Sunday, May 7, 2017

Public Health Policy and Social Class

How does social class prejudice reveal itself in public health? Among conservatives it might be the attitude that low income people deserve to be sicker, and we don’t need to help them, because they are lazy. Liberals have their attitudes, too. For example, “we are experts and know best what you poor folks need,” although that, too, is often not true. I’ve been thinking about this in connection with public health programs that just don’t work the way they should: transportation benefits that people have too much trouble using, mental health coverage that is inadequate for the problems many people face, cuts to programs that have worked well; and yet public health tolerates these situations! Why? Let’s explore one concrete example how social class works in public health: efforts to reduce tobacco smoking. 

Tobacco is the drug of choice for low income Americans. For example in Gratiot County we found that 31 percent of adults who earn $20,000 or less smoke compared to 9 percent of adults who earn $75,000 or more. Twenty-nine percent of mothers smoked while pregnant!  This is a really big deal. In another blogpost I wrote about how heart disease deaths are increasing in rural Michigan. 

Today, public health in Michigan has two favorite ways to try to help people quit. First, you can sign up to get friendly text messages that encourage you to keep trying; second, Michigan like other states has jacked up taxes on cigarettes to high levels (not high enough for some) in hopes of making smoking too expensive. You can find lots of research that says these two approaches are effective in getting people to quit, but they aren’t, at least among low income people. The reason public health says texts and taxes get people to quit smoking is because that’s all we’ve got left. Our general fund budgets are far less likely to support tobacco cessation programs than they once were, and health insurance, including Medicaid, doesn’t reimburse enough for us to support cessation programs by billing insurances—but still, we want to be able to say we’re doing something.

The Campaign for Tobacco Free Kids publication “Tobacco Tax Increases Benefit Lower Income Smokers and Families” reflects the official consensus stating “increasing price is proven to reduce smoking, especially among kids and among those with low incomes.”

But not everyone agrees. In “Poor Smokers, Poor Quitters, and Cigarette Tax Regressivity” appearing in American Journal of Public Health, Dahlia Remler found, “cigarette taxes heavily burden poor smokers who do not quit, no matter how tax burden is assessed.” In another study in the Journal of Policy Analysis and Management, Remler said, “Very high cigarette taxes, however, have a dirty little secret: their regressivity. Overwhelmingly and increasingly, smokers are concentrated among the poor. Moreover, our era of rising cigarette taxes is also an era of dramatically rising income inequality and possibly lower purchasing power for the poor.” 

The public health community has rallied behind the taxes. The Campaign for Tobacco Free Kids says, somewhat snarkily, “it is smoking itself and its health harms that are hurting the lower-income population,” not the taxes. Therefore the Campaign is not responsible for the harms of the taxes. The social class bias in this attitude is somewhat breathtaking. You can almost hear someone huffing “if they are too stupid to quit, screw them.” The Campaign is a left-leaning progressive public health organization, but here, their attitudes are similar, for example, to Republicans in the House of Representatives who think it is OK to get rid of health care benefits for low income people because they “made bad choices.”

But evidence is mounting that tobacco taxes are harmful to the poor. Katherine T. Hirono and Katherine Smith published a review of the literature and concluded that “very large cigarette tax increases unintentionally harm the most vulnerable in society: smokers who are homeless, very low income, and/or suffer from mental illness… Low-income smokers who either can't or won't kick the habit following large tobacco tax increases face increased financial hardship, and so do their families.”

But surely low income people don’t give up food or other necessities just to keep smoking? Remember that tobacco is very addictive. A study by the Research Triangle Institute showed that low-income smokers in New York, which had the nation's highest state cigarette tax, spent nearly a quarter of their household income on cigarettes. Nationally, those with the lowest incomes smoke less, but still spend just over 14 percent. 

In raising these issues, I want to challenge my colleagues to think about how social class influences our response to the unintended consequences of our liberal policies. In 1920, in the face of rampant alcoholism, who could have imagined that prohibition would cause alcohol-related mortality to soar out of control? But it did. But that wasn’t the worst failure of public health at that time. The real failure was refusing to support the repeal of prohibition once it was understood that the law had made things worse. The public health community supported prohibition to help people avoid the harms of excessive alcohol consumption, but couldn’t change course even after it understood prohibition was making things worse. 

Yes, it bothers me that Michigan’s Mackinac Center, which opposed the Affordable Care Act, also opposes tobacco taxes. And I worry my musings may be mistaken when I see that my own public health association, the Michigan Association for Local Public Health, strongly supporting increased tobacco taxes. But we need to remember that real human beings are the objects of our policy prescriptions. I remember meeting a low income woman at a community event where Chantix, a drug that helps people quit, was being distributed. She began crying. A tobacco cessation counselor hugged her and said, “You’re afraid you won’t be able to quit” and the woman sobbed, “I’ve tried so many times and nothing works.” I didn’t know people cried about not being able to quit smoking until I saw it. 

Think about this: it is difficult to argue that we raise cigarette taxes because we really want to help low income people quit, given that we do so little else to help them do so. If we wanted to help people quit we would use the tax increases to address the problems in people’s lives that keep them smoking. But we don’t. In Michigan we have used tobacco tax revenue for things like scholarships, school aid and debt service. I agree those things are important, but so little tobacco tax revenue goes for smoking cessation in Michigan that the State gets a grade of F from the American Lung Association for its paltry tobacco prevention efforts. The real reason for the taxes is to plug budget holes, and we don’t lose sleep thinking about the woman who spent her last dollar on cigarettes and doesn’t know what she will eat tomorrow.