Broad Tobacco-Related Insurance Premiums Are Unjustified & Injurious

I recently received this email:

“I am a 29 year old male from Upper Michigan, married with 3 kids.  My wife and I recently signed on with [company name redacted] as this was one of the only affordable health care options for our family and I like most all of their ‘principles’ or values.

“Only 1 problem; they require that you don't use any drugs, drink, smoke, chew, nothing.  I consider myself a healthy individual as I'm 6'3", 200 lbs and fit. I haven't seen a doctor in years, frankly because I haven't a need.  I don't use drugs, drink, or smoke. However, I've chewed Copenhagen snuff for about 15 years and never had a problem with it. I was the one who had 2, maybe 3 small dips each day, a can would last me a week. It was never excessive and never a problem.

“For the sake of [company] I quit chewing snuff a few months ago. Since I quit, I've noticed I'm short tempered with my wife and kids.  My performance at work has decreased, and I started gaining weight, and losing sleep. I think about it every day, and I feel no better without it. I feel like [company]'s penalty is harsh for dipping.  And they penalize the same for smoking or other hardcore drugs that I'd never do.

 
“I found you online, and I admire your courage to speak the truth about smoking and chewing.

“Please let me know if you can help educate my health ‘insurance’ company on the truth about chewing tobacco. Any help is appreciated.”
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This narrative is not unusual; over the years, I have received numerous similar complaints.  Many smoke-free tobacco users are pioneers; my research group published a study about them in 1995, and I have also told their stories in this blog. 
 
Unfortunately, smoke-free tobacco users continue to suffer from policies that consider all tobacco products – even medicinal nicotine – as equally dangerous, and all tobacco/nicotine users as high-risk.  This conflation of risks improperly raises premium costs, limits employment opportunities and degrades the quality of smoke-free tobacco users’ lives.  It also provides a financial windfall for insurers.
 
The federal government and health organizations often promote this conflation, and Obamacare legislation codified it, defining “smoking” as “using any tobacco product on average four or more times per week in the past six months.” (emphasis added)  It may be justifiable to charge smokers higher premiums, because they are at risk for many diseases that health insurance must cover and, on average, their lives will be shortened by 8-10 years, justifying higher life insurance premiums.  But use of smoke-free tobacco products which are associated with minimal or no added health risks should not incur such punitive premium treatment.
 

Many tobacco consumers avoid higher premiums by lying about their lifestyle choice.  Research shows that “tobacco users may be decreasingly likely to report their tobacco use status accurately to avoid surcharges” when enrolling in Healthcare.gov exchanges.  The problem for these individuals is that insurers and employers commonly require urine tests, which readily detect nicotine as long as three to four weeks after use. However, these tests do not distinguish how nicotine entered the body – via smoking or the use of smoke-free tobacco or medicinal nicotine.
  
As a health professional, I do not condone deliberate misreporting of tobacco use on insurance applications.  However, I do oppose the degradation of smoke-free tobacco users’ quality of life for no legitimate reason.

How Many Americans Use Smokeless Tobacco?

I recently described how the federal government is all thumbs when it tries to count how many Americans smoke (here).  Further evidence of the government’s ineptitude is seen in the fact that the National Health Interview Survey (NHIS), the CDC’s official source for smoking statistics, only measures smokeless tobacco use every five years or so.  That leaves the National Survey on Drug Use and Health (NSDUH) as the government’s only annual source of data on smokeless use.

I analyzed NSDUH data from 2012 and found that 7.1% of adult men (roughly eight million) use smokeless tobacco, and the prevalence of smokeless use among women is minuscule (about one-half of one percent).  For obvious reasons, I’ll limit this discussion to men.   

NSDUH asks participants if they use “chewing tobacco” or “snuff.”  Over two-thirds of smokeless users in the survey, about 5.5 million, said they used only snuff, 1.2 million used only chewing tobacco, and 1.4 million used both.  However, participants’ responses to questions about smokeless brands used most often suggest that NSDUH misclassified some users.  The problem stems from the fact that consumers of smokeless products often use the terms “chew” or “dip snuff” interchangeably.

The most common brands among “snuff” users were Copenhagen (29%), Skoal (26%) and Grizzly (25%).  Other than Red Seal (4%) and Kodiak (4%), no other brand registered above 2%.  It is interesting to note that Camel Snus, the first pouched product that introduced the Swedish experience to American smokers, was the preferred brand for 1.7% of snuff users.

The misclassification problem is evident because 16% of “chewing tobacco” users favored Skoal, 11% picked Grizzly and 7% listed other moist snuff brands.  Red Man (25%), Levi Garrett (10%) and Beech-Nut (5%) were the top chewing tobacco brands.

