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分享我在唸美國哈佛公共健康碩士時寫的一篇文章, 請不吝指教! 
Topic: Should tobacco sin taxes subsidize health care?
Sin tax is a kind of tax levied to correct socially undesirable goods or activities, such as tobacco, alcohol, gambling, firearms, and even sugary pop soda. Usually, these kinds of goods or activities have negative effects on society, and increase social costs. For instance, tobacco use has been proved to increase risk for varieties of cancers, and cardiovascular disease. Thus, it increases the costs of treating these smoking-related illnesses, and leads to productivity loss attributed to smoking. Excessive consumption of alcohol not only affects personal health, especially in increased risk for liver cirrhosis and cancer, but it can also impose costs on society in the form of increased car accident rate, lost work hours, higher health care costs, and chaos in family relationships. Gambling may incur social burden by increasing crime rates, job losses, debts and bankruptcies. In addition, the ruined quality of life of children who are raised in families headed by compulsive gamblers due to financial difficulties may also increase social welfare spending. Use of firearms increases gun violence and gunshot-related health care costs. Even consumption of sugary pop soda has been singled out for causing obesity and lead to increased health costs in treating obesity-related diseases. Therefore, the use of these goods impose superfluous costs on others. That is why there is sin tax introduced by economist Arthur Pigou to discourage the use of certain goods and to increase revenue for government at the same time. In this article, I will focus on tobacco sin tax, and issues about subsidization of health care using the revenue from tobacco sin tax.
Why does government levy sin taxes on smokers? Because people have freedom to choose whatever they want to do for their pleasure, but only when the activities which they do impose extra costs on others require a mandate for government action. Let’s consider how much smokers impose social costs on others. First, smoking increases risk of lung cancer, other cancers and cardiovascular disease not only for smokers per se, but also for those who passively inhale cigarette smoke. According to Hodgson TA , lifetime health care costs for male heavy smokers are 47 percent higher than for nonsmokers. The exact health spending, however, would be much larger because this statistics hasn’t count in the health costs of secondhand smoke. Some studies , however, state that total health care costs incurred by smokers would not surpass the total health spending of non-smokers, simply because smokers would die earlier than nonsmokers. And nonsmokers would live longer and cost more on health care in their old age. Nevertheless, smoking imposing additional costs on health care is an immutable fact. Second, smoking in pregnant women leads to an increased incidence of low-birth weight infants, which will incur both short-term costs of medical care and long-term costs of special education. Third, loss of productivity associated with smoking also impose extra burden to others. Study shows that workers who smoke are more likely to be absent from work than their non-smoking coworkers. It would be too difficult and complex to sum up the entire costs which smokers impose on others from the above sources. But at least, current sin tax on cigarette has compensated some social burden which smokers impose on others. I believe if we really sum up all the costs and distribute the costs to all smokers, the price of each pack of cigarettes would be much higher than it is now.
Since smoking has been regarded as socially undesirable activity and has imposed additional costs on the society, government has been taking actions to reduce it. Among some ways of reducing smoking, including rising tobacco tax, restriction on youth’s access, prohibition of smoking in public places, taxation of tobacco is the most important and effective way.8 A statistical data done in Italy over the past 30 years shows that a 1% increase in the price of cigarettes led to a 0.30% decline in smoking prevalence and to a 0.43% decrease in cigarette consumption. Similar results are revealed in many other countries as well. Increasing taxes on cigarettes implies punishment over smokers who impose costs on others, and also warning over nonsmokers, especially the youth, not to get into this habit. Studies show that almost all smokers in adults start their first cigarette by high-school graduation, while very few begin their smoking after age 20. In addition, youth smokers are more sensitive to prices on cigarettes than are adult smokers because they are not as financially capable as adults. Many studies show that higher cigarette prices that result from increased cigarette excise taxes are influential incentives for either smoking youths to reduce cigarette smoking and neversmoking youths not to start smoking. , , Increasing taxes on cigarettes, therefore, do have telling positive effects in reducing smoking prevalence and consumption of cigarettes in general.
In addition to the advantage of sin tax in reducing smoking, taxation on tobacco also brings in more revenues for government, approximately generating many tens of billions of dollars annually nationwide. According to Matthew C. Farrelly13, investigation of association between raising tobacco tax and state revenue shows that taxation on tobacco over five states issues revenue increase from 52.6% to 139.9%. State government can simply use these revenues as funding to subsidize health care and offset the costs imposed by smoking. Although increasing tobacco taxes seems placing more burden over smokers, the revenues coming from this taxation compensate the social burden which smokers impose on society. From the perspective of fairness and responsibility of social burden, taxation on tobacco is reasonable and feasible.
