Abstract
A recent report conducted by Access Economics for SANE Australia has comprehensively reviewed the economic costs of smoking for Australian smokers with mental illness and found that the financial cost to these smokers is $AU33bn per year [1]. Internationally, research has estimated the economic costs of smoking to reach $US500bn by 2010 [2]. This prompts a long-standing debate about tobacco control initiatives and their effectiveness and consequences for vulnerable populations. Chapman has argued for increased tobacco control, stating that those who see tobacco as a legitimate product and tobacco control as jeopardizing the financial benefits gained through tobacco excise, are ill-informed regarding its social costs and the ethics of continuing to support its revenue-raising role [3]. But the price and demand relationship of some commodities may be very elastic for some groups within the population: that is, raising taxes on them will not necessarily lead to reduced demand for those commodities. It is time to unpack the debate and advocate for more to be done for smokers with mental illness, beyond mere broad population-based tobacco control strategies and policies and piecemeal support to quit.
Costs of smoking, elasticity and people with mental illness
People in lower socioeconomic groups have previously been found to quit smoking more in response to price rises than those with higher disposable incomes [4–6]. A global report by the World Bank found that raising taxes on tobacco by 10% would lead to a 4% reduction in demand for cigarettes in high-income countries and an 8% reduction in demand in low-income countries [7]. In a review of 35 years of policy on tobacco consumption, Bardsley and Olekains argued that increasing the price of cigarettes has had the greatest impact on the decline in consumption, with education and reduced advertising having minimal effects [8], but their conclusions were strongly challenged by other researchers on methodological grounds [9], [10]. Raising taxes is clearly effective in reducing consumption and is also thought to discourage children and adolescents from commencing smoking, although some researchers have raised questions about the efficacy of this approach with adolescents [11].
Unfortunately, where government taxes on tobacco have increased, research has found that government revenue from those taxes has also been disproportionately high. That is, the expected decline in consumption from the act of raising taxes has not occurred. Increased revenue from increased taxes has been found to be disproportionately higher, suggesting that some smokers are slow to respond to price rises. Their smoking behaviour has remained elastic, despite price rises. Smokers with a mental illness may fit this description. The World Bank report expressed concern that increasing taxes on tobacco would have a disproportionate impact on poorer consumers because taxes consume a higher share of their income than richer consumers [7]. It further suggested that the loss of perceived ‘benefits’ of smoking to lower income smokers may be comparatively greater than for higher income smokers.
A number of researchers have attempted to quantify the costs and benefits of tobacco smoking to the Australian community over the past two decades. A report by ACIL Economics and Policy, an independent body funded by the Tobacco Institute of Australia, concluded that smokers at that time, ‘more than pay their way in the community’, by providing $AU12.5bn net benefits; that they subsidise our health-care services and are taxed over and above any costs to the community [12]. In 1995 the Australian Federal Government collected $AU3.8bn in sales and excise taxes for alcohol and tobacco; but only $AU36m of this was spent on programmes to decrease use. In South Australia, for the same year, only 5% of revenue raised was returned to treatment programmes, with similar figures for other states [13]. Collins and Lapsley conducted Commonwealth-funded studies in 1988 and 1992, looking at the economic and social costs of smoking to the Australian community [14]. Tangible costs to the smoker, other individuals, to business and to government such as costs of medical treatment, loss of productivity and work days, were quantified. Direct health-care costs to the Australian community were estimated to be $AU833m. Costs of passive smoking and reduced productivity were not included. Intangible costs such as loss of enjoyment of consumption forgone and the value of loss of life to the deceased, were also not quantified. Pain and suffering caused to the individual, family and friends and loss of enjoyment of life were not included. The total for tangible and intangible costs of smoking for 1992 was $AU12 736.2m [14]. In 1996–1997 the total number of hospital episodes attributable to drug use was 256 991, with 149 834 or approximately 60% being due to tobacco. The net total of government revenue from the sale of tobacco in 1991–1992 was $AU2473.9m. In 1997–1998 this figure was estimated to be $AU4231.6m [15]. In 2007 this figure has risen to $AU2.8bn, but there is little evidence of equitable funding and few programmes to help those who want to quit [1]. These figures suggest that smoking involves substantial costs for the smoker and the community and that these costs outweigh the benefits of revenue received from tobacco sales. Research by Collins and Lapsley confirms that ‘governments gain a substantial economic benefit from smoking while the community as a whole bears very high economic costs greatly exceeding revenue from tobacco taxes’ [16].