Although 35% of smokeless users in this survey never smoked and 27% are former smokers, it is a tragedy that 38% are current smokers (a figure that is consistent with my previous research (discussed here).  That percentage means that 2.8 million smokeless tobacco users don’t recognize or are ignoring the significantly greater hazards of smoking.  Any ignorance on their part may be traced to the deliberate campaign by the CDC, FDA NIH and other tobacco prohibitionists to deny Americans vital facts about the relative risks of smoking and smokeless use.  This misinformation campaign conflates risk data to damn equally all forms of tobacco. The FDA declares, (here) “Tobacco products are harmful yet widely used consumer products that are responsible for severe health problems…[including] cancer, lung disease, and heart disease, which often lead to death.” The CDC asserts, (here) “Tobacco use is the leading preventable cause of death in the United States.”

Lies of omission like these tell eight million American smokeless users: “You might as well smoke.”  That is a travesty.

A Call to Action

I am not inclined toward political action, but I am inspired by Clive Bates’s call to action against the European Union’s appalling new tobacco directive (here).  Americans should take action at home as well, in support of tobacco harm reduction and an open U.S. market for vastly safer smoke-free products.  I have long argued for this in my blog and at my Smokers Only website (here).

Bates describes the EU directive as doing “three main bad things,” which are analogous in the U.S. to local, state and federal tobacco-prohibition efforts.  The strategies are the same.  The EU directive, he writes:

1. Bans snus, the least hazardous form of tobacco known to mankind, whilst allowing cigarettes to be widely sold.  Snus (or oral tobacco) is much less dangerous than cigarettes, and widely used in Sweden, where it is the main reason why Sweden has much lower rates of cancer and other smoking-related disease than anywhere else in Europe.

Why ban these products when they have been so successful at reducing harm in Sweden?

2. Treats e-cigarettes as though they are medicines – effectively banning or marginalising them…

3. Prevents any claim that one tobacco product is less harmful than another. The truth is that smokeless tobacco products may be many times less harmful than cigarettes, perhaps 10-1000 times less harmful.  So what looks like an attempt to stop false or excessive claims, is actually going to do real harm:

It denies consumers the most relevant information about lower risk tobacco products – information they could use to reduce their own risk and protect their health. This is misleading by omitting the most important information.

Why should a manufacturer bother to make or market these products or invest in innovation if they can’t say the one (truthful) thing that makes them valuable as alternatives to cigarettes? All this does is reinforce the market for the most harmful tobacco products by shielding them from competition from less harmful forms.

This makes a law out of misleading consumers – who benefits from it?

Bates encourages tobacco users to write representatives in their home country and in the EU parliament.  American tobacco consumers who are fed up with unscientific and inappropriate U.S. laws and regulations should do the same with their elected officials and government institutions. 

In other words, tobacco users should engage in political and policy matters that threaten your rights.  You need to protest if your city or state attempts to impose TIP-TOE (Tacit Incremental Prohibition - Tobacco Elimination), which involves banning nearly risk-free smokeless tobacco and e-cigarettes and assuring the continued market dominance of killer cigarettes (here).

You should respond by writing your public officials – mayor, city council members, governor, state and federal legislators.  I have adapted Bates’s Euro-centric suggestions for Americans who wish to express their views.

1. Be decent.  Always be polite and dignified, don’t make accusations or question motives – most public officials want to do a good job.

2. Be engaging.  Assume the official is open-minded but might need some persuading.  Don’t dismiss other views; tackle them.

3. Be authentic.  Express your views in your own words; public officials want to hear genuine heartfelt views, not borrowed text.

4. Be natural.  Formal language and legal terms aren’t required; it’s their job to understand you, not your job to understand the technicalities of legislation.

5. Be concise.  Concentrate on the things that really matter to you and stay focused – if you are writing about e-cigarettes, don’t dilute your message with views on other issues.  Keep it short (max two pages or 800 words) and to the point.

6. Be personal.  E-mail each legislator individually.  You can use the same basic text with each, but the personal touch goes a long way.

7. Be relevant.  When writing to Congress, for example, only write to your own legislators.

Bates also offers some great content suggestions:

1.  Write about your own experience – e.g., have you tried to quit smoking?  What experience have you had with e-cigarettes or smokeless tobacco use?

2. Tell why you think the proposed action will hurt you personally.

3.  Suggest what the official ought to do.

4. Ask questions that require a response; ask for a reply or a meeting.

5.  Explain how the proposed action may limit smokers’ options to quit cigarettes by switching to products that are much less risky, resulting in more smoking-related death and disease.

