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Smokers and the Affordable Care Act: Q&A

WebMD Health News
By Kathleen Doheny
Reviewed by Lisa Zamosky
The Affordable Care Act has ended some age-old health insurance practices such as denying people with pre-existing conditions. But it does allow insurance companies to charge people who use tobacco 50% more for their premiums.
Supporters say the higher premiums make sense because smokers and other tobacco users have higher health care costs. Critics say the higher rate is more likely to make people lie about their tobacco use or go without coverage than it is to encourage them to quit their habit. Smokers without insurance also put their partners and children at risk.
Here’s what smokers and others need to know.

What does the Affordable Care Act allow insurers to charge tobacco users?

Companies can charge tobacco users up to 50% more. States, though, can mandate a lower percentage or no surcharge.

What is ”tobacco use,” and how is a smoker or tobacco user defined?

Tobacco use is the use of any tobacco product, including cigarettes, cigars, chewing tobacco, snuff, and pipe tobacco, four or more times a week within the past 6 months. (Religious or ceremonial use of tobacco is allowed, such as by Alaska natives or Native Americans). It’s an honor system.

Will every state charge the maximum?

Seven states and Washington, D.C., will not charge smokers higher insurance premiums. The states are: California, Connecticut, Massachusetts, New Jersey, New York, Rhode Island, and Vermont.
Connecticut voted against the higher premiums only for the small group Marketplace, not the individual Marketplace. The other states outlawed higher premiums for both individuals and small business policies.
Three states — Arkansas, Colorado, and Kentucky — will allow companies to charge tobacco users less than 50%.
The remaining states are expected to allow the full 50% additional charge.
The highest possible premiums, though, won’t be effective for the first year because of a limitation in the software systems. That is being fixed.
Tobacco users in a small business plan don’t have to pay the higher premium if they enroll in a quit-smoking program; tobacco users in an individual plan may get a break on the premium if they enroll in a program. The law, however, does not require companies to offer the break in the individual Marketplace.

Will the Affordable Care Act require coverage of quit-smoking programs?

Yes.
The law requires all new private health insurance plans and Marketplace plans to cover services recommended by the U.S. Preventive Services Task Force, with no cost-sharing fees. That includes tobacco cessation treatments.

What will quit-smoking treatments or programs include?

That is unclear.
Insurance companies don’t have a consistent approach to quit-smoking programs, says Erika Sward, a spokeswoman for the American Lung Association. “What we have seen is a patchwork quilt.”
While the Affordable Care Act requires that new plans cover services recommended by the task force, the task force does not give specifics. It recommends that doctors ask adults about tobacco use, provide cessation programs, and provide counseling for women who smoke during pregnancy.
But there are no ”typical” tobacco cessation programs, according to a survey conducted by Georgetown University researchers.
What’s needed, Sward says, is a comprehensive approach. According to the American Lung Association, tobacco cessation benefits should include the choices recommended by the Public Health Service. These include:
   -Nicotine — from a patch, gum, lozenge, nasal spray, or inhaler
   -Medications — bupropion (Zyban) and varenicline (Chantix)
-Counseling — individual, group, and phone
In one area, the law is specific: It requires that pregnant women on Medicaid be offered the treatments recommended by the U.S. Public Health Service. Those include asking about tobacco use and offering counseling, with no recommendation aboutmedication use in pregnancy.

Who supports higher premiums for tobacco users?

The insurance industry supports higher rates because smokers have much higher health care costs than nonsmokers, according to Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade industry group.
“There is clear documentation of so much greater health care costs [for tobacco users], and we think that should be reflected in the rates,” she says.
In 2004, smoking cost the U.S. $97 billion in lost productivity and $96 billion in direct health care costs, or $4,260 per adult smoker, according to the CDC.
More than half of Americans favor charging smokers more for insurance, according to a Gallup poll released in mid-August.

Who is against higher premiums for tobacco users?

