COLUMBIA — Two and a half billion dollars: That's how much tobacco use cost Missouri residents in 2010 in direct health care expenditures, according to a study published by the American Lung Association.
Supporters of Proposition B, a ballot proposal that calls for an increase in Missouri's tobacco excise tax, think the proposal would cut those costs. Opponents say the tax increase is too large and will hurt the state's economy.
Missouri ranks fourth nationally in the number of adult smokers and fifth in new lung cancer cases. As of 2011, the state also ranked 48th, spending only $58,693, in funding tobacco prevention programs and received a failing grade on the American Lung Association's Smoking Report Card for the fourth consecutive year in all four categories: smoke-free air, program spending, cigarette tax, and cessation.
Tobacco use also creates substantial health care costs. According to a Pfizer-funded study conducted by researchers at Penn State University, Americans spent $116.4 billion on health care associated with tobacco use in 2010. That same study showed that Missouri incurred $7.2 billion in total costs (including direct health care expenditures, workplace productivity losses, and premature deaths) from tobacco use. Put another way, the average price of a pack of cigarettes in Missouri is $4.30, but the average health care cost is $12.86, the study states.
This story was created with the help of the Public Insight Network.
We asked readers if they thought increasing the tax on cigarette packs would prevent people from smoking. Here's what one reader said:
"Absolutely. Especially young people because they have less disposable income to spend on cigarettes. I think it will also motivate older people to quit!" — Kimberly Nolte
Missouri has the lowest tobacco excise tax in the country. Proposition B, if approved, would push the per-pack tax on name-brand cigarettes such as Marlboro and Camel to 90 cents, a 73-cent increase from its current national low of 17 cents. The tax on a pack of value-brand cigarettes, such as Decade, would be $1.47, or an increase of 760 percent. Taxes on other tobacco products, such as snuff and chew, would rise 150 percent.
Ballot language on Proposition B says the state would use the money it generates to boost funding for K-12 public education and for state colleges and universities, as well as for programs intended to prevent people from using tobacco or to help them quit. The fiscal note on Proposition B estimates it would generate $283 million to $423 million.
Under the proposal, 80 percent of the tax revenue would go toward education. The remaining 20 percent would pay for tobacco prevention and cessation programs, including counseling and intervention; nicotine replacement therapies (gum, patches and nicotine inhalers); prescription drug treatments and alternative treatments (hypnosis and meditation).
Motivation to quit tobacco
Boone County and MU provide free nicotine replacement treatments as well as counseling, and Columbia's Housing Development Authority has offered smoking cessation classes to residents.
Data from the Centers for Disease Control and Prevention, however, show that smokers are unlikely to quit until they feel the pain in their pocketbooks. Every 10 percent increase in cigarette prices reduces tobacco consumption among young adults and teenagers by 6 to 7 percent and by 4 percent in adults, according to the U.S. surgeon general.
A 2009 national survey conducted by The National Bureau of Economic Research reported a "substantial short-term decrease" in the consumption of cigarettes and smokeless tobacco by eighth-graders and high school students after an increase in the federal excise tax on tobacco in April of that year.
Meanwhile, in the 10 years after California approved a 25-cent-per-pack excise tax increase on cigarettes in 1988, smoking rates among adults in the state fell from 22.7 percent to about 18 percent, according to the CDC.
That kind of evidence has Kevin Everett, an associate professor of community medicine at MU and a clinical psychologist, convinced that higher tobacco prices would have a profound effect on tobacco use in Missouri, both for current and potential smokers.
"The price increase makes people who were thinking about starting to smoke not want to pay that money," said Everett, who has spent more than 15 years researching tobacco consumption. "It predominantly affects young people. In that way a price increase is the best practice for reducing smoking."
Traci Kennedy, director of Tobacco-Free Missouri, agrees.
"A price increase is one of the best policy options that we know of to keep young people from starting to smoke," she said. "Raising the tax is not being done just in the hopes that people will quit, but what we do find is that in other states with higher prices there are fewer smokers."
Erica Heitzman, an MU senior who has tried to quit smoking in the past, said she thinks higher prices would have a dramatic impact. As she chewed a piece of nicotine gum at a downtown coffee shop, Heitzman talked about her past attempts to quit and the potential effects of higher cigarette prices.
At the current price — about $4.50 a pack for name brands — smoking doesn't seem too expensive for her budget, she said. "But if it was more, it wouldn't seem as worth it for me to buy cigarettes," she said. "It would feel like throwing money away."
"People are going to smoke regardless of the price of cigarettes," said Margy Chrestman, an employee at the Columbia smoke shop Eye Candy.
Her friend, Brandon Lang, who was having a smoke with Chrestman on a recent afternoon, said he thinks Proposition B is "a giant guise to get more money from regular people." He dismissed the notion that a price increase would have a substantial impact on smoking rates.
Helping people kick the habit
The proposed tax also would funnel state money — which Kennedy called "almost abysmal" at its current levels — into cessation programs.
"This funding would also provide cessation assistance to people who can't afford it, which is key because the cost of some cessation programs can be a huge barrier to quitting," she said.
Kennedy and Everett said research shows that nicotine replacement therapy or prescription drugs, combined with counseling, are the most effective individual treatments. Kennedy, however, noted that many smokers have lower incomes and lack insurance that will cover those sorts of programs.
"The prescriptions are very expensive and can have certain side effects," she said. "Large numbers of smokers come from low-income families and maybe can't see a physician or else don't have access to health care."
Opponents make their case
Two previous proposals to increase the tobacco tax — Proposition A in 2002 and Amendment 3 in 2006 — failed to win voters' approval. A Missourian questionnaire from 2006 asked local voters to explain their vote on Amendment 3, which lost by a margin of 2.8 percentage points. Those who voted against it said an 80-cent increase per pack of cigarettes, or 470 percent, was "excessive."
That's part of the reason Ron Leone objects to Proposition B. Leone, executive director of the Missouri Petroleum Marketers and Convenience Store Association, has lobbied against the proposed tax increase, which he said is "outrageous and unfair."
"The problem is that (tobacco tax proponents) are greedy. They're asking for too big of an increase," Leone said. "Everyone agrees that we could have a small tax increase. I've supported a 100-percent increase on tobacco products, which would still give us a competitive advantage over our border states."
He and other opponents of Proposition B also are skeptical that new revenue will reach any of its intended funding targets. Missouri received billions of dollars through a 1998 settlement with tobacco companies that was intended to reimburse states for health expenses related to tobacco use. An editorial from the Jefferson City News Tribune noted that while the money was intended to go toward public education and tobacco cessation programs, it was instead diverted elsewhere.
Also, a study by the Agricultural Policy Analysis Center at the University of Tennessee in 2002 showed that many states, including Missouri, have used settlement money to "plug holes" in their budgets.
Leone dismissed the notion that a vote against Proposition B is a vote against more funding for education. He said that voters have been burned in the past by promises to fund education through the state lottery and casino taxes and that Proposition B won't guarantee more money for education, either.
In a League of Women Voters forum on Tuesday, state Rep. Chris Kelly, D-Columbia, spoke in favor of Proposition B. He said it would generate millions of dollars for state education and cessation programs but could not guarantee that it would result in a net increase in funding for those programs.
State Rep. Mary Still, D-Columbia, has been a leading proponent of a higher tobacco tax. Still is running against state Sen. Kurt Schaefer, R-Columbia, who is seeking a second term in the Senate. Both candidates told students during a forum at MU last week that they support Proposition B and that they would work to ensure that any new revenue for education wouldn't be offset by reduced funding from the state's general fund.
Supervising editor is Katherine Reed.