The Real Cost of Smoking by State

By | January 16, 2017


Top-Image The Real Cost of Smoking by State
Smoking can not only 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-related issues are just as staggering. Every year, Americans collectively spend more than $300 billion, which includes “nearly $170 billion in direct medical care for adults” and “more than $156 billion in lost productivity due to premature death and exposure to secondhand smoke.” 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’s analysts gauged 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, expert commentary and a full description of our methodology.

Costs Over a Lifetime

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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 $1,136,524 $88,794
(4)
$747,960
(4)
$112,220
(2)
$178,459
(5)
$9,090
(3)
2 North Carolina $1,151,396 $86,374
(2)
$727,576
(2)
$135,249
(10)
$191,221
(10)
$10,977
(23)
3 Georgia $1,155,351 $86,932
(3)
$732,280
(3)
$122,031
(4)
$202,450
(20)
$11,658
(28)
4 Mississippi $1,184,371 $94,006
(10)
$791,866
(10)
$124,511
(6)
$161,833
(1)
$12,155
(33)
5 Tennessee $1,196,502 $93,075
(7)
$784,026
(7)
$124,329
(5)
$184,494
(8)
$10,579
(15)
6 Alabama $1,196,752 $94,006
(10)
$791,866
(10)
$120,869
(3)
$177,982
(4)
$12,030
(31)
7 North Dakota $1,196,831 $84,140
(1)
$708,759
(1)
$159,156
(29)
$233,298
(33)
$11,477
(26)
8 South Carolina $1,202,904 $92,517
(6)
$779,322
(6)
$133,584
(9)
$185,571
(9)
$11,912
(30)
9 Missouri $1,203,893 $89,910
(5)
$757,369
(5)
$149,290
(16)
$196,546
(15)
$10,778
(18)
10 Idaho $1,254,347 $94,564
(13)
$796,570
(13)
$158,176
(28)
$194,139
(14)
$10,898
(21)
11 Nebraska $1,279,930 $93,633
(8)
$788,730
(8)
$168,829
(30)
$216,228
(26)
$12,509
(35)
12 West Virginia $1,283,179 $102,755
(16)
$865,564
(16)
$136,164
(11)
$170,344
(3)
$8,352
(1)
13 Wyoming $1,292,443 $94,006
(10)
$791,866
(10)
$155,879
(26)
$240,067
(35)
$10,626
(17)
14 Indiana $1,303,617 $100,521
(15)
$846,748
(15)
$145,602
(12)
$200,960
(16)
$9,786
(9)
15 Arkansas $1,303,731 $107,595
(20)
$906,334
(20)
$110,583
(1)
$168,794
(2)
$10,426
(13)
16 Oklahoma $1,306,953 $103,313
(18)
$870,268
(18)
$128,409
(8)
$191,266
(11)
$13,696
(41)
17 Virginia $1,311,325 $93,820
(9)
$790,298
(9)
$150,533
(21)
$265,261
(43)
$11,413
(25)
18 Colorado $1,331,203 $97,356
(14)
$820,091
(14)
$153,134
(25)
$247,366
(38)
$13,255
(38)
19 Louisiana $1,343,210 $108,153
(22)
$911,038
(22)
$125,504
(7)
$183,792
(7)
$14,723
(45)
20 Oregon $1,376,898 $107,036
(19)
$901,630
(19)
$149,952
(19)
$209,071
(23)
$9,209
(4)
21 Montana $1,390,030 $110,015
(25)
$926,718
(25)
$150,233
(20)
$192,450
(12)
$10,615
(16)
22 Iowa $1,394,192 $107,595
(20)
$906,334
(20)
$152,973
(24)
$216,987
(27)
$10,304
(12)
23 Kansas $1,397,107 $108,339
