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Smoking is one the most serious health concerns in the United States, given that it kills 443,000 Americans every year. Today, the country spends “$96 billion in medical costs and $97 billion in lost productivity each year” (U.S. Department of Health and Human Services, 2010, p. 4). To make matters worse, “one in five U.S. high school students and adults still smoke” (U.S. Department of Health and Human Services, 2010, p. 4). These figures make clear that it is necessary for the government (at both the national and state levels) to come up with legislation that limits cigarette (and other tobacco related products) consumption, as well as programs that contribute in generating awareness of the harmful effect that smoking has on health.

At the federal level, Congress is yet to propose a nationwide smoking ban inside establishments and at the workplace. However, Congress has taken action to limit the incidence of smoking across U.S. territory. Following this line of thought, President Bill Clinton issued an Executive Order (13058); this order banned smoking inside all spaces occupied (either through ownership, lease, or rental) by the Federal Government. The following year, the United States Department of Transportation banned smoking on all commercial passenger flights (flights both inside the United States or operated by American carriers).

At the state level, action has already been taken by state legislatures in order to ban smoking (as a means of protecting people’s health). In New Hampshire, the state legislature passed the Indoor Smoking Act in 2007; this act effectively banned smoking inside certain establishments, including hospitals, grocery stores, elevators, restaurants, bars, and clubs. This legislative act was a significant step forward in the battle against smoking (and tobacco use in general), but, in 2011, the state legislature reversed its footing, when it approved a tax reduction on cigarette packs. The reduction was established at ten cents per pack (going from $1.78 to $1.68). Such a concession appears not only to hurt the state’s finances, but also to hinder the state’s historical efforts in combating smoking prevalence. Such a policy decision has raised several questions. The state legislature argues that it was done in order to favor the economy, but the question remains: at what cost?

Background

Smoking

Smoking is a serious matter, not only in the state of New Hampshire or the United States, but also at a global level. Countries around the world struggle in finding ways to disincentive increased cigarette (and other tobacco related products) consumption. Today, it has been stated, “the tobacco epidemic killed 100 million people in the 20th century and is projected to kill one billion people worldwide in the 21st century. Each year, smoking kills more than five million people around the globe” (U.S. Department of Health and Human Services, 2010, p. 9), which makes it clear that smoking is a pressing health risk that must be dealt with effectively.

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Today, the countries’ efforts have taken two directions. First, governments have decanted in favor of increased tax impositions on tobacco consumption. The logic behind this measure is that increased taxes will ultimately translate to increased cigarette prices. Given that cigarettes, as well as every other good/service being marketed, are subject to the laws of supply and demand, higher prices will signify a decreased demand. Based on this, increased taxes will decrease cigarette smoking, thus lessening the adverse effects that smoking has on people’s health. Second, continued efforts have been put into preventive campaigns that emphasize the damaging effects of tobacco smoke on the human body.

New Hampshire Legislature

Ever since smoking became a pressing issue in health care, the legislature of the state of New Hampshire decided to pursue a policy of increased taxation in order to disincentive consumption (thus decreasing the prevalence and health risk that smoking signifies for the people of New Hampshire). Aside from pursuing this increased taxation strategy, the state legislature passed the Indoor Smoking Act in 2007 in an attempt to restrict cigarette consumption within the state’s border further. Notwithstanding the effect of Indoor Smoking Act’s, the state’s strategy via continued increased taxes did pay off on two fronts. First, it was effective in keeping individuals to start smoking. Second, it was effective incentivizing smokers to quit smoking. In both cases, the chief factor that ultimately led to decreased smoking throughout the state was the elevated cost that smoking signified for the average American.

The public health strategy to fight tobacco use is two-fold: prevent new smokers and help current ones reduce or stop smoking. Both strategies are greatly helped by high cigarette prices. The evidence supporting cost as a barrier is clear and significant. For every 10 percent increase in tobacco price, 7 percent fewer youths initiate tobacco use, and 4 percent of adults actually quit (Budnitz & Klementowicz, 2012).

Today, great improvements that such an initiative had in reducing smoking within the state appears to have been threatened by the state legislature’s decision to decrease taxes on cigarette packs (for the first time in the state’s history). The legislature has argued that this measure was done, as a means to incentivize consumption and generate increased revenue for the state. This legislative decision, however, elevates risks, not only via increased smoking (as tobacco producers will now have an incentive to increase production, and households will have an incentive to increase consumption), but also via decreased health care resources. The bottom line is that decreased taxes will translate into decreased income for the state’s healthcare programs. This puts pressure on the legislature, as apart from imposing an unnecessary risk on the health of the state’s residents, there is now a credible threat on the stability of the state’s health care services (as decreased funding could lead to decreased coverage, quality, and employment within the sector).

