All tobacco will soon be more expensive in the United States

I recently wrote about the impending 62 cent increase in federal tax due on a pack of cigarettes (effective from April first, 2009). I thought it was worth mentioning that there will also be similar sized or larger increases in the federal tax being charged on other tobacco products. These federal tobacco tax increases are summarized below:


--Cigarettes: 39 cents per pack currently, increasing to $1.0066 per pack
-- Large Cigars: 20.719 percent of manufacturer's price, cap of 4.875 cents per cigar; increasing to 52.75 percent of manufacturer's price, cap of 40.26 cents per cigar
-- Little Cigars: 4 cents per pack; increasing to $1.0066 per pack
-- Pipe Tobacco: $1.0969 per pound; increasing to $2.8311 per pound
-- Chewing Tobacco: 19.5 cents per pound; increasing to 50.33 cents per pound
-- Snuff: 58.5 cents per pound; increasing to $1.51 per pound
-- RYO and Cigar Wrappers: $1.0969 per pound; increasing to $24.78 per pound
-- Cigarette Paper: 1.22 cents per 50 papers; increasing to 3.15 cents per 50 papers
-- Cigarette Tubes: 2.44 cents per 50 tubes; increasing to 6.30 cents per 50 tubes

Some of these changes help close some of the existing loopholes that have enabled certain tobacco products to enjoy tax advantages as compared with cigarettes. The most obvious example here is little cigars (e.g. Winchester). These are often the same size, shape etc as cigarettes and have a filter like a cigarette, but are able to call themselves cigars by virtue of the “paper” being impregnated with tobacco leaf (the legal definition of a cigar requires that it be tobacco wrapped in tobacco leaf, intended for smoking). So the increase from 4 cents to $1.01 federal tax per pack of little cigars will result in a substantial percent change in the price paid by consumers, but will bring it more in line with the tax on cigarettes.

Roll-your-own tobacco is very popular in many parts of the world (e.g. in Holland it’s the predominant smoked tobacco product) but is less commonly used in this country. I recently spoke to someone who as a cigarette smoker smoked a pack a day (costing around $6) but was able to purchase a pouch of RYO tobacco for $2.56 that would last for 3-4 days. The substantial increase in RYO tax will close that loophole also.

Whichever way you look at it, its going to become much more expensive to be a tobacco user. Think it can’t possibly become more expensive? Spare a thought for smokers in Ireland, where a pack of cigarettes costs the equivalent of $10. We’ve clearly got some catching up to do here in the United States.

Labels: cigarette tax, cigarettes, cigars, jonathan foulds, RYO, tobacco

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Celebrities killed by tobacco-caused illness

Many of us watched the Oscar award ceremony over the past weekend, which is always very entertaining and includes a good deal of reminiscing about past great actors. As I watched some of the great old faces flash across the screen I was reminded how many of them had their life and career brought to a premature end by smoking-caused disease.
In the United States, many people are aware of the fact that great stars such as Yul Bryner , Michael Landon and John Wayne were killed by tobacco, but in fact many more stars have been killed by their smoking than we are generally aware of. Part of it is an understandable desire to preserve some privacy for the person at the end of their life. But in the case of smoking-caused illnesses, it seems that the media sometimes goes out of its way not to mention the ultimate cause of death in a way that they don’t do when it comes to drug or AIDS related deaths. It is not uncommon for newspaper reports also to simply refer to the cause of death as “cancer” rather than to specify it as lung cancer, even when the diagnosis was clear and obtainable in the public domain.

Here is how Professor Simon Chapman (University of Sydney) referred to this phenomenon with regard to the death of George Harrison, in his excellent book on public health:
"His death on 29 November 2001 from smoking caused lung cancer was noted in some reports as if he had died from any other cause, despite losing more than 20 years off the average life expectancy of a 58 year old man. Indeed the ABC network in the USA went so far as to note that unlike many other rock stars of his generation (Jimi Hendrix, Janis Joplin, Jim Morrison) Harrison had died of "natural causes"44. If we assume Harrison took up smoking at the age of 15, and on average smoked 20 cigarettes a day, he therefore smoked for around 43 years, smoking 314,115 cigarettes in that time. Observations of smoking show that a cigarette takes about 5.6 minutes to smoke45. We can therefore calculate that Harrison had a cigarette alight for a cumulative total of 1221.6 days or 3.34 years of his 58 years. Recalling that he lost about 20 years off normal life expectancy for an Englishman, we can calculate that each of the 314,115 cigarettes he smoked took 33.5 minutes off his life – about 6 times longer than the time it took him to smoke each one."

I’m not writing this article to argue that celebrities shouldn’t smoke because of their role model status. Celebrities have the same right to smoke as anyone else, and the same human tendency to become addicted to the nicotine in tobacco and to be killed by it. Rather I think it is worth recognizing how much poorer the world is for having lost so many talented people too early. I suspect that George C Scott had a few more good movies in him, George Harrison a few more songs, and Peter Jennings a few more news stories. So rather than berate our current smoking celebrities, I think we should make sure they can get access to effective treatment and succeed in quitting.