(23)
$912,606
(23)
$149,814
(18)
$212,996
(25)
$13,351
(40)
24 Florida $1,426,171 $109,829
(24)
$925,150
(24)
$178,803
(35)
$193,829
(13)
$18,561
(51)
25 Ohio $1,433,524 $113,924
(27)
$959,647
(27)
$149,476
(17)
$201,670
(18)
$8,807
(2)
26 Delaware $1,442,714 $102,941
(17)
$867,132
(17)
$215,881
(43)
$246,877
(37)
$9,882
(10)
27 Texas $1,458,738 $113,738
(26)
$958,079
(26)
$152,540
(23)
$217,085
(28)
$17,296
(50)
28 South Dakota $1,484,344 $118,578
(30)
$998,849
(30)
$148,919
(15)
$207,905
(22)
$10,094
(11)
29 New Mexico $1,487,012 $120,625
(31)
$1,016,097
(31)
$155,928
(27)
$183,449
(6)
$10,912
(22)
30 Nevada $1,507,008 $120,811
(32)
$1,017,665
(32)
$147,279
(13)
$211,536
(24)
$9,717
(8)
31 Utah $1,530,670 $118,391
(29)
$997,281
(29)
$151,435
(22)
$247,766
(39)
$15,797
(49)
32 Michigan $1,569,963 $128,444
(35)
$1,081,955
(35)
$147,808
(14)
$202,270
(19)
$9,486
(5)
33 Maine $1,598,933 $126,210
(34)
$1,063,139
(34)
$198,817
(40)
$201,270
(17)
$9,496
(6)
34 New Hampshire $1,599,037 $115,971
(28)
$976,896
(28)
$222,162
(45)
$272,458
(44)
$11,549
(27)
35 Arizona $1,631,475 $131,794
(36)
$1,110,180
(36)
$172,767
(31)
$205,040
(21)
$11,693
(29)
36 Maryland $1,680,774 $123,604
(33)
$1,041,186
(33)
$199,748
(41)
$304,168
(51)
$12,068
(32)
37 Wisconsin $1,692,054 $136,634
(37)
$1,150,950
(37)
$177,100
(33)
$217,697
(29)
$9,674
(7)
38 Pennsylvania $1,742,938 $141,660
(39)
$1,193,287
(39)
$178,827
(36)
$218,684
(30)
$10,479
(14)
39 Illinois $1,770,563 $141,660
(39)
$1,193,287
(39)
$188,453
(37)
$234,902
(34)
$12,261
(34)
40 New Jersey $1,836,402 $138,496
(38)
$1,166,630
(38)
$223,227
(46)
$294,139
(49)
$13,911
(43)
41 Washington $1,840,743 $148,920
(43)
$1,254,441
(43)
$177,417
(34)
$249,133
(40)
$10,832
(20)
42 California $1,863,218 $148,362
(42)
$1,249,737
(42)
$198,103
(39)
$252,217
(42)
$14,799
(47)
43 District of Columbia $1,894,010 $144,266
(41)
$1,215,240
(41)
$232,443
(48)
$289,060
(48)
$13,001
(37)
44 Minnesota $1,904,792 $153,760
(44)
$1,295,210
(44)
$191,621
(38)
$250,887
(41)
$13,313
(39)
45 Vermont $1,916,093 $154,877
(45)
$1,304,619
(45)
$220,381
(44)
$225,118
(31)
$11,098
(24)
46 Hawaii $2,048,587 $167,535
(48)
$1,411,246
(48)
$173,258
(32)
$283,621
(46)
$12,926
(36)
47 Alaska $2,056,066 $162,881
(46)
$1,372,045
(46)
$214,495
(42)
$295,861
(50)
$10,784
(19)
48 Rhode Island $2,063,847 $166,232
(47)
$1,400,270
(47)
$251,097
(49)
$231,956
(32)
$14,291
(44)
49 Connecticut $2,183,204 $170,513
(49)
$1,436,335
(49)
$274,272
(50)
$286,950
(47)
$15,133
(48)
50 Massachusetts $2,197,197 $172,189
(50)
$1,450,447
(50)
$280,080
(51)
$279,737
(45)
$14,744
(46)
51 New York $2,313,025 $194,341
(51)
$1,637,046
(51)
$226,057
(47)
$241,818
(36)
$13,764
(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)

