The Real Cost of Smoking by State

3:10 AM

Posted by: Richie Bernardo

Smoking doesn’t just ruin your health. It can also burn a nasty hole through your wallet. Tobacco use accounts for nearly half a million deaths in the U.S. each year and is the leading cause of lung cancer, according to the American Lung Association. Even those around tobacco smokers aren’t safe from its harmful effects. Since 1964, smoking-related illnesses have claimed 20 million lives in the U.S., 2.5 million of which belonged to nonsmokers who developed diseases merely from secondhand-smoke exposure.

However, the economic and societal costs of smoking are just as huge. Every year, Americans spend more than $300 billion, which includes both medical care and lost productivity. Unfortunately, some people will have to pay more depending on the state in which they live.

To encourage the estimated 36.5 million tobacco users in the U.S. to kick the dangerous habit, WalletHub looked into the true per-person cost of smoking in each of the 50 states and the District of Columbia. We calculated the potential monetary losses — including both the lifetime and annual cost of a cigarette pack per day, health care expenditures, income losses and other costs — brought on by smoking and exposure to secondhand smoke. Read on for the complete ranking and analysis, insight from a panel of experts and a full description of our methodology.

  1. Costs Over a Lifetime
  2. Costs per Year
  3. Ask the Experts
  4. Methodology

Costs Over a Lifetime Embed on your website<iframe src="//d2e70e9yced57e.cloudfront.net/wallethub/embed/9520/smoke-geochart.html" width="556" height="347" frameBorder="0" scrolling="no"></iframe> <div style="width:556px;font-size:12px;color:#888;">Source: <a href="http://ift.tt/2k53gwH;
Overall Rank State Total Cost per Smoker Out-of-Pocket Cost (Rank) Financial Opportunity Cost (Rank) Health-Care Cost per Smoker (Rank) Income Loss per Smoker (Rank) Other Costs per Smoker (Rank)
1 Kentucky $1,145,128 $88,794(4) $745,905(4) $118,056(2) $182,829(5) $9,544(4)
2 Georgia $1,156,444 $86,932(3) $730,268(3) $119,262(3) $208,231(20) $11,751(28)
3 North Carolina $1,162,243 $86,374(2) $725,577(2) $141,844(11) $196,884(11) $11,564(27)
4 Mississippi $1,184,526 $94,006(10) $789,690(10) $123,138(7) $165,354(1) $12,339(33)
5 North Dakota $1,191,219 $84,140(1) $706,812(1) $147,718(14) $241,185(33) $11,364(23)
6 Tennessee $1,197,782 $93,075(7) $781,871(7) $122,073(6) $190,022(8) $10,741(16)
7 Alabama $1,198,089 $94,006(10) $789,690(10) $119,748(4) $182,613(4) $12,033(30)
8 South Carolina $1,202,648 $92,517(6) $777,180(6) $129,717(8) $191,344(9) $11,891(29)
9 Missouri $1,208,621 $89,910(5) $755,288(5) $150,003(17) $202,339(15) $11,081(21)
10 Idaho $1,248,479 $94,564(13) $794,381(13) $148,382(15) $200,630(14) $10,522(11)
11 Nebraska $1,283,681 $93,633(8) $786,563(8) $168,711(31) $221,887(26) $12,887(34)
12 West Virginia $1,289,961 $102,755(16) $863,186(16) $141,375(9) $173,988(3) $8,658(1)
13 Wyoming $1,292,740 $94,006(10) $789,690(10) $156,734(24) $241,303(34) $11,006(18)
14 Indiana $1,302,032 $100,521(15) $844,421(15) $141,425(10) $205,767(16) $9,898(9)
15 Arkansas $1,311,314 $107,595(19) $903,843(19) $116,115(1) $172,731(2) $11,030(19)
16 Virginia $1,324,941 $93,820(9) $788,126(9) $161,010(26) $269,888(43) $12,098(32)
17 Oklahoma $1,326,589 $103,313(17) $867,877(17) $144,377(13) $195,995(10) $15,027(44)
18 Colorado $1,334,374 $97,356(14) $817,837(14) $150,303(18) $255,082(39) $13,796(39)
19 Louisiana $1,337,361 $108,153(21) $908,534(21) $119,834(5) $186,260(6) $14,580(43)
20 Oregon $1,389,232 $107,036(18) $899,152(18) $156,153(23) $217,342(24) $9,550(5)
21 Montana $1,394,551 $110,015(24) $924,172(24) $151,931(19) $197,390(12) $11,043(20)
22 Kansas $1,404,611 $108,339(22) $910,098(22) $153,640(21) $218,570(25) $13,964(41)
23 Iowa $1,409,936 $107,595(19) $903,843(19) $164,949(30) $222,646(27) $10,904(17)
24 Ohio $1,429,453 $113,924(27) $957,010(27) $143,062(12) $206,750(17) $8,707(2)
25 Florida $1,429,458 $109,829(23) $922,608(23) $179,236(33) $199,512(13) $18,273(50)
26 Texas $1,470,116 $113,738(26) $955,447(26) $159,324(25) $223,286(29) $18,321(51)
27 New Mexico $1,495,723 $120,625(31) $1,013,305(31) $164,019(29) $186,350(7) $11,423(25)
28 South Dakota $1,502,152 $118,578(30) $996,104(30) $163,848(28) $212,478(22) $11,144(22)
29 Delaware $1,508,054 $110,573(25) $928,863(25) $209,839(43) $248,949(37) $9,830(8)
30 Nevada $1,515,965 $120,811(32) $1,014,869(32) $153,512(20) $216,624(23) $10,149(10)
31 Utah $1,537,950 $118,391(29) $994,540(29) $153,734(22) $255,073(38) $16,211(49)
32 Michigan $1,573,730 $128,444(35) $1,078,982(35) $149,378(16) $207,276(18) $9,649(6)
33 New Hampshire $1,575,036 $115,971(28) $974,212(28) $194,762(38) $279,419(44) $10,672(13)
34 Maine $1,598,473 $126,210(34) $1,060,217(34) $195,151(39) $207,370(19) $9,524(3)
35 Arizona $1,621,614 $131,794(36) $1,107,130(36) $161,825(27) $209,467(21) $11,398(24)
36 Wisconsin $1,695,364 $136,634(37) $1,147,787(37) $178,346(32) $222,809(28) $9,788(7)
37 Maryland $1,704,023 $123,604(33) $1,038,325(33) $218,736(46) $310,353(51) $13,005(35)
38 Pennsylvania $1,745,665 $141,660(39) $1,190,008(39) $179,422(34) $223,972(30) $10,604(12)
39 Illinois $1,765,168 $141,660(39) $1,190,008(39) $179,902(35) $241,520(35) $12,078(31)
40 New Jersey $1,830,777 $138,496(38) $1,163,425(38) $214,489(45) $300,704(49) $13,663(37)
41 Washington $1,856,481 $148,920(43) $1,250,994(43) $188,668(37) $256,420(40) $11,479(26)
42 California $1,879,072 $148,362(42) $1,246,303(42) $208,805(42) $260,235(42) $15,368(47)
43 Vermont $1,902,453 $154,877(45) $1,301,034(45) $206,914(41) $228,904(31) $10,724(15)
44 District of Columbia $1,916,539 $144,266(41) $1,211,901(41) $249,214(48) $297,575(48) $13,583(36)
45 Minnesota $1,919,776 $153,760(44) $1,291,651(44) $202,743(40) $257,925(41) $13,696(38)
46 Alaska $2,059,662 $162,881(46) $1,368,275(46) $214,057(44) $303,732(50) $10,717(14)
47 Hawaii $2,067,655 $167,535(47) $1,407,368(47) $185,243(36) $293,666(47) $13,842(40)
48 Rhode Island $2,167,445 $174,981(50) $1,469,918(50) $269,173(49) $238,219(32) $15,154(45)
49 Connecticut $2,188,930 $170,513(48) $1,432,388(48) $277,760(50) $292,760(46) $15,508(48)
50 Massachusetts $2,209,285 $172,189(49) $1,446,462(49) $285,966(51) $289,492(45) $15,176(46)
51 New York $2,330,381 $194,341(51) $1,632,547(51) $241,200(47) $247,823(36) $14,469(42)