Many health organizations, including the American Lung Association and the American Cancer Society, are against higher rates for smokers and other tobacco users.
The higher premium, besides being discriminatory, may backfire, Sward says.
“We really urge the carrot over the stick approach,” she says. “We know smokers want to quit and they need help to do so. It’s in everyone’s best interest that smokers have access to a good cessation program.”
SOURCES: Erika Sward, spokeswoman, American Lung Association.Susan Pisano, spokeswoman, America’s Health Insurance Plans.Alicia Hartinger, Health and Human Services.U.S. Public Health Services.U.S. Preventive Services Task ForceGallup.
 

Mayor Emanuel Cracks Down on the Tobacco Industry over Marketing of Menthol Tobacco in Continuing Efforts to Reduce Tobacco Use Among Youth

FOR IMMEDIATE RELEASE:
Mayor’s Press Office
As part of his overall campaign to curb youth smoking, Mayor Rahm Emanuel today went after the tobacco industry to curb marketing practices that target youth. This call for action comes on the heels of a cease and desist and several notices of violation issued by the City of Chicago Department of Business Affairs and Consumer Protection (BACP) against tobacco giant R.J. Reynolds for the alleged distribution of tobacco coupons without a license. The City and Board of Health will investigate these practices further and consider additional actions the City can take to combat them through a series of Town Hall meetings that will take place is September.
“Flavored tobacco is a leading gateway to smoking addiction for our youth, which is why we must come together as a community to protect our young people from what too often becomes a lifelong and life threatening habit,” said Mayor Emanuel, “The City of Chicago will continue to pursue action against the tobacco industry as we look for innovative ways to eliminate menthol use among our youth. I will work with the Board of Health and Chicagoans from across the city to expand our efforts to combat youth smoking.”
BACP issued a notice of violation to R.J. Reynolds for the alleged distribution of discount coupons for menthol tobacco products without the appropriate license. The coupons allowed for the purchase of tobacco products for one dollar, an up to 90% percent discount from their retail price, and were distributed at a Lakeview bar on August 11th 2013. The City is investigating whether the company or its agents distributed any coupons at other locations and will continue to investigate illegal tobacco activities. In other efforts to protect Chicago’s youth, BACP has closely monitored and taken enforcement actions against businesses that sell tobacco to minors, with increased enforcement in safe passage zones.
Distribution of the coupons took place after Mayor Emanuel’s call to the Chicago Board of Health to investigate the impact of flavored tobacco, including menthol, on Chicago youth. At its August public meeting, the Board will consider a resolution to hold four Town Hall meetings to solicit input from the public as it considers additional policy options for reducing youth smoking.
The town hall meetings will be held from 6:30-8:00 p.m. on:

  • September 5 (Chicago State University, 9501 S. King Drive, Chicago, IL 60628)
  • September 10 (General Robert E. Wood Boys & Girls Club, 2950 W. 25th St., Chicago, IL 60623)
  • September 17 (Center on Halsted, 3656 N. Halsted St., Chicago, IL 60613)
  • September 19 (Austin Town Hall Park, 5610 W. Lake St., Chicago, IL 60644)

Following the town hall meetings, the Board of Health and Chicago Department of Public Health (CDPH) will release a comprehensive report detailing feedback from participants, including youth, as well as policy recommendations from public health professionals, scientists and other content experts to help Mayor Emanuel create a more comprehensive public health strategy.
“Menthol-flavored cigarettes have affected generation after generation of youths in Chicago and addressing the issue now is critically important to the health of our city,” said Dr. Bechara Choucair, Commissioner of CDPH. “With minority populations so disproportionately targeted by the tobacco industry, this is truly a matter of health justice and equity.”
In a letter to the Board on July 25, Mayor Emanuel highlighted the particular dangers menthol-flavored cigarettes pose to young people. Specifically, among African American youth ages 12-17 who smoke, 72 percent use menthol-flavored cigarettes. The numbers are nearly as high for LGBT and Asian American youth (71 percent for both groups) who smoke. In addition, nearly 50 percent of Latino youth who smoke use menthol-flavored cigarettes.
Furthermore, if smokers begin the habit before age 18, they are 75 percent more likely to smoke as adults. Put simply, menthol-flavored cigarettes attract youth who would not otherwise be smokers, and taking action to limit their use will have a positive effect on the community as a whole. Derived from the peppermint plant, menthol provides a deceptively minty flavor and cooling sensation in cigarettes, covering up the tobacco taste and reducing the throat irritation associated with smoking, particularly among first-time users.
“Big tobacco is using menthol-flavored cigarettes to turn our children into lifelong addicts,” said Dr. Carolyn Lopez, president of the Board. “By passing this resolution today, the Board stands with parents and youth across the city to help stop this problem and protect our families. Together, we will help ensure our youth have the opportunity to grow into healthy adults.”
This fall, CDPH’s Tobacco Prevention and Control program will launch a public awareness campaign that focuses on menthol-flavored cigarette use. These programs are part of Mayor Emanuel’s call to action under the City of Chicago’s Public Health agenda entitled “Healthy Chicago.” This is the first-ever comprehensive plan for public health put forth by the City and it continues to serve as a blueprint for a focused approach by CDPH to implement policies and systems changes to priorities and transform the health of Chicago.