1 Kentucky $22,285 $1,741
(4)
$14,666
(4)
$2,200
(2)
$3,499
(5)
$178
(3)
2 North Carolina $22,576 $1,694
(2)
$14,266
(2)
$2,652
(10)
$3,749
(10)
$215
(23)
3 Georgia $22,654 $1,705
(3)
$14,358
(3)
$2,393
(4)
$3,970
(20)
$229
(28)
4 Mississippi $23,223 $1,843
(10)
$15,527
(10)
$2,441
(6)
$3,173
(1)
$238
(33)
5 Tennessee $23,461 $1,825
(7)
$15,373
(7)
$2,438
(5)
$3,618
(8)
$207
(15)
6 Alabama $23,466 $1,843
(10)
$15,527
(10)
$2,370
(3)
$3,490
(4)
$236
(31)
7 North Dakota $23,467 $1,650
(1)
$13,897
(1)
$3,121
(29)
$4,574
(33)
$225
(26)
8 South Carolina $23,586 $1,814
(6)
$15,281
(6)
$2,619
(9)
$3,639
(9)
$234
(30)
9 Missouri $23,606 $1,763
(5)
$14,850
(5)
$2,927
(16)
$3,854
(15)
$211
(18)
10 Idaho $24,595 $1,854
(13)
$15,619
(13)
$3,101
(28)
$3,807
(14)
$214
(21)
11 Nebraska $25,097 $1,836
(8)
$15,465
(8)
$3,310
(30)
$4,240
(26)
$245
(35)
12 West Virginia $25,160 $2,015
(16)
$16,972
(16)
$2,670
(11)
$3,340
(3)
$164
(1)
13 Wyoming $25,342 $1,843
(10)
$15,527
(10)
$3,056
(26)
$4,707
(35)
$208
(17)
14 Indiana $25,561 $1,971
(15)
$16,603
(15)
$2,855
(12)
$3,940
(16)
$192
(9)
15 Arkansas $25,563 $2,110
(20)
$17,771
(20)
$2,168
(1)
$3,310
(2)
$204
(13)
16 Oklahoma $25,627 $2,026
(18)
$17,064
(18)
$2,518
(8)
$3,750
(11)
$269
(41)
17 Virginia $25,712 $1,840
(9)
$15,496
(9)
$2,952
(21)
$5,201
(43)
$224
(25)
18 Colorado $26,102 $1,909
(14)
$16,080
(14)
$3,003
(25)
$4,850
(38)
$260
(38)
19 Louisiana $26,337 $2,121
(22)
$17,863
(22)
$2,461
(7)
$3,604
(7)
$289
(45)
20 Oregon $26,998 $2,099
(19)
$17,679
(19)
$2,940
(19)
$4,099
(23)
$181
(4)
21 Montana $27,255 $2,157
(25)
$18,171
(25)
$2,946
(20)
$3,774
(12)
$208
(16)
22 Iowa $27,337 $2,110
(20)
$17,771
(20)
$2,999
(24)
$4,255
(27)
$202
(12)
23 Kansas $27,394 $2,124
(23)
$17,894
(23)
$2,938
(18)
$4,176
(25)
$262
(40)
24 Florida $27,964 $2,154
(24)
$18,140
(24)
$3,506
(35)
$3,801
(13)
$364
(51)
25 Ohio $28,108 $2,234
(27)
$18,817
(27)
$2,931
(17)
$3,954
(18)
$173
(2)
26 Delaware $28,289 $2,018
(17)
$17,003
(17)
$4,233
(43)
$4,841
(37)
$194
(10)
27 Texas $28,603 $2,230
(26)
$18,786
(26)
$2,991
(23)
$4,257
(28)
$339
(50)
28 South Dakota $29,105 $2,325
(30)
$19,585
(30)
$2,920
(15)
$4,077
(22)
$198
(11)
29 New Mexico $29,157 $2,365
(31)
$19,923
(31)
$3,057
(27)
$3,597
(6)
$214
(22)
30 Nevada $29,549 $2,369
(32)
$19,954
(32)
$2,888
(13)
$4,148
(24)
$191
(8)
31 Utah $30,013 $2,321
(29)
$19,555
(29)
$2,969
(22)
$4,858
(39)
$310
(49)
32 Michigan $30,784 $2,519
(35)
$21,215
(35)
$2,898
(14)
$3,966
(19)
$186
(5)
33 Maine $31,352 $2,475
(34)
$20,846
(34)
$3,898
(40)
$3,946
(17)
$186
(6)
34 New Hampshire $31,354 $2,274
(28)
$19,155
(28)
$4,356
(45)
$5,342
(44)
$226
(27)
35 Arizona $31,990 $2,584
(36)
$21,768
(36)
$3,388
(31)
$4,020
(21)
$229
(29)
36 Maryland $32,956 $2,424
(33)
$20,415
(33)
$3,917
(41)
$5,964
(51)
$237
(32)
37 Wisconsin $33,178 $2,679
(37)
$22,568
(37)
$3,473
(33)
$4,269
(29)
$190
(7)
38 Pennsylvania $34,175 $2,778
(39)
$23,398
(39)
$3,506
(36)
$4,288
(30)
$205
(14)
39 Illinois $34,717 $2,778
(39)
$23,398
(39)
$3,695
(37)
$4,606
(34)
$240
(34)
40 New Jersey $36,008 $2,716
(38)
$22,875
(38)
$4,377
(46)
$5,767
(49)
$273
(43)
41 Washington $36,093 $2,920
(43)
$24,597
(43)
$3,479
(34)
$4,885
(40)
$212
(20)
42 California $36,534 $2,909
(42)
$24,505
(42)
$3,884
(39)
$4,945
(42)
$290
(47)
43 District of Columbia $37,137 $2,829
(41)
$23,828
(41)
$4,558
(48)
$5,668
(48)
$255
(37)
44 Minnesota $37,349 $3,015
(44)
$25,396
(44)
$3,757
(38)
$4,919
(41)
$261
(39)
45 Vermont $37,570 $3,037
(45)
$25,581
(45)
$4,321
(44)
$4,414
(31)
$218
(24)
46 Hawaii $40,168 $3,285
(48)
$27,671
(48)
$3,397
(32)
$5,561
(46)
$253
(36)
47 Alaska $40,315 $3,194
(46)
$26,903
(46)
$4,206
(42)
$5,801
(50)
$211
(19)
48 Rhode Island $40,468 $3,259
(47)
$27,456
(47)
$4,923
(49)
$4,548
(32)
$280
(44)
49 Connecticut $42,808 $3,343
(49)
$28,163
(49)
$5,378
(50)
$5,626
(47)
$297
(48)
50 Massachusetts $43,082 $3,376
(50)
$28,440
(50)
$5,492
(51)
$5,485
(45)
$289
(46)
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, the negative physical and financial effects of smoking can be significant. 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 individuals 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?
Steven A. Branstetter
What are the most effective strategies for individuals trying to quit smoking? What approaches typically fail?