Costs per Year

 

Overall Rank State Total Cost per Smoker Out-of-Pocket Cost (Rank) Financial Opportunity Cost (Rank) Health-Care Cost per Smoker (Rank) Income Loss per Smoker (Rank) Other Costs per Smoker (Rank)
51 New York $45,353 $3,811(51) $32,099(51) $4,432(47) $4,742(36) $270(42)

 

Ask the Experts

As studies have shown, smoking can have significant negative physical and financial effects.. To advance the discussion, we asked a panel of experts to share their insight regarding smoking-cessation programs, e-cigarettes and other smoking-related concerns. Click on the experts’ profiles to read their bios and responses to the following key questions:

  1. What are the most effective strategies for people trying to quit smoking? What approaches typically fail?
  2. Should e-cigarettes be regulated and taxed as cigarettes or as medical devices?
  3. How might marijuana legalization affect tobacco use?
  4. How can state and local authorities encourage people to quit smoking? Is there a role for employers? Health insurance companies?
< > Anthony J. Alberg Professor and Chair of the Department of Epidemiology and Biostatistics in the Arnold School of Public Health at the University of South Carolina Anthony J. Alberg

What are the most effective strategies for individuals trying to quit smoking?

Nicotine addiction is very powerful, so the most effective approach is to use multiple evidence-based methods to quit smoking. One proven method is counseling, which can be delivered in person, via telephone quit lines, and in other ways. Another important tool to increase the likelihood of smoking cessation is proven smoking cessation medications; these include nicotine replacement therapies that can deliver nicotine in several different ways, as well as non-nicotine medications, such as varenicline and bupropion. The chances of quitting are optimized by combining counseling with stop-smoking medications.

What approaches typically fail?

The approach that typically fails the most is attempting to quit "cold turkey." The tricky part is that because more smokers use this approach than any other approach, the number of smokers who quit by going cold turkey is more than any other approach.

