Smoking and Non-smoking: Weighing the Benefits

disability,฀6.75฀through฀excess฀mortality฀and฀21฀through฀premature฀invalidity,฀while฀the฀ revenues฀of฀the฀state฀from฀tobacco฀duties฀and฀taxes฀amount฀to฀only฀11.5฀billion.฀It฀should฀ also฀be฀taken฀into฀account฀in฀this฀context฀that • ฀ Considerable฀portion฀of฀the฀cigarettes฀smoked฀were฀smuggled฀into฀the฀country,฀thereby฀ reducing฀the฀state’s฀revenues • ฀ The฀treatment฀of฀smoking-related฀diseases฀is฀paid฀for฀not฀out฀of฀tobacco฀tax฀revenues฀ but฀by฀the฀health฀insurance฀funds฀into฀which฀everybody฀pays฀contributions฀ [62] ;฀the฀ costs฀for฀such฀treatment฀from฀tobacco฀duties฀and฀taxes฀by฀6–7฀billion฀ [89] The฀state฀uses฀the฀money฀from฀tobacco฀tax฀for฀all฀kinds฀of฀activities,฀but฀not฀for฀the฀health฀ system.฀According฀to฀a฀study฀by฀the฀Umwelt-Prognose-Instituts฀Heidelberg฀e.V.,฀an฀envi- ronmental฀ forecasting฀ body,฀ the฀ costs฀ for฀ the฀ treatment฀ of฀ smoking-related฀ diseases฀ amounted฀to฀15.65฀billion฀in฀1997฀ [90] .฀In฀view฀of฀this,฀the฀demands฀of฀the฀health฀insur- ance฀funds฀that฀part฀of฀the฀tobacco฀tax฀revenues฀should฀be฀used฀to฀inance฀the฀treatment฀of฀ smokers฀appear฀highly฀justiied:฀the฀Deutsche฀Angestelltenkasse฀German฀Health฀Insurance฀ Fund฀for฀Salaried฀Employees,฀for฀instance,฀has฀demanded฀that฀30฀of฀the฀revenues฀from฀ the฀duty฀on฀tobacco฀and฀spirits฀tax฀should฀be฀put฀towards฀the฀treatment฀of฀smoking-related฀ diseases฀ [91] .฀ If฀ health฀ levies฀ were฀ imposed฀ on฀ alcoholic฀ beverages฀ and฀ tobacco,฀ they฀ would,฀even฀at฀moderately฀rising฀rates,฀be฀able฀to฀generate฀revenues฀of฀up฀to฀65฀billion฀per฀ year,฀which฀would฀even฀allow฀the฀contribution฀rates฀to฀the฀health฀insurance฀funds฀to฀be฀ reduced฀from฀14฀of฀wages฀to฀8.5฀ [90] .฀At฀the฀same฀time,฀this฀would฀mean฀a฀reduction฀ in฀ancillary฀wage฀costs฀of฀40฀ [90] .฀With฀192.5฀billion฀cigarettes฀produced฀in฀the฀year฀ 1996฀ [3] ,฀a฀“cigarette฀penny”฀would฀already฀produce฀revenues฀of฀98.42฀million,฀which฀ could฀be฀put฀towards฀health฀expenditure. If฀the฀costs฀for฀the฀treatment฀of฀a฀patient฀with฀ischaemic฀heart฀disease฀or฀lung฀cancer฀are฀ compared฀with฀the฀costs฀of฀therapy฀to฀enable฀people฀to฀stop฀smoking,฀the฀difference฀in฀is฀ considerable.฀ Even฀ including฀ several฀ consultations฀ with฀ a฀ doctor,฀ nicotine฀ replacement฀ therapy฀could฀amount฀to฀at฀most฀650฀a฀head,฀while฀the฀costs฀for฀treating฀a฀patient฀with฀ coronary฀heart฀disease฀or฀lung฀cancer,฀who฀will฀then฀probably฀die฀anyway,฀is฀estimated฀at฀ 49,340฀heart฀attack฀and฀41,785฀lung฀cancer฀ [92] .