One of the most effective approaches to reducing smoking has been increasing taxes. The Framework Convention on Tobacco Control and others have established that price control of tobacco through taxation is an effective strategy to reduce demand internationally. Although this approach works better in some populations than others, it is perhaps the most straight-forward and effective approach to reducing smoking at the population-level. For every 10% increase in taxes, there is a corresponding reducing in smoking of up to 15% in youth smokers and up to 7% in adult smokers.

Our own research has been looking at if it might be possible to have smokers select less-addictive cigarettes with less nicotine by basing the price of cigarettes on the amount of nicotine — with cigarettes containing little or no nicotine costing significantly less than full-nicotine cigarettes. In theory, as smokers selected lower nicotine cigarettes, quitting would be easier and smoking would be less “rewarding” overall.

The list of things that do not work is longer and exhaustive – perhaps the “worst” way to quit are things like hypnosis and cold turkey. This is a tricky one – you will hear some people tell you cold turkey is the most effective method – in fact, most people who quit have done so using cold turkey. However, it is the most attempted and most failed method, so it’s also natural that – given the large numbers – you will find a large number of people who have done it successfully. However, most smokers have attempted and failed – multiple times – using this method. Methods such as nicotine
replacements, pharmaceuticals and behavioral therapy are pretty good, but there is a long way to go in the field. The best approaches (beyond taxation) have quit rates of no more than 25-30%. That’s still a 70-75% failure rate.

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

I think electronic cigarettes and other nicotine delivery products should be regulated as cigarettes rather than medical devices. There is too little and unconvincing research that these products are utilized for, or effective as, cessation or reduction aids. Whereas the jury is still out regarding the extent of the health consequences of electronic products, there is sufficient evidence that they can be addictive and deliver nicotine efficiently. There is also emerging evidence that these products may have their own unique risks and health issues.

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

I believe there is a large role for employers and insurance companies in smoking cessation. One approach that has been studied with some efficacy is simply paying employees to quit smoking. As we have found, with higher taxation resulting in lower smoking rates, smokers (like the rest of us) make decisions based on economic considerations – I think further research could find the right balance between paying employees to quit and the benefits in reduced health care costs.

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

The most effective way to quit smoking is behavioral counseling in combination with medication (nicotine replacement products, Zyban, or Chantix). Most people quit on their own without assistance, but the likelihood of success is substantially improved with these tools. Some popular tools that smokers use to quit, which have not been shown to be helpful are acupuncture, hypnosis, over the counter herbal remedies, and low-level laser treatment.

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

This is a question that’s getting lots of attention right now. E-cigarettes potentially could help cigarette smokers to quit, but they also have the potential to cause nicotine addiction in non-smokers, particularly teens. The jury is still out about e-cigarettes usefulness as a cessation aid, while at the same time there’s growing evidence that young people who use e-cigarettes are more likely to initiate use of cigarettes and other combustible (and dangerous) tobacco products, such as hookah. Tax policy has to grapple with these concerns while the data are still coming in.

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

Comprehensive tobacco control policies are the most effective; these include taxation, advertising restrictions, clean air laws, restricted youth access, and access to affordable cessation treatment. Employers and health insurance companies both have important roles in encouraging people to quit and providing access to cessation services. Fortunately, cessation treatment is highly cost-effective.

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

I have not followed this closely in recent years, but the last I looked at it the main impression I had was that even the best cessation programs had modest to poor success rates.

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

The paradox of e-cigs, as I see it, is that they can either help an addicted smoker get off the toxic stew that they inhale from burning tobacco or they could addict non-smokers who think it is safer than cigarettes. Given the adverse potential, especially for underage youth, who are after all the people most prone to become addicted to nicotine, I think they need to be regulated at least to restrict use by children.

How might marijuana legalization affect tobacco use?