Because smoking cessation is so difficult, a key point to emphasize is that every quit attempt -- even if it is not successful -- is a step toward eventually successfully quitting smoking. Regardless of the method used to stop smoking, the likelihood of success increases with an increased number of quit attempts. So, smokers should never give up.

How can state and local authorities encourage people to quit smoking? Is there a role for employers? Health insurance companies?

Many policies can encourage smokers to quit smoking. Governmental policies that increase smoking cessation rates at the population level include increasing cigarette taxes and enacting smoke-free workplace legislation. Taxes provide a financial disincentive to continue to smoke, and smoke-free workplaces provide an incentive to quit because sustaining the nicotine addiction is inconvenient under those circumstances.

Employers can promote smoking cessation by making their workplaces smoke-free and by ensuring reimbursement for smoking cessation services, such as counseling and stop-smoking medications.

Health insurers also play a role by reimbursing for smoking cessation counseling and smoking cessation medications, and by charging smokers higher premiums due to their much higher risk of illness and dying at a younger age due to their smoking. Unfortunately, this is the harsh reality: smoking kills. This is why quitting smoking is so important.

Michael Siegel Professor in the Department of Community Health Sciences at Boston University School of Public Health Michael Siegel

What are the most effective strategies for individuals trying to quit smoking? What approaches typically fail?

By far, cold turkey quitting is the most successful. However, it’s not clear whether that is because the cold turkey method actually works best, or because the smokers who choose to quit cold turkey are ones who are especially motivated and/or especially confident that they will be able to succeed. The method used most commonly to quit smoking today is switching from smoking to vaping. On a population level, nicotine replacement therapy has been shown to be not very effective, unless it is combined with very strong counseling and support. In terms of medical therapies, varenicline (Chantix) is probably the most effective drug, but again, it’s not clear how much is due to the actual effect of the drug compared to the counseling and support that typically accompanies provision of the drug in the clinical trial setting.

So, the bottom line is that in my view, there is no single strategy that is most effective for every smoker. Each smoker is different, and what works for one person may not work for another. I think that this is a very individualized issue, and blanket advice may not be appropriate. The most effective strategy may differ based on the individual smoker. Therefore, I believe we need to support the availability and increased access to many different treatment options, including medication, counseling, support groups, and vaping products.

Should e-cigarettes be regulated and taxed as cigarettes or as medical devices?

Neither. I believe that e-cigarettes should be regulated as a separate category of nicotine-delivery products, separate from cigarettes and from medical devices. To regulate and tax e-cigarettes like cigarettes is inappropriate, because e-cigarettes are qualitatively different from cigarettes. They contain no tobacco and do not involve combustion. They do not produce any smoke. They are much, much safer than cigarettes. So, they need to be regulated differently, by a system that takes into account the degree of risk posed by different nicotine-containing products. E-cigarettes also should be regulated as medical devices, because their purpose is not to be safe and effective. Their purpose is to be a safer alternative to smoking.

How might marijuana legalization affect tobacco use?

I don’t see marijuana legalization as having any major impact on tobacco use. Smoking is on a rapid decline in the U.S., and I think that decline will continue, with or without recreational marijuana being available. However, I do think that marijuana legalization will create problems of its own.

How can state and local authorities encourage people to quit smoking? Is there a role for employers? Health insurance companies?

The most important things that state and local authorities can do to encourage people to quit smoking are:

  • Promote increases in cigarette taxes, which we know are very effective in reducing cigarette consumption. The revenues should be used to fund smoking prevention and cessation programs, as well as treatment for smoking-related diseases.
  • Promote smoke-free workplaces and public places, including bars, restaurants, and casinos. These laws have been documented to change social norms and reduce smoking.
  • Develop and implement counter-advertising campaigns using state of the art media strategies, including social media.

Employers can play a role by not only encouraging their employees to quit, but by either providing free smoking cessation programs and resources, or by offering financial support for employees to take part in such programs.

Health insurance companies can play a role by providing coverage for smoking cessation medications and programs.

Edward M. Bednarczyk Clinical Associate Professor of Pharmacy Practice and Director of the Center for Health Outcomes, Pharmacoinformatics and Epidemiology at The State University of New York at Buffalo Edward M. Bednarczyk

Should e-cigarettes be regulated and taxed as cigarettes or as medical devices?

E-cigarettes, until such time that they can be shown to have a role in smoking cessation (they haven’t yet), should be regulated and taxed in a fashion analogous to tobacco. They are nicotine delivery systems, with nicotine being used as a “recreational” drug. They are probably safer than smoking tobacco, but it’ll be a while before that can be established. The safety benefit, if any, would come from reduced carcinogens.

As part of a smoking cessation program (think nicotine patches, gum, etc.), they could side-step that and be treated as adjuncts to help people quit the cigarette habit.

How might marijuana legalization affect tobacco use?

I see no reason that marijuana legalization, recreational or medical, will have an impact on tobacco use.

Joshua E. Muscat Professor in the Department of Public Health Sciences at The Pennsylvania State University College of Medicine Joshua E. Muscat

What are the most effective strategies for individuals trying to quit smoking? What approaches typically fail?