฀If฀patients฀were฀themselves฀to฀pay฀for฀ the฀nicotine฀instead฀of฀for฀the฀cigarettes฀they฀smoked,฀the฀costs฀for฀medical฀consultation฀in฀ Germany฀would฀amount฀to฀200–250฀at฀most. Cause Reproduction฀costs a Costs฀of฀lost฀resources b Total Smoking 15.7 19.6 35.2 Alcohol 0.9 4.2 5.1 Sugar,฀meat฀animal฀fats 7.1 4.1 11.2 Road฀trafic 5.6 25.2 30.8 Total 29.2 53.2 82.4 Table 14.3 ฀Costs฀to฀the฀economy฀through฀damage฀to฀health฀in฀Germany,฀with฀attribution฀to฀the฀ various฀causes Figures฀in฀billion฀€฀per฀year฀ [87] a Costs฀of฀medical฀treatment,฀including฀administrative฀costs b Loss฀of฀economic฀production฀because฀of฀illness,฀injury฀or฀death Each฀employee฀in฀the฀tobacco฀industry฀accounts฀for฀annual฀sales฀revenue฀of฀1฀billion฀ [3] .฀If฀the฀purchasing฀power฀of฀smokers฀was฀diverted฀from฀cigarettes-to฀other฀products฀of฀ our฀economy,฀many฀times฀the฀number฀of฀jobs฀would฀be฀created฀in฀other฀industries,฀because฀ these฀ generate฀ much฀ less฀ sales฀ revenue฀ per฀ employee:฀ according฀ to฀ 1996฀ igures,฀ the฀ amount฀of฀purchasing฀power฀volume฀that฀would฀have฀to฀be฀diverted฀would฀be฀at฀most฀ 15.13฀billion฀ [3] . At฀the฀end฀of฀this฀section,฀here฀are฀just฀a฀few฀remarks฀on฀an฀analysis฀of฀a฀kind฀which฀ will฀certainly฀already฀have฀been฀done฀before฀by฀health฀insurance฀funds,฀insurance฀compa- nies฀and฀politicians,฀with฀the฀aid฀of฀actuaries:฀namely,฀the฀study฀carried฀out฀in฀the฀Czech฀ Republic฀by฀Philip฀Morris฀in฀the฀year฀2000.฀The฀aim฀of฀the฀study,฀conducted฀by฀the฀irm฀of฀ A.฀D.฀Little฀on฀behalf฀of฀Philip฀Morris,฀was฀to฀ind฀out฀whether,฀taking฀the฀revenues฀from฀ tobacco฀tax฀and฀duties฀and฀the฀expenditure฀on฀health฀and฀social฀costs฀into฀account,฀the฀ Czech฀state฀makes฀a฀“proit”฀or฀a฀“loss”฀from฀smokers.฀For฀the฀period฀of฀the฀study,฀the฀year฀ 1999,฀the฀study฀shows฀the฀Czech฀state฀to฀have฀made฀a฀proit฀of฀฀±฀5,815฀million฀Czech฀ crowns฀CZK฀conidence฀interval:฀CZK฀±1,347฀to฀±13,650฀million,฀equivalent฀to฀US฀ 147.1฀million.฀In฀the฀analysis,฀it฀is฀shown฀that฀the฀negative฀effects฀of฀smoking฀increased฀ health฀and฀social฀costs฀are฀outweighed฀by฀the฀positive฀effects฀tobacco฀duty฀and฀value฀ added฀tax฀on฀tobacco฀products.฀This฀therefore฀means฀that฀smoking฀has฀a฀positive฀effect฀on฀ the฀state฀balance฀sheet.฀“This฀conclusion฀would฀hold฀even฀if฀the฀indirect฀positive฀effects฀of฀ smoking฀were฀neglected.”฀After฀being฀submitted฀to฀the฀government฀of฀the฀Czech฀Republic,฀ this฀study฀was฀immediately฀analysed฀and฀several฀accounting฀errors฀found฀ [93,฀94] .฀The฀ central฀message฀of฀the฀Philip฀Morris฀study,฀namely฀that฀“smoking฀has฀a฀positive฀effect,”฀is฀ indicative฀of฀the฀unethical฀character฀of฀the฀study฀with฀its฀unacceptable฀disregard฀for฀funda- mental฀human฀values,฀and฀Philip฀Morris฀ought฀to฀make฀a฀public฀apology฀for฀it฀ [95] .