I am concerned that marijuana users do not understand that inhaling any combustion product, and especially the concentrated toxins during active smoking, is hazardous. There is a lot of misinformation that marijuana smoke is somehow not toxic. In fact, all combustion produces particles and gasses that cause adverse health effects.

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

Health insurance companies? Getting people to quit smoking is hard. Increased cost of cigarettes drives down smoking rates some. And cessation programs have some limited success. But I think the main thing has to be to prevent new smokers from starting, given how hard it is to get people to quit. We should focus on youth, which is when the vast majority of smoking starts. Making smoking uncool seems to me the best way to reduce its appeal to young people.

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

People point to cigarette taxes as the obvious policy lever to encourage smoking cessation, but the data do not generally support the idea that current cigarette tax increases reduce smoking. Indeed, average cigarette taxes did not start to increase dramatically until around 1990, but the huge decline in smoking from its peak in the mid-twentieth century largely happened in the 60s, 70s, and 80s. In fact, recent estimates suggest that it would take a 100% increase in cigarette taxes to decrease smoking prevalence by just 5%. However, the national average estimates of the effects of taxes on smoking do hide large regional differences: cigarette taxes are considerably higher in the northeast and west coast.

Generally, the extent to which state and local policies may encourage smoking cessation varies for light versus heavy smokers. For light smokers, some combination of more dramatic warning labels (or health information campaigns generally), higher taxes, and indoor smoking bans have been shown to be effective. For heavy smokers with a strong nicotine addiction, policies designed to encourage cessation need to increasingly heavy-handed. For example, consider the case of information campaigns. How can we expect warning labels to encourage cessation when some evidence shows that heavy smokers often fail to quit following a smoking-related health shock to their spouse? Heavy smokers don’t quit because policy makers ban smoking in bars, they simply stop going to bars – and there is evidence that health concerns for children from secondhand smoke increased following state-level indoor smoking bans.

But I do think that indoor smoking bans may have an important long-run effect on heavy smoking by de-normalizing cigarette smoking. Research suggests that, compared to the 1970s, smokers are much more isolated today – friend groups are in some sense more defined by smoking. This is partly due to information campaigns (policy) that has made smoking less socially acceptable. In the short-term, for heavy smokers, the literature suggests that personalized sources of information and interventions are needed.

From a policy perspective, I think it’s important to consider unintended consequences. For example, the ACA allows health insurance companies offering plans on the exchanges to charge up to a 50% surcharge on premiums for smokers. Clearly this reflects the fact that smokers are more costly/risky from the perspective of the insurance firm. While we might expect this surcharge to convince light smokers to quit, it could also be the case that heavy smokers simply forgo purchasing health insurance.

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

The most effective strategies are medications and counseling. There are seven medications approved by the Food & Drug Administration for quitting smoking – five forms of nicotine replacement therapy (nicotine patch, gum, lozenge, nasal spray or inhaler) and two non-nicotine medications (bupropion and varenicline). All of the medications either double or triple someone’s chances of quitting smoking in general. Counseling also generally doubles someone’s chances of quitting and the more counseling the better. Counseling can be delivered by telephone and every state has a free telephone Quitline. Counseling can also be delivered in person (individually or in groups) and by text message. A great place to find quitting resources is Smokefree.gov, run by the National Cancer Institute. The combination of medications and counseling is even better than either one alone.

Many people try to quit on their own, which can work but is much harder and less successful that using medications and/or counseling. I tell my patients that the tobacco companies have invested so much in getting them hooked, so why not give themselves every bit of help possible.

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

I feel that e-cigarettes should be regulated but not taxed. There is still considerable debate about the overall public health impact of e-cigarettes. However, nearly all experts agree that e-cigarettes
are much, much less harmful than combustible cigarettes. The goal is to use them to help people quit (not just cut down) and many people indeed have quit using e-cigarettes. Taxing them mean fewer people would use them to quit smoking and therefore there would likely be more smokers. Taxes have been the most effective public health strategy at lowering the prevalence of cigarette smoking. In this case, it could have the opposite effect, since higher taxes would mean fewer people using a potentially helpful strategy for quitting.

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

The two biggest things state and local authorities can do to encourage people to quit smoking are: 1) increase taxes on cigarettes (preferably with tax revenues directed towards further programs to help people quit) and 2) pass (and enforce) clean indoor air laws, which ban smoking indoors. Employers can also have a role, both by offering treatment and by ensuring that all health plans they offer include smoking cessation treatment. Employer incentives to help people quit also work but should be done in a way that is equitable for non-smokers. And finally, insurers should all cover smoking cessation treatment. When all preventive interventions were reviewed, smoking cessation treatment and childhood vaccinations were the two most cost-effective preventive services, enough for people to describe smoking cessation treatment as the “gold standard for cost-effectiveness.”