The standard recommendation is behavioral counseling by a trained smoking cessation counselor, in combination with FDA-approved nicotine replacement therapy or non-nicotine replacement therapy (or sometimes both). Very few smokers quit successfully without assistance. However, only about a third of smokers who use these approaches are successful quitters after a couple of months of therapy. That may reflect lack of adherence to the treatment regimen.

Should e-cigarettes be regulated and taxed as cigarettes or as medical devices?

The Food and Drug Administration assumed regulatory authority over e-cigarettes under the Family Smoking Prevention and Tobacco Control Act, although any regulations have been delayed for now. There is an FDA interest in regulating and approving them as medical devices for cessation. That would have to be worked out.

FDA is not involved in taxes, but as far as I know, state governments haven’t taxed e-cigs like tobacco. E-cigs are presumably less harmful, so higher taxes would prevent switching to e-cigs.

How might marijuana legalization affect tobacco use?

Marijuana does not contain nicotine, so it would be unlikely to facilitate tobacco addiction and use.

How can state and local authorities encourage people to quit smoking? Is there a role for employers? Health insurance companies?

State indoor smoke-free laws to prevent secondhand exposure to non-smokers might have indirectly caused some smokers to quit. The CDC provides funding to all state health departments for tobacco control programs. I think this has been successful, as smoking rates among adults have come down considerably over the years. Many larger employers have wellness programs in collaboration with their insurance companies that include tobacco cessation efforts.

Kenneth A. Perkins Professor of Psychiatry, Epidemiology and Psychology at the University of Pittsburgh Kenneth A. Perkins

What are the most effective strategies for individuals trying to quit smoking? What approaches typically fail?

Varenicline plus some counseling (on how to cope with craving and withdrawal, avoid cues for smoking, etc.) is best approach. Needs to be used by those highly motivated to quit; won’t help anyone not already trying to quit to stop smoking. All approaches typically fail, as even varenicline succeeds only about 30 percent of the time after one year.

Should e-cigarettes be regulated and taxed as cigarettes or as medical devices?

E-cigarettes need to be studied carefully to assess toxic effects, whether they help tobacco smokers quit or cut down (formal controlled trials not yet done). Tobacco cigarette taxes should be increased, with the tax related to the harmfulness of the product. So, smoked tobacco should have very high tax, e-cigs (probably) smaller tax (pending study of toxic effects), and nicotine patches, gum, etc. should have virtually no tax (maybe even subsidized by the taxes raised via tobacco products).

How might marijuana legalization affect tobacco use?

Not sure, but could increase tobacco use by increasing use of other smoked products. So, if marijuana smoking increases in “normalized behavior”, smoking tobacco may resume being a normalized behavior, damaging the counter-marketing efforts to decrease smoking in teens, etc.

How can state and local authorities encourage people to quit smoking? Is there a role for employers? Health insurance companies?

One step would be to set 21 as the minimum age limit for purchasing tobacco (or e-cigs), because very few who refrain from smoking by age 21 go on to become dependent smokers. That is likely due to the effects of smoking and nicotine on the developing adolescent brain. Enforcing laws against sales to teens can help, along with raising taxes (above response), since teens are very price-sensitive (i.e., won’t smoke as much if they are expensive). Employers and insurance companies should cover co-pays for treatments to quit, especially medications, etc. They could also reduce cost of health insurance for those shown to be non-smokers through biochemical verification of abstinence (saliva cotinine measure, or expired-air carbon monoxide reading).

J. Taylor Hays Medical Director of the Nicotine Dependence Center at Mayo Clinic J. Taylor Hays

What are the most effective strategies for individuals trying to quit smoking? What approaches typically fail?

It is clear that the approach resulting in the best long-term tobacco abstinence rates is combined behavioral and pharmacologic therapy. The approach that results in the lowest long-term abstinence rates is simply to quit unassisted. The group of smokers who simply purchase nicotine replacement and try to quit on their own do worse than people who try quitting unassisted and use no particular technique or support.

This does not mean that people should not try to quit on their own. The more times someone tries, the more likely it is that they will be successful at some point. But when we look at what really works well, it is clearly getting behavioral support and using medications approved for smoking cessation. I would also add that the success rates with any treatment will vary depending on several factors, mostly related to the individual trying to quit. Some factors associated with low success on any given attempt (or stated another way, a high rate of relapse) include high level of tobacco dependence (e.g., smoking more than 20 cigarettes per day), associated serious mental illness (e.g., schizophrenia) or a current or past history of another substance use disorder, most commonly alcohol use disorder. These people clearly do much better with the combined behavioral and medication approach (including longer use of medication for up to one year).

Should e-cigarettes be regulated and taxed as cigarettes or as medical devices?

E-cigarettes should be regulated to ensure quality and safety as a consumer product. In the unregulated industry we have up to now, products do not need to meet any standards for a consumer product. If an e-cig product is going to be marketed as an aid for smoking cessation, then it should meet the standards of all other proven therapies, meaning they have to prove efficacy and safety to meet FDA standards. An irony of increasing regulation in general is that as the regulatory bar for e-cig consumer products gets higher, only the tobacco companies will have the horsepower to get products approved for sale. That may not be a good thing.