Smoking is a serious concern for Nurse Practitioners (NPs) given its increased prevalence and the elevated number of illnesses associated to it (most of which have a devastating effect on individuals’ health and bring death). Today NPs struggle to cope with a condition, which “kills an estimated 443,000 people each year, with secondhand smoke responsible for 50,000 of those deaths” (U.S. Department of Health and Human Services, 2010, p. 9) in the United States alone. Today the government (both at the federal and state levels) spend billions of dollars every year trying to treat diseases brought about by smoking; efforts also go into prevention programs, so as to try to disincentive smoking among Americans at all age levels. These efforts, albeit successful, are still a long way to go, in terms of eliminating the serious health concern that smoking continues to be, at present (as smoking rates among adult Americans has decreased significantly, going from 42.4% to 20.6% between 1965 and 2008).

The challenges that smoking poses to NPs are varied. First, they are charged with the responsibility of offering high quality, integral health care services for all those who suffer from any smoking-related condition. This means that NPs must cope to deliver the best possible service to people suffering from cancer (including, though not limited to, cervical, kidney, pancreatic, stomach, and lung cancer), chronic lung disease, cardiovascular diseases, SIDS, and ear problems. The reality of the matter is, “tobacco use causes more deaths than HI/AIDS, alcohol use, cocaine use, heroin use, homicides, suicides, motor vehicle crashes, and fires combined” (U.S. Department of Health and Human Services, 2010, p. 9).

A second challenge that NPs must face is contributing to the prevention of tobacco use, especially among American youths. Today, 3.4 million of high school students smoke; these youths smoke an average 800 million packs of cigarettes per year. Furthermore, 32 million youths (between the ages of 3 and 19) are subject to secondhand smoke. This is a serious problem that NPs must face, provided that smoking youths will inevitably grow up to become adult smokers; they will end up suffering from the many diseases caused by smoking and will be overly likely to die from them. This means that in order to be effective, NPs will have to revisit any training available on treating and helping to prevent smoking (and smoking related health conditions).

Environment

Historical

New Hampshire has historically suffered from elevated smoking prevalence rates among its adult and teenage populations. At present, prevalence remains at a 19% level, meaning that almost two out of every ten adult state residents indulge in smoking. Figures are similar when talking about teenagers; today 16% of teenage state residents indulge in smoking. Throughout recent years, vast improvements have been made; they have all been achieved by a continued policy of raising taxes on cigarettes. As it has already been mentioned, through increased taxes, the state legislature has attempted to decrease consumption and smoking prevalence within the state.

Over the past decade, as New Hampshire increased cigarette taxes several times, the state's population of smokers declined somewhat. It remains relatively high among adults, however; at 19 percent, it is the second-highest rate in New England. We have been more successful among young smokers, where smoking rates declined from 25 percent to 16 percent from 2001 to 2009. Those high school students who do smoke are addicted, as 40 percent say they would like to quit, and 52 percent have tried to quit (Budnitz & Klementowicz, 2012).

Evidently, taxes have proven to be quite effective throughout the state’s historical fight on smoking. However, it appears that the decision made last year by the state legislature to reverse its historical policy and decrease taxes on cigarettes (instead of elevating them) will have an adverse effect on consumption and prevalence (among both adults and teenagers).

Sociocultural

Tobacco has always been a socially accepted drug (similarly to alcohol); governments do not prosecute and jail people who smoke cigarettes (similar to do people who smoke marijuana or ingest other drugs such as cocaine or heroin). Given that tobacco has always been perceived as an accepted drug, consumption has steadily increased, and so has prevalence. Today the situation is unsustainable given that smoking has become one of the chief causes of death, not only in the United States, but in the whole world; “according to the World Health Organization, tobacco is the second major cause of death and the fourth most common risk factor for disease, worldwide” (Smith & Leggat, 2007, p. 1).