Smoking is an expensive habit. The social implications for people on limited incomes are recognized [17]. Some have questioned whether people with mental illness who are chemically dependent should be allowed to spend their funds as they choose, without supervision, or to receive government payments at all. In the USA, specific restrictions on pension eligibility have existed where the person is dependent on substances. Time restrictions on pension payments and the obligation to seek treatment have been part of these conditions [18]. Research has found that controlling the supply of pension funds to people with substance dependence does not necessarily alter their desire for substances, although it may assist in imposing some control and thereby improving treatment effectiveness, quality of life [19] and compliance with treatment [20].
Clearly, the human costs of smoking for the individual and the community are substantial [21], [22]. Tobacco control measures are needed and they have been internationally successful [23]. Of relevance here is the identification of who bears that cost, how disproportionate that cost is and how the community and society respond to this. People with mental illness already experience high levels of social exclusion and health inequality, which are exacerbated by smoking [24]. In the UK, for example, 83% of prisoners smoke and 90% of homeless people smoke. Internationally, multiple research studies have confirmed that approximately 75% of people with a mental illness smoke. In Australia, 40% of smokers have a mental illness [1]. In the USA 45% of all cigarettes are smoked by people with mental illness [25]. In Australia this figure is more than 42% for people with mental illness [1]. Social disadvantage and smoking go hand in hand [26] and this is likely to be an increasing trend as these groups increasingly and disproportionately make up those who continue to smoke, while those who are more able will successfully quit. Tobacco control strategies on their own are clearly inadequate and will be increasingly so.
Raising the cost of cigarettes to depress the demand for them has been shown to induce some smokers to quit or cut down their consumption, and to prevent others from commencing smoking [7], [27]. But a Canadian study looking at disadvantage and low quit rates found that people's immediate circumstances were overwhelming motivators to continue smoking as a mechanism for coping with those circumstances, regardless of long-term goals for better health and financial stability [28], [29]. With this in mind, the impact of price rises on the smoking behaviours of people with mental illness has not been comprehensively studied and, therefore, price increases as sufficient motivators for change cannot be assumed for this group. What we do know is that they spend a great deal on cigarettes as a proportion of their income. A study by Lawn found that smokers with a mental illness were returning approximately 27.7% of their total income to the government treasury in excise taxes on tobacco [17], [30]. Another study found that mentally ill smokers elevated the importance of cigarettes, often choosing them over food, security of accommodation and safe interactions with others. Few of these smokers altered their smoking behaviour when the price of cigarettes increased, although most expressed wanting to quit [31]. These smokers therefore demonstrated the elasticity of their responses to cigarette price rises.
Role for mental health services
Current tobacco control policies may well work at reducing the incidence and prevalence of smoking within the general population but they do little to reduce rates among vulnerable populations. Policies that increase the cost of cigarettes raise significant equity and social justice questions because of their potential to exacerbate the poverty of people with mental illness. The aforementioned evidence also suggests that such strategies largely do not work for these populations. Recommendations restricting payment of government benefits to mentally ill smokers as a means of reducing their spending on cigarettes, and therefore the prevalence of smoking in this group, may likewise be misdirected. Jarvis asked, ‘If improved overall life expectancy as a result of current tobacco policy leads to a situation in which widening health inequalities mean that such disadvantaged groups are left behind, does this matter?’ [Jarvis M: unpublished data, 2002]. The answer must be ‘yes’. If we consider that one in five people experience mental illness then they are not a minority that can be ignored. Therefore, strategies that are based on sound evidence and involve the full consultation with people with mental illness and the mental health sector [1] are needed to make support and treatment for nicotine dependence more readily available to these populations. One example of positive change is the recent New South Wales Cancer Council launch of its tobacco control and social equity strategy [32] to help guide policy in that State, one of the first nationally to clearly link the two initiatives and to see tobacco control firmly as a social justice issue. The time is ripe for mental health service staff to increase their advocacy and lobbying on this issue with and for people with mental illness. Smoking is a behaviour that has evolved over the past decades from a position of being a social choice, to recognition that it is a serious addiction that requires comprehensive support to quit. The complexity of this issue for people with mental illness means that a multi-layered and systematic clinical response is needed, as part of a holistic response that recognizes the need to address social inequality fundamentally. Psychiatry is increasingly understanding and espousing the importance of the social world of people with mental illness and is therefore ready to lead this process.