The whole e-cig debate is clouded by such a dearth of evidence that it is unclear what is best. As “big tobacco” gets more into the “reduced harm product” market (e-cigs and the heat-hot-burn, e.g., IQOS) we in the tobacco control community become warier of reliving another several decades of big tobacco being able to market their real cash cow -- combustible cigarettes -- while the use of reduced harm products re-normalizes smoking in our populations, especially among young people. It is fair to say that big tobacco has never been a strong advocate for public health (despite their public statements).

How might marijuana legalization affect tobacco use?

There is no reliable evidence that recreational marijuana crosses over to increase combustible tobacco use. But we are only now at the beginning of this vast natural experiment among the states, with some approving recreational use and others banning all use. In a few years we will know more. For now, this issue does not make me worried about increased tobacco use as a result of legalized pot.

How can state and local authorities encourage people to quit smoking? Is there a role for employers? Health insurance companies?

The best approach for governments is to provide coverage for effective therapy for people on medical assistance. Public health departments and community mental health providers should offer support for treatment for the most vulnerable populations for whom they provide care -- lower SES groups and people with co-occurring serious mental illness. Employers and payers should provide coverage for effective therapy, including support for the medications. Employers should make all their facilities and grounds smoke-free. Many employers have policies about banning smoking during the work day (especially hospitals and clinics), and some employers have stated they will not hire smokers (Cleveland Clinic did this). The Public Health Service Clinical Practice Guideline has a chapter on recommendations for payers and employers.

Janice Putnam Senior Academic Policy and Compliance Specialist, Professor of Nursing and Chair of The Missouri Nurse Editorial Advisory Board at the University of Central Missouri Janice Putnam

What are the most effective strategies for individuals trying to quit smoking? What approaches typically fail?

When one is ready to quit, there are many evidence-based strategies available. These include medications, education about coping strategies, removing smoking triggers from the environment, adding exercise, engaging in coaching, and social support. All these methods may work better than cold turkey by itself. Research shows that these interventions are more effective when used together. In my opinion, the American Lung Association’s Freedom from Smoking is one of the most effective programs for quitting smoking. Quitting smoking is a difficult process. The most successful people are those who keep trying and build their skills for resisting tobacco by trying new methods. Some methods that we don’t know if they work include dietary supplements and e-cigarettes. At this time, the Surgeon General considers e-cigarettes, and especially e-cigarettes co-used with cigarettes, as a health risk for children and adults.

Should e-cigarettes be regulated and taxed as cigarettes or as medical devices?

E-cigarettes are a relatively new product, primarily manufactured in China, and appearing on the market around the turn of the century. E-cigarettes are designed to deliver an aerosol that contains nicotine, but we don’t know the exact quality, quantity, and types of ingredients e-cigarettes contain. We do know that e-cigarettes are also being modified to deliver substances other than nicotine, such as marijuana. Some of the regulatory concerns for e-cigarettes include their health effect on children, their health effect on adults when used with cigarettes, marketing that claims e-cigarettes are effective with smoking cessation, and that e-cigarettes may normalize smoking behavior in general.

In 2013, The World Health Organization recommended e-cigarettes be regulated as cigarette products until we have evidence supporting e-cigarettes in the cigarette quitting process. A study published by Kennedy at al. (2017) said that 68 countries regulate e-cigarettes. Many e-cigarette regulations stem from tobacco regulations. The most common controls included bans on the sales of e-cigarettes, restrictions on where you can use e-cigarettes (called “vape-free public places”), minimum purchasing age, and advertising bans.

How might marijuana legalization affect tobacco use?

We know that tobacco is often co-used with marijuana. Schauer and colleagues (2015) report that from 2003 to 2012, the co-use increased overall among men and women, whites, blacks and Hispanics, and those aged 26-34, as well as those over 50. In this study, tobacco use for marijuana users decreased and marijuana use for tobacco users increased. Wang and colleagues (2016) have expressed concern that co-use will complicate what we know about nicotine dependence and smoking cessation. We need more information to answer this question.

How can state and local authorities encourage people to quit smoking? Is there a role for employers? Health insurance companies?

State and local authorities can take a leadership role in enforcing smoke-free regulations, providing smoking cessation assistance, normalizing non-smoking cars and homes, as well as supporting social media campaigns promoting smoke-free as the new normal. The ALA recommends a comprehensive tobacco cessation insurance benefit for all employees. Comprehensive insurance should include all treatments prescribed in the U.S. Public Health Service Guideline, e.g., all seven medications and all three forms of counseling. The ALA also recommends removing pre-authorization, removing limits on quit attempts, and removing requirements for counseling or stepped-care therapy.

Fawaz Mzayek Associate Professor of Epidemiology in the School of Public Health at The University of Memphis Fawaz Mzayek

What are the most effective strategies for individuals trying to quit smoking? What approaches typically fail?

The best strategy is “cold turkey,” with help (counseling and/or nicotine patch, etc.) The strategy that usually fails is the gradual decrease of daily smoking, without seeking any help or nicotine replacement therapy.

Should e-cigarettes be regulated and taxed as cigarettes or as medical devices?