Letter: NDQuits wins a commendation

By: Jessie Azure, West Fargo, INFORUM
I would like to commend those with NDQuits on finding a creative way to reach a “tobacco at risk community!”
Clearly, representatives from the North Dakota Policy Council need to sit down and read the 2007 Best Practices manual issued by the CDC on Tobacco Prevention and Control Policy before commenting. Maybe then they’d understand the importance of reaching target populations with education and support.
Their comments make me ask a far more important question: What if the parade had been for an organization raising awareness for mental health (as this is another community with a high rate of tobacco use)? Would Zach Tiggelaar still be compelled to question such actions? I bet he’d agree that we shouldn’t dismiss one community over another; rather, look to find ways to reach all of our citizens, just as the folks at NDQuits did. After all, as Rep. Josh Boschee, D-Fargo, reminds us, the cost of tobacco is far more staggering to treat than prevent.
http://www.inforum.com/event/article/id/406374/

Tobacco tax: Myth vs. facts

To the editor:
We were disappointed to read the opinions expressed in the July 6 editorial. We would like to provide your readers with accurate information based on fact (references readily available).
The following points address several myths presented by Mr. Peterson:
Myth: The new tobacco tax will help pay for the Vikings Stadium. Fact: The revenue from the tobacco tax will go into the general fund. Some of the money from a one-time tax on cigarette inventory in stores may go to the stadium.
Myth: Raising the tobacco tax is unfair to smokers. Fact: The cost of treating tobacco-related disease far exceeds the amount of tobacco tax collected by smokers. Every man, woman and child in Minnesota pays $554 in excess health care costs due to smoking whether they smoke or not.
Myth: Smokers won’t quit even if the price increases. Fact: Research shows that a $1.60 per pack tax increase will help more than 36,600 current Minnesota smokers quit. In our state, we are fortunate that all smokers have access to free cessation services through QUITPLAN. In addition, low-income smokers suffer disproportionately from the health effects of smoking, and are 70 percent more responsive to price increases.
Myth: Tobacco tax revenue isn’t reliable. Fact: Every state that has significantly raised its tobacco tax has seen an increase in state revenue and health benefits for residents.
The new tax on cigarettes and other tobacco products is estimated to generate approximately $400 million over the next two years and will save our state more than $1.65 billion in long-term health care costs.
Myth: Raising the tobacco tax will force people over the border. Fact: In most places, the price difference isn’t substantial enough to cause people to cross the border to buy cigarettes. Some may cross occasionally, but the number of individuals who do this is statistically very low. Most smokers will continue to buy their cigarettes in Minnesota.
Research has consistently shown that raising the price of tobacco is one of the most effective ways to help smokers quit and prevent kids from starting. Saving Minnesota lives and our kids from a lifetime of addiction is “fair” and a great idea in our book (of facts).
Southwest Community Health Improvement Program (C.H.I.P) members
Paula Bloemendaal
Val Dallenbach
Judy Pitzl
Kris Wegner
http://www.marshallindependent.com/page/content.detail/id/540688/Tobacco-tax–Myth-vs–facts.html?nav=5072

