Defining “tobacco use” for cigar smokers

Sarah Kliff has two very interesting articles at The Washington Post this week about the Affordable Care Act and tobacco. In the first, she looks at how the law prohibits or limits insurance companies charging higher prices to higher risk clients, with one key exception: They can charge smokers up to 50% more. Interestingly, anti-cancer groups and tobacco companies have teamed up to oppose this provision, though obviously for different reasons.

Her follow-up post examines the under-the-radar question of how the government should define “tobacco user” for health insurance purposes:

[...] the law says nothing more about what counts as “tobacco use.” And that’s a hard factor to regulate: Unlike age, where subscribers have one definite birth date, the idea of who counts and doesn’t count as a tobacco user is really fuzzy. Enter the regulators!

The impact on the cost of insurance for smokers could be huge, especially for those with lower incomes:

For a low-income American faced with the surcharge, their premium could jump from $708 to $3,308. That jump is larger than 50 percent due to the fact that the base premium gets a federal subsidy, while the tobacco surcharge does not.

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Regardless of whether this is good policy, it’s clear that frequent smokers of cigarettes should count as tobacco users. But what about people who only smoke an occasional cigarette socially? Or enjoy an infrequent cigar? Or people who use other forms of tobacco entirely? These users have very different risk profiles, but the law could treat them equally. This would put them in the difficult position of either paying exorbitantly for health insurance or lying about their status, the latter option putting them at risk for losing coverage.

Health and Human Services has invited comment on what questions should be asked of insurance applicants to determine whether they count as tobacco users. Kliff mentions a few suggestions, all of which inquire about use within a given period of time:

The Campaign for Tobacco Free Kids argues that it should be defined as smoking within a set amount of time.

“The Department will need to determine a period that is not so short as to allow allow a person to identify himself or herself as not a tobacco user if he or she ‘quit’ the day they applied for health insurance but not so long as to include people who have actually quit,” the group writes in public comment.

America’s Health Insurance Plans, which represents most health insurance companies, proposes a two-part question: “Have you used tobacco in the last twelve months?” and “Are you currently using tobacco products?”

These suggestions simply reframe the question, grouping people into smokers or non-smokers/quitters. They don’t address casual use. A casual cigar smoker would have to answer yes to both questions posed by America’s Health Insurance Plans. Twelve months is a long time! Should someone who enjoys an occasional cigar have to pay 50% (or more) higher on their insurance premiums, the same penalty faced by pack-a-day smokers?

A sensible definition would address not only recency of tobacco use, but also frequency within that time period (and possibly the form of tobacco used). Unfortunately, this consideration doesn’t appear to be part of the current discussion. That oversight, along with the looming threat of FDA regulation and calls for higher tobacco taxes, is one more item that could make this a tough year for the cigar industry.

Related: Here’s my article from The Atlantic a couple months ago arguing for a different approach to tobacco regulation. And at Quora, I reference some of the research comparing the risks of cigars and cigarettes.

Comments

  1. occasional smoker says:

    When I first got my life insurance, I was asked about tobacco use. At the time, I smoked maybe one cigar every one to two months (now it’s down to one or two a year). The rep told me that any level level of tobacco use did indeed count as a non-weighted risk factor — in other words, my smoking was seen as an identical risk to the risk incurred by a smoker with a two-pack-a-day habit. I called back a half a year later to say I had stopped smoking altogether, effecting a substantial drop in my premium. I understand why they ask the tobacco question, but it seems odd that this is an all-or-nothing game. The truth, as you point out, isn’t necessarily so binary.

  2. occasional smoker says:

    Forgot to add: During the initial phone calls, I inquired about an offset in premium as I lived in a pristine part of the country where people don’t tend to die of stress, where there are fewer traffic accidents than in and around metropolitan areas, and where the environmental pollution was more or less negligible.

    No dice, of course. Those factors did not appreciably reduce my premium. But identifying myself as a (sometime) smoker sure did raise ‘em.

  3. Jonathan Bagley says:

    In the UK, the insurance industry regards cigar smoking as harmless. I know this with absolute certainty. If you smoke cigarettes you can buy a substantially bigger pension with a lump sum of money. You can’t if you smoke cigars or a pipe. You are treated the same as a non smoker. BTW, it has been repeatedly shown that the healthy consume more health resources over a life time than do smokers – who die more quickly and cheaply. Why the increased premiums. Does this health insurance cover only people of working age? The elderly “healthy ” non smokers are a menace. They carry on for years, rattling with pills, visiting the hospital evry other week and eventually spending a couple of years wetting the carpets in a nursing home.

  4. Derek says:

    I learned recently from a friend in the health insurance industry that there is an official, if informal, answer for occasional smokers under the PPACA: just lie. There are no viable options for recision of lying smokers under Obamacare, regardless of how much they smoke, that there is absolutely no downside to just denying everything. You won’t want to be reeking of Partagas Black when you go in for your annual physical, just because if your doctor reports you as a smoker, your costs will go up 50%. But they have no means to either investigate you or punish your for lying under PPACA.

    Anti-selection is fun!

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