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Given the seriousness of the health care situation that smoking poses, ways to disincentive consumption have been developed (taxes being one of them). The fundamental idea behind these strategies to disincentive smoking aim at doing two things: instilling fear and generating financial distress. Campaigns, which highlight the dangers of smoking and illustrate graphically, how smoking can affect a person’s body, aim at frightening people out of smoking. The incentive is the fear that people have of suffering from such conditions and dying from them. Secondly, increased tax policies aim at generating financial distress for households, which will have to choose ultimately between indulging in smoking or choosing other goods/services that they might require to maintain a given standard of living.

Ethical

Throughout the years, questions have been raised on whether or not the strategies being pursued by governments and health care organizations around the world to disincentive smoking are ethical. There are those, who not only question the ethics behind such policies, but also their legality and validity. In the case of increased taxes, as a smoking deterrent, some people feel that they are being cheated out on their right to smoke if they want (by means of elevated prices on cigarette packs). They consider that it is amoral and unethical to force people to quit smoking through taxes that unfairly increase cigarette prices.

These arguments, however, lack foundations. No strategy that attempts to ban smoking in the interest of public health can be deemed unethical (or amoral, for that matter). In fact, it can further be said, “the prohibition is ethically and morally justifiable in defense of public health, which should of necessity, trump individual rights to smoke freely” (Oriola, 2009, p. 838). In general terms, the argument is that under no circumstance can an individual interest outweigh the fundamental interest of the majority (which in this case is health).

Economic

In discussing the economics behind cigarette smoking, it must be said that the figures are quite impressive. First, it is necessary to point out that cigarette smoking costs the United States government $193 billion per year (without mentioning the incalculable costs that result from the productivity loss). Furthermore, yearly public healthcare expenses are in the order of $96 billion. Based on these figures, it becomes evident that a solution, which allows for the procurement of these funds, and that disincentives smoking is developed. New Hampshire, as well as other states, has recognized increased tax policy as the solution for the problem. Increased taxes translate into increased resources, which are required to fund public healthcare programs; it also disincentives smoking provided that the opportunity cost of smoking increases vastly (becoming unappealing in the eyes of more state residents).

The state legislature appears to have lost sight of this fact. The decision to decrease taxes on cigarette packs not only incentives more residents to smoke, but it also translate into decreased financial resources for funding public healthcare programs. It is expected that this decision will cost the state of New Hampshire anywhere between 12 million and 20 million dollars in the next two years (resources that will be desperately needed considering that increased cigarette consumption will further elevate the costs of healthcare services).

Political and Legislative

In terms of political and legislative considerations, first of all,“there is no right to smoke freely as such, and that to the extent that the laws prohibiting tobacco smoking in enclosed public spaces do not impinge smokers’ rights, they are morally and legally justifiable” (Oriola, 2009, p. 838). In other words, the state legislature does have the right (and the moral obligation even) to ban smoking in closed spaces so as to protect the state’s non-smoking residents from the damaging effects of the cigarette smoke.

Furthermore, it must be said that there is no law that forbids increased taxes on cigarettes packs. In fact, the country’s legal framework is configured in the way that promotes smoking restrictions (instead of promoting smoking). Based on this, and on the fact that the vast majority of states apply high taxes on cigarettes (much higher than tthose applied by New Hampshire, even before the tax reduction), it becomes clear that the state legislature made a mistake in choosing to decrease taxes (from a political and legislative point of view).

Discussion

Legislation Difficulties

The legislation passed to decrease state taxes on cigarette packs faces no real difficulties, at least from a legislative point of view. In other words, the state legislature did not violate any other law and so it was a valid decision to make. However, the problems associated with such a decision are evident and varied. As it has been repeatedly mentioned, lesser taxes mean that the state will perceive lesser financial resources with which to fund healthcare programs, including those that have been specifically created to care for people suffering from diseases directly related to smoking (including cancer). Furthermore, the policy will fail because it would not disincentive people from smoking (but quite the contrary).

It is true that the legislators included a provision that clearly states that if, after two years, the state’s income turns out to be less than it was before the decreased tax was enforced the original tax will automatically be reinforced, this does not solve the problem. The new, decreased tax will already have been in existence for two years, and this will produce tremendous damage as the number of smokers in the state will surely increase (while, at the same time, the state’s financial resources will surely decrease). Healthcare organizations and programs will surely suffer from budget costs; this will mean less coverage (in terms of healthcare services) and might strongly signify job loss (as NPs will surely be let go as state facilities will have no resources to pay their salaries). Therefore, the only plausible alternative for avoiding such damaging effects is to eliminate the decreased tax immediately and impose one that is higher and more competitive, than taxes being charged by other states.