Higher cigarette prices do save lives

These findings are a result of a World Health Organization (WHO) study of 41 countries where smoking policies have been in place since 2007.
From their MPOWER model – which stands for Monitoring tobacco use and prevention policies, Protecting people from tobacco smoke, Offering help to quit tobacco use,Warning people about the dangers of tobacco, Enforcing bans on tobacco advertising, and Raising taxes on tobacco – the WHO was able to predict that 7.4 million deaths could be prevented by 2050.
The research has shown that increasing taxes on cigarettes by up to 75% had the greatest impact on smoking, even more so than anti-smoking policies. While smoke-free air laws in 20 of the focus countries had averted 2.5 million premature deaths, tax rises prevented 3.5 million smoking-related deaths.
“Tobacco use is the single most preventable cause of death in the world, with six million smoking-attributable deaths per year today, and these deaths are projected to rise to eight million a year by 2030, if current trends continue,” said Douglas Bettcher, WHO director of the department of non-communicable diseases.
However, even with greater scientific evidence that smoking kills, some people are still resistant to change. And South Africans are no exception.
An uphill battle
Readers’ responses to an article on Heath24 earlier this year, titled ‘SA set to go 100% smoke-free’, are redolent of the resistance faced by advocates for a smoke-free society.
The article covered the announcement by the South African government that new legislation would make all indoors and some outdoor areas 100% smoke-free.
According to the proposed legislation, smoking will be prohibited in:

  • Stadiums, arenas, schools and childcare facilities
  • Health facilities
  • Outdoor eating or drinking areas
  • Places where outdoor events take place
  • Covered walkways and covered parking areas
  • Outdoor service areas and queues
  • Beaches, within 50 metres of a demarcated swimming area
  • Five to 10 metres of entrances, doorways, windows and ventilation inlets

What some of our readers have to say:
Martin said: “I shall continue to smoke in my office, and people needing to see me will continue to wait outside… I’m sorry, cigarettes contribute so little to general air pollution. Look at cars, industries etc. – there are your culprits… my guys suck up welding fumes all day, but smoking is banned, WTF?!?”
Dieter asked: “Is he [the minister of health] that bored with life that they would do something like that? What about overweight people, are they gonna make them stop eating as well? Get a job you’re good at!”
Raven said: “So, my freedom of choice is removed. Where do I sign to have this law scrapped?”
Charmain Nel said: “People give me the sh*ts when all they talk about is smoking. First do something about the DRINKERS WHO KILL PEOPLE. I have never KILLED WHEN SMOKING. The ones that are having a fit are all DRINKERS, which is why nothing gets done. LEAVE US SMOKERS ALONE!”
But with more studies concretely pointing to the dangers of smoking, both for smoker and non-smokers, it’s clear that researchers are not ready to leave the matter alone.
Scientifically speaking
Scientists from the Lawrence Berkeley National Laboratory, in the USA, recently proved that third-hand smoke can also kill over time.
They proved that the smelly residue (third-hand smoke), which sticks to almost all surfaces long after the second-hand smoke has cleared out, can actually cause significant long-term genetic damage to human cells.
The researchers said that chemical compounds found in third-hand smoke are among the most potent carcinogens around and are capable of causing most cancers in humans.
And estimated 30% of South Africans are smokers, and about 60% of all lung cancer deaths in South Africa are due to tobacco smoking, according to the national Lung Cancer Association.
“By taking the right measures, this tobacco epidemic can be entirely prevented,” concluded WHO’s Douglas Bettcher.
Hayden Horner
http://www.health24.com/Lifestyle/Stop-smoking/News/Higher-cigarette-prices-do-save-lives-20130717

Poor Diet, Tobacco Use and Lack of Physical Activity Taking Toll on Nation's Health