14.11 Concluding Remarks

On฀the฀basis฀of฀the฀problems฀outlined฀above,฀the฀following฀measures฀are฀necessary: • ฀ Ban฀on฀all฀advertising฀for฀tobacco฀products. • ฀ Effective฀primary฀and฀secondary฀prevention฀measures,฀taking฀into฀account฀the฀fact฀that฀ the฀majority฀of฀smokers฀are฀to฀be฀found฀among฀people฀with฀lower฀intellectual฀ability฀or฀ lower฀ school฀ qualiications,฀ so฀ that฀ the฀ programmes฀ must฀ therefore฀ be฀ designed฀ accordingly. • ฀ Increase฀in฀tobacco฀duty,฀which฀has฀always฀been฀an฀important฀regulative฀for฀reducing฀ tobacco฀consumption฀among฀the฀population฀see฀Fig.฀ 14.4 ฀and฀may฀be฀more฀effective฀ than฀public฀health฀information฀programmes฀ [87] . • ฀ Ban฀on฀the฀sale฀of฀cigarettes฀to฀young฀people฀under฀18฀years,฀and฀abolition฀of฀cigarette฀ vending฀machines. • ฀ Increase฀in฀health฀insurance฀premiums฀for฀smokers,฀taking฀the฀latest฀developments฀in฀ the฀health฀system฀into฀account. • ฀ Financial฀support฀for฀the฀activities฀of฀the฀health฀insurance฀bodies฀towards฀preventing฀ smoking฀among฀young฀people฀and฀helping฀adults฀to฀give฀up฀smoking. • ฀ Commitment฀by฀members฀of฀the฀medical฀profession฀to฀reduce฀smoking฀among฀their฀ own฀ranks฀and฀to฀update฀their฀own฀knowledge฀about฀smoking฀and฀the฀substances฀con- tained฀in฀nicotine,฀with฀their฀effects฀on฀the฀human฀body. • ฀ Urgent฀appeal฀to฀politicians฀to฀reconsider฀their฀attitude฀towards฀the฀tobacco฀industry,฀to฀ take฀a฀stand฀against฀smoking฀in฀public฀and฀to฀adopt฀measures฀to฀beneit฀non-smokers,฀ who฀form฀the฀majority฀of฀the฀population. • ฀ Implementation฀ of฀ directives฀ on฀ tobacco฀ control฀ and฀ full฀ recognition฀ of฀ deleterious฀ effects. • ฀ Recognition฀of฀nicotine฀as฀an฀addictive฀substance. References ฀ 1.฀Brundtland฀ GH฀ 1999,฀ Jan฀ 30฀ Health฀ for฀ the฀ 21st฀ Century.฀ Davos,฀ Switzerland,฀ World฀ Economics฀Forum ฀ 2.฀Roemer฀R฀1993฀Legislative฀action฀to฀combat฀the฀world฀tobacco฀epidemic฀2.฀Aul.฀24.฀Genf ฀ 3.฀Anon฀1997฀Zahlen฀aus฀der฀Tabakwirtschaft.฀Die฀Tabak-Zeitung ฀ 4.฀Internet฀Mitteilung฀vom฀1998,฀Dec฀28฀Statistisches฀Bundesamt฀Wiesbaden ฀ 5.฀Odenwald฀M฀1993฀Wie฀der฀Regenwald฀im฀blauen฀Dunst฀aufgeht.฀Nature฀6:28–34 ฀ 6.฀Kessler฀ DA,฀ Myers฀ ML฀ 2001฀ Beyond฀ the฀ tobacco฀ settlement.฀ N฀ Engl฀ J฀ Med฀ 3457:฀ 535–537 6 5 4 3 2 1 Tax Revenue Tax Rate 1961 1966 1971 1976 1981 1986 1991 1996 1,9 1,8 1,7 1,6 1,5 1,4 1,3 1,2 1,1 1,0 Tobacco Sale Fig. 14.4 ฀฀฀Increase฀in฀sales฀ turnover฀from฀tobacco฀illed฀ box,฀tax฀revenues฀illed฀circle฀ and฀tax฀revenues฀s฀from฀1961฀ to฀1996;฀base฀year:฀1960฀=฀1฀ [87]