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

The USDHHS 2008 Clinical Practice Guideline has good recommendations. The likelihood of success is increased by use of an FDA approved medication and also by counseling. Support from others can be exceedingly helpful. Being able to engage in effective coping and problem solving strategies also is useful. Simply relying on “will power” without other sources of support is less likely to be successful. Treatobacco also is a good resource.

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

E-cigarettes definitely should be regulated. There is a lot that we do not know currently, including long-term effects. Most regular smokers who also use e-cigarettes continue to smoke and may not appreciably reduce their risk, if they reduce their risk at all. Different e-cigarettes may have different toxicity profiles and e-cigarettes are continuing to change and evolve. Almost surely, they are safer than conventional cigarettes, but it is unclear that they will have positive public health impact. Adequate levels of taxation also are important. I am not very knowledgeable about the differential implications of treating e-cigarettes as cigarettes as opposed to medical devices.

How might marijuana legalization affect tobacco use?

Unclear. Cigarette smokers also are more likely to use marijuana. I think we need more time to assess trends.

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

CDC has a document that describes best practices for promoting tobacco reduction, including cessation. Adequate funding of tobacco control programs is critical, and few states meet the CDC recommended funding guidelines. It is important that tobacco users have access to effective treatments, including counseling and medication. Smokers in all 50 states and DC can access quitlines. Employers can subsidize tobacco cessation programs including medications and large employers can offer programs onsite. Health insurance companies can cover cessation programs and medications. Both employers and health insurance companies could offer incentives for quitting. Some insurers give preferential rates to nonsmokers.

Amy L. Copeland
What are the most effective strategies for individuals trying to quit smoking?

The most effective strategy for individuals trying to quit smoking is the combination of behavioral counseling, typically offered in individual or group sessions, along with some form of pharmacotherapy. Pharmacotherapy can be in the form of nicotine replacement therapy (e.g., transdermal patch, gum, nasal spray, inhaler) or the medications, Zyban or Chantix, available by prescription. This combination of behavioral counseling and pharmacotherapy yields the highest success rates for smoking cessation.

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

At this time, it appears that regulating and taxing e-cigarettes would be more appropriate. Although e-cigarettes have been shown to reduce craving and nicotine withdrawal symptoms, their efficacy as a long-term aid to smoking cessation has yet to be determined. Although 85% of adult e-cigarette users report explicitly using e-cigarettes to quit smoking, research has thus far not supported the role of e-cigarettes as an effective cessation tool.

There are also data showing that many e-cigarette users, who are not traditional smokers, are ingesting nicotine, which may then lead to smoking traditional cigarettes. Many of these novice users are young people who are attracted to the various flavors (e.g., cinnamon, cherry, mango) that are being marketed.

How can state and local authorities encourage people to quit smoking?

Smoking bans can be useful, but there are some smokers who are simply unable to quit without professional assistance. These may be individuals who suffer from other psychological difficulties such as depression, anxiety, or more serious mental illnesses such as Schizophrenia. Smoking rates are higher among these individuals, and they have a more difficult time with cessation. They often need specifically tailored cessation programs. Also, those individuals who are socioeconomically disadvantaged have higher rates of smoking and have a more difficult time quitting. Therefore, it’s likely that if nicotine replacement therapies were offered at low cost or covered by Medicaid or employers, this would be beneficial.

Dr. Lorraine R. Reitzel
What are the most effective strategies for individuals trying to quit smoking? What approaches typically fail?

The most effective strategies to help people quit smoking include the use of medications (e.g., Chantix, nicotine replacement therapies) and behavioral support. The 2008 update to the Treating Tobacco Use and Dependence Guidelines is available online and outlines these effective treatments, as well as potential modifications for particular subgroups of tobacco users (e.g., pregnant women). Although the Guidelines do not include the most recent research in the field, its recommendations are still highly relevant. One recent development in the field of note is that the FDA recommended that the “black box” warning on Chantix be removed. This warning previously indicated a possible link between the use of Chantix and neuropsychiatric side effects, including suicidal ideation; its removal reflects the latest research on the topic and will be helpful in increasing the use of Chantix among consumers with behavioral health needs.

Our website offers brief videos about evidence based approaches for tobacco use cessation in English and Spanish that may be of interest to individuals wanting to quit and their healthcare providers.

What approaches typically fail? Most tobacco users have difficulty quitting “cold turkey,” and it may take several tries  even with medications and behavioral support  to achieve abstinence. It is important to recognize that multiple quit attempts are common and may be necessary to find the approach that will work. Additionally, nicotine dependence might be most appropriately seen as a chronic condition, whereby former smokers may be at risk of relapse for many years following a successful quit attempt.