By Derek Yach, executive director, The Vitality Institute, and a former executive director of the World Health Organization (WHO), and Will Rosenzweig, institute commission chair and managing partner, Physic Ventures
While we’re living longer, poor diet, tobacco use and inadequate physical activity are negatively impacting our health. These are some of the findings of research released this week by the U.S. Burden of Disease Collaborators, prompting much discussion and debate. To those of us on the front lines of promoting workplace health this comes as no surprise. This study should only add to the sense of urgency that we as a nation must have in solving this crisis.
There is a direct link between the health of the U.S. workforce and the overall wellbeing of the U.S. economy. Currently, greater than 50 percent of Americans live with one or more chronic disease. With this rising burden of chronic disease comes rising costs within the health care system, and increased premiums at a cost to employers. Compounding this, employees with chronic disease take more sick days and are less productive on the job. Workplace health is of significant importance to the economic productivity of the nation and critical to reducing the national debt. The U.S. is slipping behind its major Organization for Economic Co-operation and Development Countries (OECD) competitors regarding improvements in population health. Specifically, the U.S. falls in the bottom 20 percent of the 34 OECD countries for the following chronic diseases: ischemic heart diseases (rank: 27), lung cancer (28), COPD (32), diabetes (31), cardiomyopathy (31), chronic kidney disease (31), and hypertensive heart disease (27). Poorer health today could translate into lower productivity tomorrow.
This is the first major analysis of the health status of the U.S. population in more than 15 years, led by a global collaborative of scientists from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. The study found that while Americans are showing progress in reducing death rates (adjusted for age, across a variety of diseases), we aren’t living healthier. Additionally, death rates from illnesses associated with obesity, such as diabetes and kidney disease, as well as neurological conditions like Alzheimer’s disease, are on the rise. Poor diet, tobacco use and physical inactivity are driving the disease burden.
The negative impact on our health care system cannot be understated as people who live longer and unhealthier lives are costly — not only in terms of health care spend, but the impact on the productivity of our workforce and the ability of U.S. businesses to compete in a global economy. A point made recently in the Bipartisan Policy Center’s recent report.
None of this is news to The Vitality Institute, a global health think tank focused on reducing chronic disease risk. In fact, we recently released new data indicating a dangerous gap in the chronological age of Americans and their risk adjusted Vitality Age, as calculated based on a variety of factors including those cited in this new report.
So now that we so clearly understand the problem, what are we going to do about it? To that end, we’ve recently assembled The Vitality Institute Commission. We’re bringing together prominent thinkers in health and business including: Dr. Rhonda Cornum, with deep expertise from the Department of Defense; Susan Dentzer, with Robert Wood Johnson Foundation; Ginny Ehrlich, with the Clinton Health Matters Initiative; Jeff Levi, with Trust for America’s Health; Ellis Rubinstein, with the New York Academy of Sciences; Dr. Dennis Schmuland, with Microsoft; and Dr. Kevin Volpp, from the University of Pennsylvania. All with the urgent goal of placing the power of evidence-based prevention at the center of health care policies and actions in the U.S. Better evidence, smarter laws and higher levels of innovation we believe could make a difference.
There is strength in numbers, and we are working with corporations, associations, federal, state, and local government to identify multi-stakeholder solutions that will address the issues facing our nation’s health in bold and transformative ways.
For the U.S. to maintain its economic competitiveness, our health policy efforts need to address the risk factors of preventable chronic diseases that disproportionately affect the U.S. population (e.g., physical inactivity, diet, and alcohol and tobacco consumption) by effectively investing resources to ensure that each individual has the opportunity to make beneficial contributions to society and therefore progress the economy. We will soon issue a call for wide participation to harness the myriad of great ideas and actions already making a difference at the community, city or state level to ultimately improve America’s health.
http://www.huffingtonpost.com/dr-derek-yach/americans-health_b_3588588.html