I can tell you that the jury is still out on this. Although the health effects of e-cigarettes are not well-characterized yet, some evidence suggest that they can be a safer alternative to cigarette smoking, and even help in quitting cigarette smoking. However, I personally doubt that, since e-cigarette solutions contain nicotine, which is the addictive substance in tobacco. Still, the fact that e-cigarettes produce vapor instead of smoke may still mean that they are less harmful to health.

How might marijuana legalization affect tobacco use?

In general, persons who use drugs, use more than one. Smokers tend to also drink and vice versa. Prevalence of smoking is also higher among illicit drug users. However, these are correlations, not causal associations. So, it is not necessary that legalizing marijuana will lead to increase in tobacco smoking prevalence.

How can state and local authorities encourage people to quit smoking? Is there a role for employers? Health insurance companies?

The evidence shows that the most effective policies were those that included some form of financial incentives (raising tobacco taxes, lowering insurance premiums for not smoking, educational campaigns illustrating savings from quitting smoking, etc.) Also, complete or near-complete banning of smoking in public places, with serious enforcement, helps.

Robert A. Schnoll Associate Professor in the Department of Psychiatry, Co-leader of the Tobacco and Environmental Carcinogenesis Program at the Abramson Cancer Center, Senior Fellow at the Center for Public Health Initiatives, and Program Leader for the Center for Interdiscplinary Research on Nicotine Addiction at the University of Pennsylvania Robert A. Schnoll

What are the most effective strategies for individuals trying to quit smoking? What approaches typically fail?

The most effective methods for quitting smoking are behavioral counseling -- individual, group, quit-line -- and use of an FDA-approved medication (a nicotine replacement therapy, varenicline, or bupropion). In terms of quit rates, the most effective is the combination of behavioral counseling and either varenicline or combination NRT (patch and gum or lozenge). About a quarter to a third of smokers who use these approaches will quit successfully. Cold turkey most often leads to a failed quit attempt.

Should e-cigarettes be regulated and taxed as cigarettes or as medical devices?

Currently, despite widespread and growing use, we do have sufficient scientific data on which to base conclusions and recommendations for the safety and efficacy (to quit) of e-cigarettes. NIDA has developed a standardized e-cigarette and is supporting evaluations of its safety and efficacy to reduce use of combustible tobacco. Until then, the only reasonable oversight would be as a nicotine product like cigarettes.

How might marijua na legalization affect tobacco use?

It is too early to know, since there are limited data. One study in Oregon found no significant increase in tobacco smoking among adolescents after legalization, compared to before (Kerr et al., 2017; Addiction).

How can state and local authorities encourage people to quit smoking? Is there a role for employers? Health insurance companies?

State and local governments can continue to use taxation, bans on smoking in public places, and health communication approaches (warning labels, PSAs) to reduce smoking rates. Improving access to treatments through the quit-line is also important. Some employers and health insurance carriers incentivize cessation (reduced premiums; refusal to hire smokers), but especially refusing to hire smokers can have inadvertent negative effects, such as forcing smokers to lie and avoid effective treatment.

Nathan Cobb Assistant Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at MedStar Georgetown University Medical Center Nathan Cobb

What are the most effective strategies for individuals trying to quit smoking?

The most effective strategy for an individual is the one that ultimately works. Very few smokers succeed in quitting on the first try; staying quit is like learning to stay upright on a bicycle. You’ve got to fall a few times first. In general, there are several widely available and effective aids for quitting, and people who use them are more likely to succeed.

Nicotine replacement and the oral medications (Chantix/varenicline and Zyban/bupropion) essentially double the chances of quitting and staying quit. Compared to even just a few years ago, we now have a much better understanding of how to use these medications, including adding the gum or lozenge on top of the patch and starting Chantix earlier. And even though the medications are easy to access, it’s always worth speaking with a professional to get some help before starting one of them.

That sort of help is easy to get, because every state in the U.S. has a free telephone quitline, which can be accessed by calling the national number at 800-QUIT-NOW (784-8669). These quitlines are staffed by professionals who can offer advice, strategies, and more. And there is clear evidence that people who take advantage of these services do better.

How can state and local authorities encourage people to quit smoking? Is there a role for employers? Health insurance companies?

At the public health level, we’ve been working for decades to get smoking rates down, and it appears that we currently have real traction. The reality is that the majority of smokers want to quit, and we estimate that about half make a quit attempt in any given year. So, getting more people off cigarettes requires increasing the number of quit attempts and making each one more successful than the last.

At the state level, the most important driver is taxes. Over the years, we’ve seen a very clear tie between higher taxes and more people quitting. There are still a number of states, mostly those that have a historical tie to growing tobacco, that have both low taxes and high smoking rates. These states could get the biggest return by simply raising their cigarette taxes to match their neighbors’.

Many employers, working in conjunction with state and local regulations, have done a great job over the past number of years. The increasing denormalization of workplace smoking has been a large part of this. But not every employer has gone in this direction. Creating smoke-free workplace policies, and then supporting employees with smoking cessation services, can go a long way. These approaches pay for themselves, even independent of health care spending. It’s estimated that a smoker costs the average employer slightly over $1,000 a year in absenteeism and presenteeism alone.