6. Describe how the proposed action could tie e-cigarettes in regulatory red tape, effectively banning these products by the back door.  It makes no sense to ban safer products while leaving dangerous cigarettes on the market.

7. Explain why the proposed action will make smoke-free products less attractive, more expensive and less innovative – for example by banning flavors, making the packaging look like medicine, and limiting advertising and marketing.

8. Tell the official why it is wrong to pretend that all tobacco and nicotine products are the same – smokers should have accurate information about risks so they can make informed choices.

9.  Explain why all smokeless tobacco products are much safer than cigarettes and are viable substitutes for smoking.  Smokers should not be denied this option.

10.  Convince officals that e-cigarettes should be regulated for what they are – consumer products, placed on the market as alternatives to cigarettes. 

11.  Note that if e-cigarettes are removed from the market, vapers will return to smoking.

12. Tell officials that government should encourage smokers to switch to e-cigarettes or smokeless tobacco, not ban or marginalize these products through regulation.

I will add one more content tip that is especially relevant to Americans: Strongly object to tobacco prohibitionists’ baseless claim that adult access to safer tobacco products is a problem for children.  It isn’t a children’s issue.  FDA regulation will ensure that tobacco companies don’t advertise or sell tobacco to children.  There are 45 million smokers in the U.S., and the eight million who will die from smoking-related illnesses in the next 20 years are not children today; they are adults, 35 years and older.  Preventing youth access to tobacco is vitally important, but that effort should never be used as a smokescreen to condemn smoking parents and grandparents to premature death.

In the U.S., the Consumer Advocates for Smoke-Free Alternatives Association (here) is active on e-cigarette issues.  They post calls to action on their website, and members of CASAA’s board of directors, including Elaine Keller, Kristin Noll-Marsh, Gregory Conley and Carl V. Phillips, are credible, persuasive spokespersons on the full range of smoke-free tobacco issues.

Smokeless tobacco users and switchers should take CASAA’s approach.  This post gives you some basic tools.  Get involved!

Indefensible Action By the U.S. Army Public Health Command

On February 28, I saw the “Great American Spit Out/ Tobacco Cessation” webpage (from my archive here), published by the Army Public Health Command (APHC) to “raise awareness of the dangers associated with smokeless tobacco.” The site was inaccurate and unprofessional with regard to smokeless tobacco use among army personnel.

After the ironic introductory statement, “Unfortunately, the myths concerning smokeless tobacco are still in existence,” the webpage contained this egregious claim: “Smokeless tobacco is as harmful as smoking tobacco.”

I contacted two APHC staffers and explained that this statement was factually incorrect and indefensible. A 2004 National Cancer Institute study concluded: … “[smokeless] products pose a substantially lower risk to the user than do conventional cigarettes. This finding raises ethical questions concerning whether it is inappropriate and misleading for government officials or public health experts to characterize smokeless tobacco products as comparably dangerous with cigarette smoking.” (abstract here).

To its credit, the APHC responded quickly. Less than 24 hours later, on February 29, the just-as-dangerous myth was removed from the website (here).

I also explained to the APHC that the word “spit” is demeaning, disrespectful and deplorable, as I pointed out in a previous post (here). Two years ago, I wrote to federal officials, strongly objecting to use of this term (here). The Centers for Disease Control, the Food and Drug Administration and the National Institute for Dental and Craniofacial Research responded by removing the offensive term from websites and other publicly available materials (here).

It’s time for the Department of Defense and the U.S. Army Medical Command to abandon this offensive language, treat smokeless tobacco users with respect, and provide accurate medical information, particularly on the subject of tobacco harm reduction.

International Sports Monitoring Agency: Nicotine, Smokeless Tobacco May Enhance Performance

The World Anti-Doping Agency (WADA), an international agency composed and funded by sport organizations and governments, on September 27 announced it will “monitor the effects nicotine can have on performance when taken in oral tobacco products such as snus,” starting in 2012 (here). This followed publication of a report from the agency’s laboratory on over 2,000 urine samples from athletes in 43 sports. The report, by François Marclay and colleagues at the University of Lausanne in Switzerland, is abstracted here.

The research measured exposure to and active use of nicotine by athletes. While the prevalence of active use was only 15%, the authors noted high prevalence in some sports, included in this table:

Active Nicotine Consumption Among Athletes
Sport (No. of samples)	Active Consumers (%)
American football (19)	56
Basketball (24)	25
Biathlon (38)	18
Bobsleigh (38)	31
Football (soccer) (205)	19
Gymnastics (48)	29
Ice hockey (108)	32
Rugby (25)	28
Skating (41)	20
Skiing (143)	26
Volleyball (46)	20
Wrestling (31)	32

Marclay wrote that these results provide “alarming evidence” about nicotine consumption among athletes. But the report had no information about the athletes who were tested, and the number of samples was minuscule. For example, Marclay’s claim that 56% of American football players actively used nicotine was based on only 19 samples. There are over a million football players at the high school level in the U.S., thousands at the college level, and hundreds in the NFL, and there are 18 other countries with American football leagues. The most alarming aspect of this report is that it made sweeping claims based on very little evidence.

