Correspondence

Tobacco Litigation

N Engl J Med 1997; 336:1832-1834June 19, 1997

Article

To the Editor:

In his review of tobacco litigation (Jan. 23 issue),1 Annas suggests that increasing taxes on cigarettes to fund social programs such as Medicaid is unfair to addicted smokers. However, I believe that such taxes are not only fair, but also beneficial to such smokers. When cigarette taxes are increased, there is always a decline in consumption.2 Although this decline involves a reduction in the average number of cigarettes smoked per smoker, it mainly constitutes a reduction in the prevalence of smoking.3 Thus, offering increased financial incentives to quit smoking causes more smokers to quit and lead longer, higher-quality lives. Those who do not quit will be funding programs such as Medicaid, which their smoking will inevitably lead them to need to a greater degree. What could be more fair?

A decline in smoking with increased taxes is seen to an even greater degree among teenagers. The General Accounting Office estimated the effect on teenage smoking of a tax increase and predicted that a 21-cent tax increase would result in the number of teenage smokers being reduced by more than one-half million.4 Because deterrence in the teenage years may result in lifelong abstinence from smoking, the effect on the health of this group is especially important.

In addition, I question Annas's claim that “Prohibition has not worked and will not work, and to the extent that the proposed OSHA [Occupational Safety and Health Administration] workplace rules would amount to a total prohibition on smoking in all workplaces, they would not work either.” The experience of numerous cities, states, and industries has shown that global prohibitions of smoking, such as those applying to all restaurants, all public places, or all domestic flights, are highly supported by both smokers and nonsmokers and are virtually self-enforcing.

Edward Z. Lawyer, M.S.
University of Wisconsin–Madison, Madison, WI 53705

4 References

1. 1

   Annas GJ. Tobacco litigation as cancer prevention: dealing with the devil. N Engl J Med 1997;336:304-308
   Full Text | Web of Science | Medline

2. 2

   Department of Health and Human Services. Reducing the health consequences of smoking: 25 years of progress: a report of the Surgeon General. Washington, D.C.: Government Printing Office, 1989. (DHHS publication no. (CDC) 89-8411.)
   

3. 3

   Lewit EM, Coate D. The potential for using excise taxes to reduce smoking. J Health Econ 1982;1:121-145
   CrossRef | Medline

4. 4

   General Accounting Office. Teenage smoking: higher excise tax should significantly reduce the number of smokers. Washington, D.C.: General Accounting Office, June 1989. (GAO publication no. HRD-89-119.)
   

To the Editor:

“Secret” documents showing that tobacco companies knew that their product was addictive are titillating and fuel the prejudicial fires being lit under the industry, but since when is keeping business documents and opinions secret a crime? People understood centuries ago that cigarettes and tobacco were addictive, but the precise definition of addiction is subject to disagreement among specialists even today. Holding tobacco companies liable for their past opinions on what constitutes addiction is a tenuous legal stance at best. Self-addiction should not create liability for others.

The goal of the anti-tobacco jihad — to eliminate tobacco smoking by any means possible — does not justify using the courts to blackmail the tobacco industry into accepting responsibility for the ills created by selling their product to a free people. Tobacco is, after all, a legal commodity, a product nobody forces anyone to buy or use. Millions of people who took up smoking have quit. Those who continue to smoke do so with full knowledge of the considerable risks of smoking, which are conveniently printed in bold type on each pack of cigarettes.

Using lawsuits to force politically incorrect businesses into bankruptcy is backdoor tyranny. The corrosive effects on personal freedom engendered by shifting the consequences of making a choice from the individual to a deep-pocket third party are immeasurable. I may not agree that you smoke, but I will defend to your death your right to do so.

Perhaps the tobacco industry should follow the medical model and ask customers to sign a statement of informed consent in exchange for, say, a carton of cigarettes or a baker's dozen of snuff cans. If society accepts as moral that a person can give consent for an elective medical procedure that carries a 0.5 to 1 percent risk of death or complication, then acknowledging that tobacco also has a risk–benefit ratio that the individual must judge and holding the tobacco industry to no less than the medical standard of informed consent should be equally acceptable.

Jesse A. Cole, M.D.
330 Basin Creek Rd., Butte, MT 59701

To the Editor:

Annas ignores some crucial points. The Centers for Disease Control and Prevention estimated conservatively that in 1993 the direct medical costs associated with smoking in the United States totaled $50 billion (or $2.06 per pack of cigarettes).1 Those figures do not take into consideration the indirect medical costs, the effects of subsequent inflation, the detrimental effects of lost productivity and early death, or the adverse consequences for the national debt.

The group most affected by an increased tax would be people under 18, those least able to pay. This is the group most desirable to target. In addition, a tax increase would affect the smoking rates of all other age groups. Government efforts to limit childhood smoking are very important. However, a much quicker and more pronounced decrease in smoking-associated morbidity and mortality would be seen if excise taxes were greatly increased, because of both the decrease in the number who start smoking and the medical benefits of stopping.

