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Raising tobacco taxes: a timely prescription for U.S. public and fiscal health.

The President and Congress continue to struggle with finding effective solutions to our nation’s fiscal health. Both Democrats and Republicans agree that the cost of health care is a major driver of the nation’s growing public debt. But one reasonable proposal has been missing from the political discussion, one that would be good for both public and fiscal health: raising the federal tax on all tobacco products. Fifty years after the first Surgeon General’s Report on Smoking and Health, tobacco use remains the single most important preventable cause of death in the United States. Tobacco is estimated to cause 443,000 premature deaths and costs the nation dearly both in direct health care costs ($97 billion) and lost productivity ($97 billion) every year (1). The membership of the American Thoracic Society is acutely aware of the terrible human toll exacted by tobacco use, as they provide daily care to patients suffering from lung cancer, chronic obstructive pulmonary disease (COPD), and other tobaccorelated diseases. Tobacco control campaigns have been effective in reducing the prevalence of smoking over the past 50 years. Despite our efforts to date, 20% of the U.S population continues to smoke, with an estimated 3,800 young people under age 18 smoking their first cigarette each day and 1,000 of those going on to become addicted to tobacco (2). The tobacco industry continues to promote tobacco addiction and offers an increasingly diverse line of tobacco products. The available evidence supports the efficacy of robust clean air laws, mass media campaigns against smoking, and limits on the advertising of tobacco products on reducing tobacco use. But raising the retail price of all tobacco products through increased tobacco taxation may be the most cost-effective means of reducing both teenage and adult smoking. It follows the fundamental economic principle that as the price of a product increases, consumption of that product goes down, a principle that has been shown to hold for tobacco products (3). Research has shown that for every 10% increase in the cost of cigarettes there is a 3–5% decrease in cigarette consumption. Increasing the cost of cigarettes reduces both the prevalence of smoking and also the average number of cigarettes each smoker uses. Furthermore, children and teenagers are two to three times more likely to reduce smoking in response to a price increase than are adults (4). Federal and State Excise Taxes are key determinants of the price of tobacco products. States that increased tobacco taxes by at least 50 cents in the years 2006–2010 saw both a decline in pack sales and an increase in state revenue (5). Those states with low tobacco taxes (6) (and therefore low prices) have the highest smoking prevalence rates (7). The effectiveness of tobacco taxation as a means to reduce tobacco use has recently been confirmed. In 2009, Congress approved the Children’s Health Insurance Program Reauthorization Act (CHIPRA), which increased the federal tax rate on tobacco products. The tax increase reduced the percentage of students who smoked cigarettes in the last 30 days by 9–13%, which in turn reduced the number of young smokers by about 220,000 in the United States (8). Unfortunately, CHIPRA also created large federal excise tax disparities among tobacco products that made pipe tobacco less expensive than roll-your-own tobacco and manufactured cigarettes and large cigars less heavily taxed than small cigars and manufactured cigarettes. This created shifts in marketing by the tobacco industry and steered price-sensitive consumers to lowerpriced products. The tobacco industry, for example, increased the unit weight of certain “small” cigars so as to place them in the less heavily taxed “large” cigar class. The tax disparities also caused pipe tobacco to become a less expensive substitute for roll-yourown tobacco. As a result, from January 2009 to September 2011 monthly sales of “large” cigars increased from 411 million to over 1 billion, while the sale of “small” cigars fell from about 430 million to 60 million, the sale of pipe tobacco increased from approximately 240,000 pounds to over 3 million pounds, and the sale of roll-your-own tobacco dropped from about 2 million pounds to 315,000 pounds (9). To further complicate the situation, cigars and pipe tobacco are not regulated by the Food and Drug Administration, thus allowing the use of flavorings and misleading labels such as “light” and “low tar” that in turn makes them more appealing to the consumer. The effect of the disparity in tobacco taxes created by CHIPRA was that while there was a decrease in cigarette smoking from 2009 to 2011, it was accompanied by a large increase in smoking of other combustible products (10). These data argue strongly in favor of Congress closing the loophole created by CHIPRA by taxing all tobacco products at the same rate. Closing the CHIPRA loophole and equalizing tobacco taxes could generate up to $3.6 billion in new revenue over 10 years (11), improving our fiscal health. But, more importantly, these changes have the potential to greatly improve the nation’s public health by discouraging children and teenagers from becoming addicted to tobacco, either with puffed-up cigarettes masquerading for tax purposes as cigars or with pipe tobacco masquerading as roll-your-own tobacco. Taxes are an effective deterrent to smoking and also contribute to state and federal revenues. Taxes must be adjusted to allow for inflation and to counteract the manipulation of the price of tobacco products by the tobacco industry through promotions and discounts. There is a wide variation in state taxes on cigarettes. As of January 1, 2013, the average state tax on a pack of cigarettes was $1.49, with a range from $0.17 in Missouri to $4.35 in New York. Unfortunately states have failed to increase taxes on smokeless