyone else, going forward, the fewer smokers the less smoke to impair the health of would-be nonsmokers and, predictably, the lower the health care costs for those people.

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  18. One thing that’s rarely acknowledged about smoking or obesity is this: as much as there is increased public health spending on people who smoke and are obese, if they live 7-10 years less on average, think of the savings to Social Security and Medicare…

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  24. Smoking is the process of flavoring, cooking, or preserving food by exposing it to the smoke from burning or smoldering plant materials, most often wood. Meats and fish are the most common smoked foods, though cheeses, vegetables, and ingredients used to make beverages such as whisky[1], Rauchbier and lapsang souchong tea are also smoked.

  26. This is my first time i visit here. I found so many interesting stuff in your blog especially its discussion. From the tons of comments on your articles, I guess I am not the only one having all the enjoyment here keep up the good work.

  29. What about the longer time that non-smokers spend in nursing homes at the end of their lives. What about the increase in costs from diabetes from the generally heavier non-smokers?

  30. The only intelligent approach that I have ever seen to the financially wise use of healthcare dollars came out of Oregon years ago and was abandoned because it was so unpopular.

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