Although anyone can read about the most effective tobacco use cessation interventions in the Guidelines and obtain over-the-counter medications and support from freely available services (e.g.,
QuitLine: 1-800-QUIT-NOW), some individuals may want to work directly with a knowledgeable healthcare provider, especially inasmuch as quitting smoking may increase the efficacy of some medications that will require dosage titration.

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

E-cigarettes and other electronic nicotine delivery systems (ENDS) were “deemed” to fall under the regulatory authority of the FDA, similar to conventional cigarettes and other tobacco products that also deliver the highly addictive drug, nicotine, to the user. In 2016, the FDA was granted the authority to regulate these products, including their manufacture, import, packaging, labeling, advertising, promotion, sale, and distribution. Thus, their regulation is supported by this rule. Among other things, this will protect consumers by assuring consistency in the composition of products sold under similar cover and prohibiting the sale of these products to minors (at the federal level), including through vending machines.

E-cigarettes and ENDS are not considered to be medical devices by the FDA by default, and may be subject to taxation  similar to tobacco products. Based on the lack of consensus about the efficacy of e-cigarettes and ENDS as means to quit conventional cigarette smoking and the need for longer-term research on the potential harms of ENDS use, it seems appropriate that it not yet be routinely marketed as an effective and safe method for quitting conventional cigarette smoking.

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 absolutely encourage people to quit smoking. One evidence-based strategy for doing so is to implement tobacco-free campus and workplace policies that prohibit the use of tobacco and ENDS in public places, healthcare agencies, and businesses. This makes tobacco use increasingly inconvenient, which can spur quit attempts and protect non-tobacco using adults and minors from environmental tobacco smoke exposure.

Research indicates that when employees quit tobacco use, there is a significant return on investment in saved healthcare costs and reduced absenteeism. These policies also send a message regarding an organizational priority to promote the overall wellness of their patrons and employees. Tobacco-free workplace policies can be supplemented by other components of effective multi-component, comprehensive tobacco-free programs, which include the provision of insurance coverage for tobacco use cessation services, the explication of services available to employees for cessation, etc. More detail on such organizational programming, particularly for healthcare agencies, can be found here.

An additional policy level approach that has had an impact on tobacco use rates at a population level is cigarette taxation increases, although supplementary approaches may be needed to affect rates among some population subgroups. Other tobacco control initiatives that are becoming increasingly more popular include tobacco no-hire policies and insurance premium surcharges for tobacco users.

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

Quitting smoking is difficult – most smokers try many times before succeeding, but most do succeed. There are now more former smokers living in America than current smokers. In other words, of all Americans alive today that have ever smoked, more have quit than have continued to smoke.

How smokers quit is quite varied and different approaches work for different smokers. What is common is that to be successful, a smoker has to truly want to quit smoking entirely, that it is one of their highest priorities and that they believe in their ability to be successful (self-efficacy). In other words, a strong desire (will) to quit and confidence in their ability to succeed, and essential irrespective of the method used (e.g., cold turkey or nicotine replacement).

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

This is a controversial issue. I believe that there should be a comprehensive regulatory framework for nicotine, with policies, taxes and regulations commensurate with the harm the product causes. In this framework, combustible cigarettes (typical cigarettes on the market today) would have the most restrictive policies and the highest taxes, and FDA-approved nicotine replacement products would be least regulated with the lowest taxes (if any). Electronic cigarettes and other novel products would fall somewhere in the middle based on the evidence of their effectiveness in helping smokers quit, or their relative harm for nonsmokers.

We are a long way from this type of rational nicotine regulatory framework. In fact today, the most deadly products, cigarettes, have very little regulation and prices are low (compared to harm caused) and safer products are often ignored from a regulatory standpoint, or are treated identically to cigarettes.

How might marijuana legalization affect tobacco use?

Good question! As marijuana use has increased, smoking rates have generally decreased, but this is simply correlational, and doesn’t really answer the question if one causes the other. We also know that
a large segment of young people mix marijuana with tobacco in little cigars, or what are called blunts, and are inhaling both products at the same time. As recreational marijuana laws become more common, we should have a better idea if one influences the other. At this time, the evidence is somewhat mixed, but I would hypothesize that if you inhaling one combusted product (marijuana) that might make it more likely to inhale others (tobacco).

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

Yes. As government regulation becomes more disparaged, there will be an increasing role for employers, insurance companies and health care providers to put in place policies, programs and systems that
will promote health generally, and specifically help reduce tobacco use. Increasingly, incentives and penalties are being used to influence health behavior, e.g., surcharges to health insurance for smoking employees, or even some companies not hiring smoking.

These types of programs will be expanded to other health behaviors through prevention and wellness programs, and will be effective to the extent that they are designed smartly and avoid discrimination
against those with pre-existing health conditions or disabilities. Behavioral economics has great potential for institutions to nudge positive behavior change.