Legislation Evaluation and Impact

Upon evaluation, decided upon by the state legislators it becomes clear that its effects are entirely negative. First, the legislation fails to take into account the increased health risks that a decreased cigarette tax signifies. Clearly, legislators did not take into account the risk that such a decision might signify to the state’s residents, especially the sexual minorities, which have been found to be at greater risks. In fact, studies have conclusively demonstrated, “sexual minority young adults may experience respiratory health disparities that may be linked to their higher smoking rates, and their higher rates of smoking lend urgency to the need for cessation interventions” (Blosnich, Jarrett & Horn, 2010, p. 401).

Furthermore, the state legislature’s decision to apply a lower tax is not consistent with the observed tendency of policy design and implementation. Studies demonstrate “that individual and aggregate public opinion is influenced by the policies of other states. Citizens may not move to neighboring states, but instead, change their opinions and pressure state officials to adopt similar policies in the home state” (Pacheco, 2012, p. 199). In New Hampshire’s case, the historical trend is consistent with such findings, as state taxes were increasing (much like they were in neighboring states). However, the decision made last year breaks away from this historical trend, and it surely goes against the public interest (especially considering that public health is the highest public interest, and as such, the one that legislators should protect more zealously).

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New Hampshire in a Global Context

The decision made by the state legislature, so as to decrease taxes on cigarette packs, goes directly against the policies being applied in other states and other countries, as well. First, in comparing New Hampshire’s decision with the policies being applied in other states, California stands out as a great example of how effective the increase in taxes can be, as a measure of reducing smoking prevalence.

The estimated results show that sales of cigarettes were reduced by 819 million packs from the third quarter of 1990 through the fourth quarter of 1992 owing to an additional 25-cent state tax increase, while the anti-smoking media campaign reduced the cigarette sales by 232 million packs during the same period (Teh-Wei, Hai-Yen, & Keeler, 1995, p. 1218).

The policy applied by the state of California (same strategy that the New Hampshire legislature has historically pursued) has also been the norm across other countries, particularly in Europe. In fact, upon assessing the policies being applied in Europe for combating smoking, the World Bank prepared a report on those which were most effective in bringing down tobacco prevalence. The World Bank’s report “recommended cost-effective tobacco control initiatives included tobacco price increases, bans or restrictions on smoking in public places, consumer information, tobacco advertisement bans, and health warnings on packages and treatment to quit” (Hublet, Schmid, Clays, Godeau, Gabhainn, Joossens, & Maes, 2009, p. 1918).

This policy has been further complemented by other policies, such as the one implemented by the state legislature, to ban smoking in closed spaces, where people gathered (such as restaurants and hospitals). In Ireland, for example, increased tax rates on cigarettes have been complemented with a ban for smoking at the work place settings (i.e. office buildings and other business locales). The results clearly indicate that this is also an effective way to combat smoking prevalence. In Ireland, for example, “the work-place smoking ban resulted in a 79% decrease in exhaled breath carbon monoxide, an 81% reduction in salivary cotinine and significant reductions in self-reported respiratory symptoms” (Currie & Clancy, 2011, p. 21).

Improving New Hampshire’s Legislation

In order to improve the state’s legislation it would be advised, first of all, that the legislators reverse the decision made last year and enforce a new tax that is higher (so as to continue the state’s historical handle on smoking). It should be noted that this would not be an arbitrary decision, but rather one based on irrefutable evidence that high taxes have a positive effect on reducing smoking prevalence. In fact, recent studies conclude, “policy and price increases appeared to affect rates of some health conditions, but the effect of the program was larger and more frequently significant” (Dilley, Harris, Boysun & Reid, 2012, p. 23). This means that even though elevated taxes are effective, they cannot be the only strategy that the legislature pursues in combating smoking prevalence. Such a strategy has to be accompanied by a program that promotes smoking awareness and prevention.

Finally, in order to justify the recommendation being made of enforcing higher taxes further, it is necessary to mention that the effects of increased taxes are directly related to the magnitude of the taxes being applied. In other words, “the strength of those effects, however, is influenced by the magnitude of the taxes and the amount of media campaign expenditures” (Teh-Wei, Hai-Yen & Keeler, 1995, p. 1218), which follows from what was stated earlier. The state legislature’s efforts must be carried out on both fronts: increased taxes and increased prevention campaigns/programs. This is possible, especially considering that increased taxes would generate increased financial resources with which to finance aggressive prevention programs/campaigns.

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