The True Cost of Tobacco

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The World Health Organization estimates that almost 5 million people die each year from tobacco-related causes, a figure that is expected to double in the next 20 years, especially among the poor in the developing world.

Smoking in the developing world is rising by 3.4 percent every year, and with aggressive marketing by tobacco companies there, that growth is likely to be sustained. By 2030, approximately 70 percent of smoking-related deaths worldwide will occur in developing countries.

But the cost of smoking isn’t only measured in mortality — it can be measured in dollars or yuan or rupiah, that is to say when the poor spend money on cigarettes, they’re not spending it elsewhere.

Stephen Block and Patrick Webb, professors at Tufts University, have linked tobacco use in developing countries to malnutrition in children.

Why? Because it decreases the proportion of income spent on food. The pair published their findings in October’s edition of the journal Economic Development and Cultural Change.

In Indonesia, where 18 percent of the population lives below the poverty line, the smoking rate is approximately 3 percent for women and 60 percent for men. The World Bank estimates that tobacco is the nation’s second-biggest business and the second-largest expenditure among the country’s poor.

Meanwhile, the Indonesian government has shown little interest in reducing tobacco use, according to professor Hasbullah Thabrany of the Universitas Indonesia, even as other social monitors, like the clergy, have grown concerned enough to issue a fatwa against smoking by kids and pregnant women.

Block and Webb used data from a survey of more than 33,000 households in rural Java to assess the impact of tobacco use on child nutrition. They found that households of nonsmokers spend on average 75 percent of their budget on food, whereas households in which at least one person smokes allocate 68 percent of their budget to food and 10 percent to cigarettes.

“This suggests that 70 percent of the expenditures on tobacco products are financed by a reduction in food expenditures,” the researchers write.

Households with smokers allocate a larger portion of their food budget to rice, a low-nutrient food, whereas those of nonsmokers spent more on high-quality foods, like meats and vegetables.

Their work echoes that of Sarah Barber of the University of California, Berkeley, and the World Health Organization, who told the Australian Broadcasting Corp. that the tenth of income spent on tobacco, “compares with, for example, 2.1 per cent on health, 1.8 per cent on education, and so what we feel is that households with smokers are dedicating a very, very large amount of money on tobacco and this has serious welfare implications for the rest of their family.” (Barber co-authored a paper in the June edition of the Journal of Public Health Policy showing that Indonesia’s tax on tobacco, already among the lowest in the world, tends to “promote” affordable tobacco products.)

Block and Webb also found that the average height among preschool children living with smokers is slightly lower than that of children in nonsmoking households, which suggests that the decreased food expenditure in smoking households negatively impacts children’s health.

Parental education, which has been linked to reduced smoking and improved quality and quantity of food choices, also coincides with increasing average height of preschool children.

Block and Webb argue that smoking has a strong, if indirect, impact on child malnutrition.

“The combination of direct health threats from smoking coupled with potential loss of consumption among children linked to tobacco expenditure presents a development challenge of the highest order,” they assert.

But beyond making cigarettes too expensive to buy, can government turn the tide on smoking in developing countries?

For one thing, economic advancement might help, even if in the short term it makes cigarettes more affordable. In America, at least, wealthier people are less likely to smoke. While this finding doesn’t apply to a country-level analysis (smoking rates are not necessarily higher in poorer countries), it does suggest some hope.

And if Massachusetts is any indication, making it affordable for poor people everywhere to quit smoking might be a step in the right direction.

When Massachusetts began offering next-to-free smoking cessation products in 2006, it hoped to reduce the number of low-income smokers within state lines. New data suggest that it has done so, and fast — by 2008, the proportion of poor smokers in the state dropped from 38 percent to 28 percent, a 30,000-person decrease (but still significantly higher than the rate in the general population, estimated at 21 percent).

The program covers almost the entire cost of counseling and prescription drugs for Medicaid participants, capping copayments at $3. Enrollees aged 18 to 64 are eligible for 180 days of drugs and 16 counseling sessions per year. The total cost to the state was $11 million for the first two years.

Although the data has not yet been peer reviewed, U.S. senators and anti-smoking advocates are already working to include a tobacco addiction provision in the new health care bill. The current Senate health care bill would only allow pregnant women on Medicaid (who are generally advised to avoid smoking-cessation products) to take advantage of lower-cost treatment.

If true, the Massachusetts findings indicate that poor people will quit smoking when given the opportunity to do so affordably.

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