Marclay wrote that “…smokeless tobacco is a very attractive drug from a doping perspective, considering the performance enhancement pharmacological properties of nicotine and the absence of direct adverse effects on the respiratory tract.” Nicotine “exhibits a variety of pharmacological properties sought-after by consumers,” and it “results in vigilance and cognitive function enhancement together with relaxation, reduced stress, mood modulation and lower body weight.”

These effects are well known among tobacco users, but Marclay cited no authority for the claim that these properties enhance performance to an extent that justifies prohibition in sports. In fact, Marclay acknowledged that “the frontier between recreational consumption and use for doping purpose is difficult to ascertain with social drugs, including nicotine, caffeine or tetrahydrocannabinol (THC)[marijuana].” Would Marclay and WADA ban caffeine along with nicotine?

In trying to tie smokeless tobacco to performance enhancement, Marclay offered a startling non-sequitur: “Since smoking may be responsible for noticeable respiratory effects and numerous health threats detrimental to sport practice at top level, likelihood of smokeless tobacco consumption for performance enhancement is a hypothesis of very serious concern.” Simply put: Smoking is very bad, so smokeless tobacco must be a performance enhancer. The association of these two very different products in this manner defies logic.

Marclay was especially concerned about athletes involved in winter sports. Citing his own work (abstract here), he wrote that “a recent study on the 2009 Ice Hockey World Championships brought alarming findings as active nicotine consumption before or/and during the games was highlighted for about half of the athletes.”

If WADA rules eventually that smokeless tobacco and nicotine enhance athletic performance, it will refute tobacco prohibitionists’ persistent claim that tobacco provides no tangible benefits to consumers. As I have written (here), “It’s time to be honest with the 50 million Americans, and hundreds of millions around the world, who use tobacco. The benefits they get from tobacco are very real… It’s time to abandon the myth that tobacco is devoid of benefits, and to focus on how we can help smokers continue to derive those benefits with a safer delivery system.”

How to Use Smokeless Tobacco: A Primer for Smokers

If you have been directed to this page, you want to go to my update on products for smokers here.

This blog is devoted to correcting myths and misconceptions about tobacco harm reduction. Here is some practical advice on to make the switch to smoke-free tobacco products.

1. Pick the right product. Choose a pouch -- a small “teabag” containing tobacco and flavors -- or try one of the other products from this list and decide which works best for you. There are many options, so don’t be discouraged if one product doesn’t fit your lifestyle or taste.

2. If you’re using a pouch, put it in the right place. Place it under your upper lip, near the corner of your mouth. Most smokeless tobacco users put products behind their lower lip – a practice that generates tobacco juice and leads to spitting. In Sweden, snus users tuck the product behind their upper lip, where it’s spit-free and invisible. Simply pop a pouch in your mouth and move it in place with your tongue. Alternatively, pull your upper lip out with your fingers and position the pouch. At first, the pouch will feel like a cannonball. Look in the mirror, and you’ll see that it’s hardly noticeable.

3. Get your nicotine buzz, but don’t overdo it. When you inhale cigarette smoke, you get an immediate nicotine kick. The effect from smokeless tobacco takes longer, but slower nicotine uptake also means slower nicotine decline. One- or two-pack-a-day smokers who switch often need to use only 4 or 5 smokeless pouches… saving money.

Light and ultra light smokers might get too much nicotine from some smokeless products. Choose one that’s satisfying but not overwhelming.

At first, use the smokeless product for only a few minutes. You’ll learn how much time you need to get tobacco satisfaction.

4. Expect the unexpected. You might feel minor burning where you place the tobacco, and your throat might get irritated. This is from the nicotine, and it’s normal. Sipping some water or a beverage can help. You may get the hiccups, feel dizzy or experience an upset stomach, but these minor symptoms will quickly disappear.

5. Stick to the switch. Although some smokers make the transition quickly, smoke-free tobacco products don’t automatically “cure” you of wanting another cigarette. These products will make it easier to quit and they’ll make those cravings less intense, but they don’t entirely replace the smoking ritual. If you’ve smoked for years, breaking the habit can still be a challenge.

Remember, it’s the smoke that kills. Stay committed to being smoke-free.