If you are in the entertainment business and would like help to quit smoking, contact : http://www.picturequitting.org/

You can see a long list of just some of the celebrities killed by smoking-caused diseases at: http://roswell.tobaccodocuments.org/hall_of_shame.htm

You can find more information on Simon Chapman’s book: Public Health Advocacy and Tobacco Control: Making Smoking History at:
http://www.wiley.com/WileyCDA/WileyTitle/productCd-1405161639.html

Labels: celebrity, cigarette smoking, jonathan foulds, nicotine, picture quitting, premature death, simon chapman

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Why are mentholated cigarettes more addictive?

My colleagues and I just published a research study which examined the quit rates of patients attending our specialist Tobacco Dependence Clinic, and focused on the differences between those who smoked mentholated cigarettes and those who smoked non-menthol cigarettes.
Consistent with numerous other studies, we found that far more African American (81%) and Latino (66%) smokers smoked menthols, as compared with non-Latino Whites (32%). But the more interesting finding was that while African American and Latino smokers of non-menthol cigarettes had similar quit rates to whites, the quit rates of those smoking menthols was significantly lower. For example, African Americans who smoked menthols had half the odds of quitting of African Americans who smoked regular non-menthol cigarettes.
This “menthol effect” on quitting occurred despite the fact that menthol smokers typically smoked fewer cigarettes per day. So why do many smokers, and particularly African Americans and Latinos find menthol cigarettes to be particularly hard to quit?
In an earlier study we found that menthol cigarette smokers have higher nicotine, cotinine and carbon-monoxide levels than non-menthol smokers. This suggests that they tend to inhale more smoke from each cigarette. Menthol stimulates cold receptors and may therefore cool the harshness of cigarette smoke and make it easier to inhale larger amounts. It seems that the “menthol effect” is more pronounced in situations where the smoker may need to try to inhale more nicotine from fewer cigarettes. Thus in New Jersey, where we have amongst the highest cigarette taxes in the country, many people on low incomes can no longer afford to smoke a pack or two per day, but they have become addicted to that amount of nicotine. When a smoker reduces their cigarette consumption it is typical that they “compensate” by inhaling more from each one. This can be easily achieved, without any conscious effort, by taking larger puffs. But there comes a point where the larger puffs are difficult to sustain because of the smoke harshness causing an unpleasant effect on the throat. But for menthol cigarettes the larger puff means a larger cooling effect from the menthol. So the menthol enables the smoker to inhale more nicotine per cigarette, and perhaps obtain a stronger “hit” and become more addicted.
So it is possible that even if you are a relatively light smoker of menthol cigarettes, you may be more nicotine dependent than the simple daily cigarette consumption would imply. A summary of the new study may be found at: http://www.ncbi.nlm.nih.gov/pubmed/19222622?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum


For more information about our Tobacco Dependence Clinic, check out: http://www.healthline.com/blogs/smoking_cessation/2008/02/what-does-tobacco-treatment-clinic-do.html

Labels: addiction, cessation, cigarette smoking, jonathan foulds, menthol

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Walmart sells smoking cessation medicine for $9.

Last month Walmart announced that it has started selling the prescription-only smoking cessation medicine, bupropion (same drug as brand version, Zyban) at a lower price than any other effective smoking cessation medicine.

The starter pack, consisting of 17 bupropion 150mg extended-release tablets (a 10-day supply), sells for $9, and subsequent 30-day supplies (60 tablets) will cost $27 (less than $7 per week). Bupropion is typically taken as a single 150mg tablet per day for the first 3 days, then two tablets a day for the next 4 days. The smoker is advised to quit smoking completely on day 8, and continue on two tablets a day for approximately 8 weeks thereafter .

Currently smokers who don’t have health insurance coverage that includes smoking cessation medicines have to pay prices ranging from around $20 for a small box of generic nicotine gum intended to last a few days, up to around $55 for a 2-week supply of nicotine patches or around $130 for a month supply of varenicline (Chantix).