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

The most effective methods are usually multi-modal. For motivated adults, a combination of three components is generally considered to be best. Those include: (1) nicotine replacement of some sort (gum, lozenges, inhalers, nasal spray, patches), (2) some type of medication to help control cravings. This might be Varenicline (Chantix® or Bupropion®), and (3) some type of talk therapy (counseling or a telephone quitline counseling). But many adults also spontaneously decide to quit and simply put the cigarettes down. Some people also find that the use of E-cigarettes helps them quit smoking. While these products are not considered safe, they are clearly less risky than cigarettes.

There are any number of approaches that fail. There is no clear evidence that techniques like acupuncture or hypnosis are any more effective than placebo. With that said, though, some people believe that they might help. There is little downside to such techniques except that they might distract someone from a known effective method.

There really is no single “best” method though. Smokers should try to find something that helps them make progress. A big part of progress is remembering that there is a good chance that they’ll slip up
at some point. That’s not a failure, but a chance to examine what was happening around them and what they were feeling when they slipped, make a new plan, and then move forward. I tell people that two steps forward and one back still gets you there.

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

I believe that they should be regulated by the FDA. There is far too much variance not only in product components and nicotine delivery, but many imported products are made with shoddy manufacturing practices and parts. While electronic nicotine delivery systems (ENDS or e-cigarettes) are a less risky product than combustible tobacco, they can clearly be made safer. The batteries and charging systems are sometimes poorly made and are susceptible to overcharging or developing shorts that lead to fires and explosions in the devices.

The issue of taxation is sticky. Youth are pretty responsive to taxation because of limited income and less severe dependence on tobacco. We’ve seen that taxation can reduce youth use of cigarettes. But
many in the public health community would prefer that E-cigs and liquid not be taxed at a rate equivalent to cigarettes. If the tax rate is less then it may add another incentive to smokers to switch from cigarettes to ENDS, which can reduce harm to current smokers.

There is a lot of disagreement in the public health community about how best to manage e-cigs. A recent surgeon general’s report argues that they are pretty much just another form of tobacco. This is a bit simplistic in that, while many contain nicotine, they do not burn tobacco because they do not contain tobacco. E-cigs are probably somewhat harmful to users. But they are not nearly as unsafe as combustible products.

Last December, the Washington Post ran an opinion piece arguing that restricting youth access to ENDS may, by reducing choices, end up contributing to increases in youth smoking. This leaves many of us in a painful intellectual position if the studies quoted are replicated. Nicotine is addictive and clearly harmful to the developing adolescent brain. But if a youth is determined to consume nicotine, there is less harm in electronic devices than combustible cigarettes. This is not to argue for youth to have unlimited access to E-cigs, but merely to illustrate the uncomfortable position in which many of us find ourselves. “It’s complicated” is the response that we often have to give to many public health questions.

While we are still learning a lot about ENDS, and there is some optimism that ENDS may help adults to quit smoking, we don’t want youth starting to use them. Cigarette consumption is dropping in youth and we want that to continue. Some researchers worry that E-cigs may be the gateway that starts some youth using cigarettes.

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

Smoking cessation is now covered as a preventive service under the ACA, which makes it available to anybody with insurance. It could be strengthened to add a longer period of coverage of medications (90 days is pretty standard), but this is a good start. There are also a number of workplace incentives to quit now that so many workplaces are either smoke-free or tobacco-free.

State and local authorities help by creating strong smoke-free indoor air laws. As more public spaces go smoke-free, the environmental barriers make it harder for smokers to find places to smoke. But smoke-free ordinances can cause unintended consequences. For example, in cities in Europe where cafes are smoke-free, now smokers often take up the outside tables, creating unpleasant conditions for nonsmokers who would also enjoy sitting outside. If ordinances have a set distance from doorways for smoking, people don’t have to sit in or pass through a cloud of smoke and smokers are more discouraged from smoking in public. Ordinances should cover not only restaurants & bars, but all indoor workspaces. Outdoor spaces where people congregate (parks, sporting events, outdoor cafes, etc.) should also be covered.

As more housing units go smoke-free that represents another pressure on those who would smoke.

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’s analysts 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 thereafter of 51 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, 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 detriments 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 incurred from smoking — and divided that amount by the total number of adult smokers in each state.

Income Loss per Smoker

Previous studies have demonstrated that smoking can lead to loss of income — either because of absenteeism, workplace bias or lower productivity due to smoking-induced health problems — and 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 accounting for the fact that, according to a recent study from the Federal Reserve Bank of Atlanta, 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, NYsmokefree.com, Federal Reserve Economic Data (FRED), Kaiser Family Foundation and the Independent Insurance Agents & Brokers of America.

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