Increasing the excise tax is a very effective public policy. Between 1980 and 1991, the Canadian federal and provincial taxes on a pack of cigarettes increased from $0.46 to $3.72 (Canadian), while cigarette sales fell by 39 percent; tobacco consumption in Canada declined by 30.0 percent — more than the corresponding U.S. rate. Per capita cigarette consumption fell by 0.5 percent for every 1 percent increase in price2 — a change similar to the 0.42 percent decline in consumption often cited for comparable price increases in the United States.3

A federal excise tax of $2 per cigarette pack is advocated by many medical organizations. On the basis of historical rates of decline in consumption per percent price increase, a tax in that amount could eventually prevent more than 100,000 tobacco-related deaths per year in the United States. It may be the quickest and most effective method of implementing a healthy public policy — allowing people to smoke but making them pay the bills that result from their behavior.

Michael Rabinoff, Ph.D., D.O.
UCLA Neuropsychiatric Institute, Los Angeles, CA 90024

3 References

1. 1

   Medical-care expenditures attributable to cigarette smoking -- United States, 1993. MMWR Morb Mortal Wkly Rep 1994;43:469-472
   Medline

2. 2

   Green LW. Taxes and the tobacco wars. Can Med Assoc J 1997;156:205-206
   Web of Science

3. 3

   Lewit EM, Coate D. The potential for using excise taxes to reduce smoking. J Health Econ 1982;1:121-145
   CrossRef | Medline

To the Editor:

Here is professional heresy — I believe adults should be allowed to smoke. Lawyers and states should abandon their interest (and potential windfalls) in antitobacco litigation. Such efforts are costly, monetarily and constitutionally.

Am I heralding the cause of smoking? No. I believe it is harmful and expensive. But why should smoking be targeted more than any other noxious activity? Suppose, for a moment, that we litigated against other sources of health problems as we do against tobacco. What would we have? There could be litigation against fatty foods, people who do not exercise regularly, alcohol consumption (and perhaps even the use of marijuana), morbid obesity, diabetics who do not vigorously maintain their blood glucose levels in a therapeutic range, gamblers, promiscuous carriers of the human immunodeficiency virus who do not follow appropriate precautions, guns, illicit-drug users, as well as suicidal people who recklessly forget to take antidepressant medications. The list, ridiculous as it may appear in parts, is endless.

In a democratic society, adults should be able to decide many aspects of their existence.

Stefan P. Kruszewski, M.D.
Pottsville Hospital and Warne Clinic, Pottsville, PA 17901

Author/Editor Response

Professor Annas replies:

To the Editor: Since the publication of my article and the writing of these responses, the Liggett Group has settled lawsuits brought by 22 states by acknowledging that nicotine is addictive and that cigarettes cause cancer, admitting that cigarette companies advertise to children, and agreeing to pay 25 percent of its pretax profits to the 22 states for the next 25 years.1 Liggett will also turn over secret documents that the states may use to pursue their lawsuits against the other tobacco companies. Of course, it is no secret to anyone that nicotine is addictive, that cigarettes cause cancer, and that tobacco companies market to children.

Nor is celebration in order. As these letters indicate, in the tobacco-control field there always seem to be paradoxes that flatter neither side. Liggett, for example, may well have been saved from bankruptcy by the settlement, and after 25 years it will be essentially immune to addiction-related lawsuits. The states have been all too eager to become economic partners with Liggett, and with this settlement they stand to profit directly and in proportion to Liggett from the sale of a product that both the manufacturer and the states now recognize as deadly and addictive. As my article indicated, any settlement that does not include mandatory reductions in the levels of nicotine and cancer-causing substances in cigarettes is not healthy.

The views of Drs. Cole and Kruszewski at least suggest that they believe the state lawsuits are mistaken in the first place and that transforming the states from enemies of tobacco to partners compounds the error in the litigation strategy. There is much to be said for this view. Lawyer and Rabinoff, on the other hand, would probably applaud the settlement, because they encourage states to gain even more revenue from tobacco sales by increasing taxes. They are correct in noting that I generally oppose taxing addicts to meet society's obligations to the poor. Nonetheless, if the only politically viable way to fund health care for our uninsured citizens is to raise the tax on tobacco, this is probably not too high a price to pay.2,3

George J. Annas, J.D., M.P.H.
Boston University Schools of Medicine and Public Health, Boston, MA 02118

3 References

1. 1

   Broder JM. Cigarette maker concedes smoking can cause cancer. New York Times. March 21, 1997:1.
   

2. 2

   Clymer A. 8 G.O.P. senators back bill to aid uninsured youths. New York Times. April 9, 1997:1.
   

3. 3

   Clymer A. Cigarette tax rise pays for child health plan: expanding care in Massachusetts. New York Times. February 28, 1997:A14.