Health insurance companies are generally required to offer any FDA-approved smoking cessation service for free without copay, but many make this difficult, including requiring physician prescriptions for over-the-counter medications (like the patch or gum). Other insurers, like Blue Shield of California, make it easy, integrating free delivery of nicotine replacement products to the member’s door with enrollment in a digital cessation program. Removing barriers to obtaining medications can significantly impact cessation rates, and employers should aggressively raise this issue with their carriers.

Should e-cigarettes be regulated and taxed as cigarettes or as medical devices?

Most people are surprised that e-cigarettes aren’t really regulated, perhaps the only product legally marketed in the U.S. that can be sold without effective oversight. Unlike an electric toothbrush, there are no regulations on the circuits or the batteries to promote safety (e-cigarette explosions are widely reported, but when was the last time you heard one about a toothbrush?). There’s no regulation on chemicals, the nicotine dosing, or how they work in general. It's the wild west at the moment, and this seems unlikely to change in the near future.

There is, however, widespread agreement that e-cigarettes should be regulated, but none about in which ways, or how much. In general, there is a critical and urgent need for the FDA to put into place safety regulations related to the supply chain, electronics, child-resistant packaging, and so on. Beyond that, we need regulations that prevent the existing tobacco companies from evolving e-cigarettes in directions that are highly addictive or more toxic. Smaller companies can make a large profit by poaching combusted cigarette users, even if those people eventually quit nicotine entirely. However, the large tobacco companies have enormous revenue streams to protect, and they need heavily addicted users to keep them. Without regulation, they will figure out how to build and market those highly addictive and potentially more toxic products.

Despite this, the e-cigarettes that are on the market today are in general far safer than smoking cigarettes, by an order of magnitude. Getting smokers off combusted cigarettes is paramount, and although the preference is for quitting altogether (perhaps with the temporary use of nicotine replacement, like the patch or gum), switching to e-cigarettes is still preferable to smoking. But this switch won’t happen if taxes on e-cigarettes and combusted cigarettes are the same; there needs to be a clear economic benefit to switching. States that place taxes on e-cigarettes to drive their prices up to the level of combusted cigarettes are shooting themselves in the foot.

Joanna E. Cohen Bloomberg Professor of Disease Prevention and the Director of the Institute for Global Tobacco Control at the Johns Hopkins Bloomberg School of Public Health Joanna E. Cohen

What are the most effective strategies for individuals trying to quit smoking? What approaches typically fail?

There are several ways to quit smoking. Some of them can be categorized as population approaches (taxes, smoke-free environment, etc.), and others can be thought of as individual approaches. Individual approaches consist of non-pharmaceutical quit methods, such as quitting cold turkey, self-help resources, using the Internet or text messaging programs as an interactive tool, 1-800 quitlines, advice from health professionals and cognitive behavioral therapy. The pharmaceutical quit methods include nicotine replacement therapy, bupropion and varenicline.

Based on the current clinical practice guideline, the quit rate of these methods are as follows:

  • Non-pharmaceutical quit methods:
    1. Self-help: 9-12 percent;
    2. Counseling: 13-17 percent.
  • Pharmaceutical quit methods:
    1. Bupropion: 24 percent;
    2. Varenicline: 33 percent;
    3. Nicotine replacement therapy: 19-26 percent.
  • Medication combination: 26-36 percent.
  • Counseling and medication combination: 26-32 percent.

The great majority of smokers (more than 90 percent) who successfully quit smoking did so on their own, using self-help strategies such as quitting abruptly and completely (cold turkey). Increasing tobacco product taxes is one of the most effective ways of reducing tobacco consumption. There is a role for governments (federal, state, local), employers, health insurance companies and others, including health care professionals, in encouraging people to quit smoking.

Should e-cigarettes be regulated and taxed as cigarettes or as medical devices?

E-cigarettes are currently regulated as tobacco products in the U.S. In 2009, the U.S. Food and Drug Administration (FDA) attempted to regulate e-cigarettes as drug-delivery devices subject to the Federal Food, Drug and Cosmetic Act; however, the tobacco industry challenged this in court. In December 2010, the federal appeals court ruled that the FDA could not apply the Federal Food, Drug and Cosmetic Act to e-cigarettes unless they were marketed as cessation or therapeutic devices. The court ruled that instead, e-cigarettes would be considered tobacco products under the Family Smoking Prevention and Tobacco Control Act, which regulates products derived from tobacco, including nicotine.

How might marijuana legalization affect tobacco use?

More research is needed to understand the link between marijuana legalization and tobacco use. Marijuana can be used or ingested in different forms. The California EPA (Environmental Protection Agency) has listed marijuana smoke as a carcinogen. According to their report, marijuana smoke and tobacco smoke share some similarities with respect to their chemical composition and toxicological properties. At least 33 constituents present in marijuana smoke and tobacco smoke are already listed as carcinogens.

Matthew L. Myers President of the Campaign for Tobacco-Free Kids Matthew L. Myers

What are the most effective strategies for individuals trying to quit smoking? What approaches typically fail?