Mental illness, tobacco turn out to be deadly combo

By: John Lundy, Duluth News Tribune
It’s hard to quit smoking.
For individuals struggling with a mental illness, it’s even harder.
“They have higher levels of biological or physical addiction to nicotine, in many cases,” said Dr. Jill Williams, an addiction psychiatrist. “In illnesses like depression, studies show that they’re more addicted than other smokers.”
Yet mental health treatment is lagging when it comes to tobacco addiction, said Williams, who specializes in mental health and tobacco at the Robert Wood Johnson Medical School in New Jersey.
Her effort to correct brings Williams to Duluth today. At the behest of the American Lung Association in Minnesota, Williams is conducting a daylong conference for mental health professionals at the University of Minnesota Duluth.
About 75 people were signed up for the event, said Pat McKone of the lung association. Earlier this week, Williams led a similar conference in Moorhead, Minn., with 100 in attendance.
The Minnesota group brought Williams to the state because of the toll smoking takes on people with mental illness, an American Lung Association news release said. It cites studies from several states showing that people with severe mental illness die, on average, 25 years earlier than the general public. Their No. 1 cause of death? Heart disease related to tobacco use, the studies show.
Moreover, the percentage of people with mental illness who smoke is much higher than that of the general population, the Centers for Disease Control and Prevention reported earlier this year. From 2009-11, 36 percent of adults with mental illness smoked, compared with 21 percent of the rest of the population, the CDC said.
The numbers in Wisconsin are similar, but the discrepancy in Minnesota is even greater: Just over 40 percent of Minnesota adults with mental illnesses smoke, compared to just under 20 percent of the rest of the population.
Part of the problem, Williams said in a telephone interview, is the lack of treatment.
“If you get your care from the behavioral health system, it’s just unlikely that you’ll be able to get treatment for your tobacco addiction in those settings,” she said. “Traditionally, that’s not been offered there.”
People with mental illness respond to medication and counseling to treat tobacco addiction, Williams said, although it may need to be more intense. And the mental health treatment centers and residences already have the counselors trained in addiction treatment, she said. They just need the specific training for tobacco.
“That’s why these trainings are so important,” Williams said. “When we do the training, it’s not unusual that people say this is the first time they ever had training on tobacco addiction in their professional career.”
Another issue, Williams said, is addressing public policy so that people who provide tobacco treatment are reimbursed as well as people who treat other forms of addiction.
“If we paid people better to do tobacco treatment, I think a lot more of it would be available,” she said.

How Obama’s tobacco tax would drive down smoking rates

By Sarah Kliff, Washington Post
President Obama’s proposal to nearly double the federal tobacco tax would help fund a universal pre-K program. And, if history is any guide, it would likely have a marked impact on driving down the country’s smoking rates.
“Increasing the price of tobacco is the single most effective way to discourage kids from smoking,” CDC director Tom Frieden told reporters Tuesday afternoon. “We estimate this would result in at least 230,000 fewer kids smoking than would have smoked if the tobacco tax does not go into effect.”
Researchers have conducted over 100 studies that have “clearly and consistently demonstrated that higher cigarette and other tobacco product prices reduce tobacco use,” Frank Chaloupka, a professor at the University of Illinois in Chicago, writes. While tobacco is an addictive substance, demand tends to be surprisingly elastic: Price increases have reliably shown to decrease cigarette purchases.
The Congressional Budget Office recently looked at what would happen if the country implemented a 50-cent per pack tax on cigarettes. It estimates, given the research we have on tobacco taxes, that the price increase would lead to 1.4 million fewer smokers by 2021.
Many of those gains would be concentrated among younger Americans, who would take up smoking at lower rates:
A few years after the hypothetical tax increase took effect, the number of 12- to 17-year-olds who smoked cigarettes would be about 5 percent lower than it would be otherwise, the number of 18-year-old smokers would be 4.5 percent lower, the number of 19- to 39-year-old smokers would be almost 4 percent lower, and the number of smokers age 40 or older would be about 1.5 percent lower.
The CBO data suggests that a cigarette tax is more successful at reducing tobacco use among shorter-term smokers, vs. older Americans who may have been smokers for a longer period of time.
Even among those who don’t fully quit, tobacco taxes do appear to effect the intensity of smoking. A 2012 study in the journal Tobacco Control interviewed thousands of smokers over a time period where states increased their tobacco taxes. It found that the most intense smokers — those who smoked 40 or more cigarettes per day — saw the steepest decline in cigarette consumption.
“The dramatic reductions in daily smoking might be driven,at least in part, by heavier smokers’ desire to reduce the number of cigarettes they smoke per day,” lead study author Patricia A Cavazos-Rehg writes. “This could be because of their comorbid health problems and/or advice from influential persons (eg, doctors/friends/family) to try to quit and/or reduce smoking.”
http://www.washingtonpost.com/blogs/wonkblog/wp/2013/04/11/how-obamas-tobacco-tax-would-drive-down-smoking-rates/