Did they trick us into smoking?

Most smokers would reply that no one tricked them into smoking. It was and has always been their sole decision to smoke. However, when one looks back it is not uncommon to see the different reasons why people, both young and old smoke. The common ones we all know: “we need it to be part of the group; it makes us look cool; it helps keep my weight down; it relieves my tension; …. the list is endless.

“I’ve asked him to stop smoking many times, but he says I will not understand how much tension he has. Do I not have tensions too? Should I also start smoking”? asks Moushami Mondal (name changed), who resides in a village in West Bengal. Anyone looking at this from the outside can see clearly how this vicious cycle continues leading to ill health, both physical and mental, and a series of effects which degenerate one’s quality of life. The globalization of the tobacco epidemic has been greatly contributed by global marketing, rising trade within and across borders and foreign investments.

One often hears that, ‘Tobacco thrills but kills’. The World Health Organization (WHO) claims that tobacco kills almost 6 million people globally each year, 600,000 of whom are non-smokers exposed to second-hand smoke. About 80% of the one billion smokers in the world live in low- and middle- income countries. According to the WHO Report on the Global Tobacco Epidemic 2013, out of 1.2 billion Indians, 14.6% of youth (13 -15 years of age) use tobacco with 4.4% of them being cigarette smokers while 9% of the youth indulge in smokeless tobacco. 14% of adults currently smoke tobacco while 25.9% use smokeless forms of tobacco. While the percentage of women using tobacco is lesser than that of men, this number has been on the increase in the last few decades, with 8.3% of girls in the age group 13-15 using tobacco currently. A much larger percentage – about 26.6% youth are exposed to second hand smoke in their homes.

The current direct costs of smoking is 1,195 million US dollars (about Rs. 750 crores), according to the 4th Edition of the Tobacco Atlas from the World Lung Foundation. This amount does not include the indirect costs due to loss of days of work, loss of days at school, out of pocket expenditure for medical management of lung and oral cancers, asthma, chronic obstructive pulmonary disease, hypertension, heart attacks, infertility and many other diseases known to be aggravated by smoking.

Penalties hit smokers hardest

Next year many more companies plan to penalize workers who use nicotine because of their much higher healthcare costs. Proctor & Gamble Co, the Cincinnati-based household-product giant, will begin charging such employees an additional $25 per month in 2014 until they have completed a company-paid cessation program.
Under similar provisions, state employees in Wisconsin and Washington State will pay as much as $600 more per year, while nonunion smokers at United Parcel Service Inc will pay as much as $1,800.
“We found that while less than 10 percent of workers at large employers smoke, their impact to healthcare costs is disproportionately huge,” said LuAnn Heinen, vice president for the National Business Group on Health. “Helping them quit — however you do that — has the most obvious near-term payoff in terms of savings and productivity gains.”
A recent Ohio State University study found that businesses pay nearly $6,000 more annually per employee who smokes compared with a nonsmoker. Other research suggests that less than 16 percent of employees participate in voluntary smoking cessation programs, Heinen added.
A.H. Belo, owner of the Dallas Morning News, Providence Journal and other publications, told staff in September that for 2014 it would require employees and their spouses to complete a biometric health screening or face a $100 annual surcharge. In 2015, employees will be asked not only to undergo the screening but to meet three out of five as yet unspecified health goals to avoid the additional fee.

Costly punishments

Under Obama’s Affordable Care Act, which takes effect in January, companies can offer a reward of up to 30 percent of healthcare costs paid by the employee to those who complete voluntary programs like smoking cessation, a risk assessment or biometric tests like waist measurement.
The financial incentives could add up to about $1,620 annually per worker. But if wellness programs don’t end up saving costs, companies can raise premiums across the board or slap them on workers who don’t get with the programs. In some states, tobacco users who sign up for insurance through the new state health exchanges could be charged 50 percent higher premiums than nonsmokers.
Research suggests savings may be harder to achieve when programs are voluntary than has often been thought. A report released in May by the RAND Corp found workers who participated in a wellness program had healthcare costs averaging $2.38 less per month than nonparticipants in the first year of the program and $3.46 less in the fifth year.
Some health and labor experts are concerned that penalties may be unduly harsh, especially for low-wage workers and those who have health conditions beyond their control. According to the Centers for Disease Control and Prevention, 29 percent of adults with incomes below the federal poverty level smoke, compared with 18 percent of those above the poverty level.
Mark Rothstein, a lawyer and bioethics professor at the University of Louisville School of Medicine, chooses to pay a higher annual premium rather than complete a health questionnaire for his employer, calling it a “privacy tax.” Lower-paid colleagues, he said, “don’t have the same luxury to opt out.”
Fierce resistance forced Pennsylvania State University in September to abandon a plan to charge employees $100 per month if they did not participate in various health screenings and fill out a detailed health questionnaire administered by WebMD, which asked among other things whether a worker had recently driven after drinking too much, whether female employees planned to become pregnant in the next year and how frequently male workers performed testicular self-exams. This led to an outcry over privacy concerns and the potential for hacking of computer databases.
“These were just things no employer has the right to ask,” says Brian Curran, a professor of art history at Penn State who started an online petition to protest the questionnaire.
University officials had argued the penalty was needed to tamp down healthcare costs and avoid tuition hikes. In January it still plans to implement a $100-a-month surcharge for spouses and a $75-a-month penalty on tobacco users.
Courts so far have shown little resistance to such programs. The 1996 Health Insurance Portability and Accountability Act prohibits workers who are in a group health insurance plan from being discriminated against on the basis of health, and Obamacare extends that right to individuals. But neither bans penalties outright.
The law does specify that wellness programs must be voluntary, but Lewis Maltby, president of the National Workrights Institute, a legal advocacy organization, says that can be a slippery slope. Most employees don’t feel like they have a choice, Maltby says. “In today’s job market, any reasonable request by one’s employer is essentially read as a demand.”