Tobacco use kills more than 480,000 Americans and costs our nation about $170 billion in health care expenses each year. The most effective way to help more smokers quit is with a comprehensive strategy that includes both proven, population-level policies to reduce tobacco use, and improved access to effective smoking cessation treatments that can help individual smokers quit. These population-level policies include significant tobacco tax increases, comprehensive smoke-free air laws in every state, hard-hitting mass media campaigns, well-funded tobacco prevention and cessation programs, and effective FDA regulation of tobacco products. In addition, both public and private health plans should provide comprehensive coverage for effective smoking cessation treatments, including both FDA-approved medications and counseling, and states should fund telephone quitlines that provide smokers with assistance and support.

According to the U.S. Public Health Service clinical treatment guidelines for tobacco cessation, counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication. Learn more in our cessation fact sheet.

Should e-cigarettes be regulated and taxed as cigarettes or as medical devices?

In 2010, a federal court ruled that e-cigarettes should be regulated as tobacco products and can only be regulated as medical devices if they are marketed for a therapeutic purpose (smoking cessation). In 2016, the FDA issued a rule to begin regulating e-cigarettes as tobacco products. Full implementation of the FDA’s rule is critical both to prevent kids from using e-cigarettes and to assess the evidence whether e-cigarettes are effective at helping smokers quit, and ensure smokers have accurate information. Our view is that e-cigarettes should be taxed as tobacco products until such time as the FDA determines that e-cigarettes are effective at helping smokers give up cigarettes completely.

How can state and local authorities encourage people to quit smoking? Is there a role for employers? Health insurance companies?

At the state and local levels, elected officials should support strong policies to reduce tobacco use including: significant tobacco tax increases; comprehensive smoke-free laws; increasing the legal sale age for tobacco to 21; coverage for comprehensive quit-smoking benefits; well-funded prevention and cessation programs; and, in the absence of FDA action, prohibitions and restrictions on flavored tobacco products, including menthol-flavored cigarettes. Employers and health insurance plans should provide coverage for comprehensive quit-smoking benefits, including medicine and counseling, which are proven to help smokers quit.

Methodology

In order to assess the impact of tobacco use on a smoker’s finances both over a lifetime and in a single year, WalletHub calculated the potential monetary losses — including the cumulative cost of a cigarette pack per day over several decades, health-care expenditures, income losses and other costs — brought on by smoking and exposure to secondhand smoke.

For our calculations, we assumed an adult who smokes one pack of cigarettes per day beginning at age 18, when a person can legally purchase tobacco products in the U.S. We also assumed a lifespan of 51 more years, taking into account that 69 is the average age at which a smoker dies.

Out-of-Pocket Costs

To determine per-person Out-of-Pocket Costs Over a Lifetime, we took the average cost of a pack of cigarettes in each state and multiplied that figure by the total number of days in 51 years. For Costs per Year, we multiplied the average cost by 365 days.

Financial Opportunity Cost

To determine the per-person Financial Opportunity Cost, we calculated the amount of return a person would have earned by instead investing that money in the stock market over the same period. We used the historical average market return rate for the S&P 500 minus the inflation rate during the same time period to reflect the return in present-value terms.

Health-Care Cost per Smoker

Direct medical costs to treat smoking-connected health complications are one of the biggest financial drains caused by tobacco use. To calculate related health-care costs, we obtained state-level data from the Centers for Disease Control and Prevention — namely the annual health care costs caused by smoking — and divided that amount by the total number of adult smokers in each state.

Income Loss per Smoker

Previous studies have shown that smoking can lead to loss of income, either because of absenteeism, workplace bias or lower productivity due to smoking-related health problems. This can create a wage gap between smokers and nonsmokers. To represent the negative relationship between earnings and smoking, we assumed an average 8 percent decrease in the median household income for each state. We arrived at this figure after a recent study from the Federal Reserve Bank of Atlanta found that smokers earn 20 percent less than nonsmokers, 8 percent of which is attributed to smoking and 12 percent to other factors.

Other Costs per Smoker

Nonsmokers are generally entitled to a homeowner’s insurance credit of between 5 and 15 percent, according to the Independent Insurance Agents & Brokers of America. Given that fact, we assumed an 11.1 percent increase (i.e. the inverse of a 10 percent credit, or the average between the two percentages) in the average homeowner’s insurance premium for each state to represent the penalty cost for smokers.

We then took into account the costs for victims of secondhand-smoke exposure. To calculate these costs, we used the per-nonsmoker expenditure in the state of New York as a proxy. We then multiplied that figure by the number of nonsmokers in each state to obtain the total costs of exposure to secondhand smoke at the state level. Finally, we divided the resulting total by the number of smokers in each state. This approach assumes that, in a perfect society, smokers would also pay the costs related to the harmful smoke that tobacco releases into the air.

Formula for Financial Cost of Smoking

Financial Cost of Smoking = Out-of-Pocket Costs + Financial Opportunity Cost + Related Health-Care Costs + Income Loss Due to Smoking-Related Issues + Increase in Homeowner's Insurance Premium + Secondhand Smoke-Exposure Costs.

 Sources: Data used to create this ranking were collected from the U.S. Census Bureau, Bureau of Labor Statistics, Centers for Disease Control and Prevention, Insurance Information Institute, Campaign for Tobacco-Free Kids, NYsmokefree.com, Federal Reserve Economic Data (FRED), Kaiser Family Foundation and the Independent Insurance Agents & Brokers of America.



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