So the chance to get started on bupropion for an initial outlay of only $9, is much less expensive than other options, as is the continuing cost of around $27 per month. Not everyone can tolerate bupropion’s slightly stimulant initial side effect (including agitation and insomnia), but the initial 10-day supply is designed to take people to 3-days after their target quit date. So the smoker can find out if bupropion is helpful to them without a large initial financial outlay.
Bupropion also has the advantage that it can be combined with nicotine replacement therapy (e.g. nicotine gum) to obtain better results, as discussed in a prior blog posting: http://www.healthline.com/blogs/smoking_cessation/2007/09/does-it-help-to-add-nicotine-gum-to.html

You can find full details of the outcomes of smoking cessation treatment with bupropionas described in the New England Journal of Medicine at: http://content.nejm.org/cgi/content/abstract/340/9/685

You can find details of the Walmart announcement at: http://walmartstores.com/FactsNews/NewsRoom/8904.aspx

Labels: bupropion, Chantix, cigarette, jonathan foulds, nicotine gum, NRT, smoking cessation, varenicline

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Cigarette taxes to increase across USA

On February 4th President Obama signed legislation designed to provide health insurance to uninsured children in low-income families, which will be funded by a 62 cent increase in the federal cigarette tax per pack . This will increase the federal cigarette tax from 39 cents to just over a dollar per pack. The federal tax per packet of “little cigars” is also increasing to the same level ($1.01 per pack).This is the first time there has been a national increase in cigarette taxes for over a decade. Although the tobacco companies typically try to reduce the initial impact of such increases by offering temporary discounts, it will inevitably lead to an overall increase in the cost to the smoker per pack of cigarettes. This increase in federal cigarette taxes is in addition to increases in state and city cigarette taxes that are also sweeping the country. Although the cost per pack across the country will be around $5, in places such as New York City a packet of cigarettes will soon be well over $7. If you needed another reason to quit smoking, having to spend over $2000 a year on cigarettes, in tough financial times, might be the one. I hope you can find some helpful tips on other blog posts on this site that might help you succeed.Try some of the links on this post:http://www.healthline.com/blogs/smoking_cessation/2008/12/get-ready-for-smoke-free-2009.html

Labels: cigarette, cigarette tax, jonathan foulds, little cigar, smoking cessation

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What percentage of smokers can quit for $750?

It is sometimes suggested that the best way to get people to quit smoking is to pay them a decent amount of money to do so. Studies to date have found that financial incentives don’t have much effect on quitting, but in these studies the incentives on offer were often relatively weak (eg. $40).

However, a large trial has just been published in the New England Journal of Medicine today, which examined this issue. The team of researchers, led by Dr Kevin Volpp of the Philadelphia VA Medical Center, recruited 878 smokers at a large multinational company and randomly allocated each one to either (a) information about smoking cessation programs available within 20 miles or (b) the same information, plus a $100 incentive for completing a program, $250 incentive for quitting during the first 6 months, and $400 incentive to remain quit 6 months later (i.e. total potential incentive = $750).

What proportion of smokers do you think would be quit 9-12 months after receiving the incentive offer?

In this study 5% of the no-incentive group attended the smoking cessation programs, but 15% of the incentive group did. 21% of the incentive group quit in the first 6 months, compared with 12% of those with no incentives. And 15% of the incentive group remained quit 9-12 months after receiving the offer, compared with 5% of those just receiving the information about quit smoking programs (but no incentives).

Among the very heavy smokers (2 packs/day or more) in the study none of those with no incentives succeeded in quitting (0/27), and 2/22 (9%) of those offered the incentives succeeded in quitting.

Among those who participated in smoking cessation programs those who had incentives had higher quit rates (46% vs 21%).

This study therefore shows that if smokers are offered access to smoking cessation programs and a $750 incentive to quit, they are more likely to succeed (15%), than those with no incentive (5%).

The study participants were all employees and 90% were white. It remains to be seen if this effect would generalize to other groups. The authors point out the estimated financial benefit of having employees stop smoking is $3400 per year (savings in healthcare costs, absenteeism etc), and that it may therefore be cost effective to provide employees with incentives to quit. The effectiveness of such incentives also requires that smoking cessation programs be available, which they often are not.

It is worth highlighting what this study did NOT show. It did not show that all you have to do to get smokers to quit is offer them $750. In fact 85% of the smokers offered that incentive were unable to quit. Secondly, the findings from this study do not imply that we don’t need treatment services for smokers, we just need to pay them to quit. On the contrary, all the smokers in this study had treatment services available to them.

So it looks like an extra 10% of smokers can quit when offered $750 incentive, and when some treatment services are available. This is a worthwhile increase. The more complicated challenge is turning that finding from a research study into something that could be implemented on a wider scale. I dont believe there will be general acceptance of the principle of paying people to change their unhealthy behaviors. I also suspect that there may be more problems of implementation outside a thorough research study. Whats to stop a non-smoker claiming to be a smoker so they will be eligible for the bonus when they are (still) not smoking a year later? Can the average employer arrange the biochemical verifications necessary for the research study?

Ultimately I believe money may be better spent making sure all smokers have easy access to quality treatment services at no cost, and making sure they are fully aware of the personal benefits that will come to them from succeeding in quitting (cost savings from not buying cigarettes, improved health, lower health insurance premium etc).

Ref: Volpp K et al. A randomized, controlled trial of financial incentives for smoking cessation. N Eng J Med, 2009, 360:699-709

Labels: cessation, cigarette smoking, financial incentive, jonathan foulds

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