There are, however, some implicitly prejudicial effects coming with raising tobacco taxes. For instance, as a matter of course, if the costs of products and consumption get too high, the effect will be to give rise to \"informal\" or \"underground\" markets for goods and services.13 From experiences in many countries for a long time, higher tobacco taxes inevitably results in higher cross-border sales and interstate smuggling of cigarettes.13 The poor, also the most vulnerable group, would try to avoid legal purchasing of cigarettes so that they could afford their habits constantly. The consequence of these underground sales is that the revenues coming from tobacco taxes will decline because government is unable to trace these secret transactions and levy taxes on them. As John Baptiste Colbert (1619-1683) said, “taxation is the art of trying to pluck the most feathers from a goose while producing the least hissing.” Hence, it really requires government to have brilliant tactic of how to tax tobacco.
Historically, the phenomenon of smuggling of tobacco is almost inevitable when price difference is too large. Nevertheless, the effect that the revenues would decline on account of underground sales is disputable. According to Matthew C. F13, increasing taxes on tobacco in New York city still brought in new revenue over the first year despite legal cigarette sales plummeted. If the proportionate increase in the tax rate exceeds the proportion decline in tobacco consumption, total revenues will increase and vice versa. In many industrialized countries, the consensus estimate is that a 10% increase in cigarette price will create approximately a 4% decline in the quantity of cigarettes demanded by smokers.8 In other words, government can still gain more new revenue from the increased tobacco tax per pack sold than they lose from the related decline of taxable tobacco sales at least for some period of years, though it would be hard to predict how long this revenue will be maintained.
Another debate on raising tobacco tax is that higher excise taxes on tobacco could impact more on poor smokers than on the rich. In most countries of the world, tobacco consumption is highest among poorer socioeconomic groups, and accordingly, so is the incidence of tobacco-related disease in these groups. For poor smokers, they often spend a considerably larger proportion of their income on tobacco tax than the affluent. These indigent people frequently face with trade-off between cigarettes and home heating, food, even the medication they need. While for the rich, they tend to preserve their usual habits despite more expensive taxes on cigarettes. Taxation of tobacco, therefore, may lead to strongly decreased quality of life among poor smokers, while only mildly affect rich smokers.
The basic reason that the poor has higher prevalence of smoking, even government having provided information and bans on smoking, is that the poor usually has less capability to use the information than does the rich. Thus, simply applying higher tobacco tax on these poorer groups may only deepen their hardship. Government may need to subsidize access to cessation advice or nicotine replacement therapies for the poor. On the other hand, just as taxation of tobacco have definite effect in reducing smoking in vulnerable youth group, so will this strategy have same effect on the vulnerably poor group. A study done by Farrelly et al. shows that that people with lower income had a price responsiveness 70% greater than those with higher income.14 Moreover, poor smokers, when they get smoking produced illnesses, are more likely to use public health care system which is funded by the general public, while the rich smokers usually have their own health insurance and impose the least of financial burden over the public taxpayers. If the taxation of tobacco could reduce smoking in the poor, it will also lessen the social costs incurred by treating smoking-related disease in poor smokers.
It is also assumed that taxation on tobacco resulting in decline of consumption of cigarettes will put tobacco industry, thousands of jobs in this industry even the economics of the United States in jeopardy. But according to Kenneth E Warner , the role of tobacco industry in the economics in the United States is not as significant as before. And due to the privilege of modern techniques, fewer farmers are needed in the tobacco fields. In addition, tobacco industries have their own way of survival. Mainly, they expand their business in poorer developing countries where people are still poorly educated and not knowing so much about adverse effects of smoking.
Counting in the above pros and cons of sin tax on tobacco, it seems that sin tax is a win-win strategy in raising revenue and at the same time reducing smoking and promoting health. Now, there comes the question of how to use the revenue collected from the increased tobacco taxes properly. Theoretically, the social burden incurred by smoking is principally on increasing health care spending in treating smoking-produced diseases, thus, it is equitable to use this revenue to subsidize health care.
Personally, I strongly agree to increase tobacco excise taxes and use the tax revenue to subsidize health care. Generally speaking, there are two main sub-categories in health care. One is preventive medicine, which includes health education and promotion. The other is direct medical care, which includes hospital and physician services. The ways we earmark the tax revenue for these two categories will have decisive effects on consequential success of public health. For example, among numerous governmental intervention of reducing smoking, Proposition 99 created by California in 1989 was the largest public health program of its kind in the world. The program was originally designed to collect revenue by twenty-five cents increase in cigarette tax and allocated 20% revenue for health education, 35% for hospital services, 10% for physician services, 5% for research, 5% for public resources, and the rest for above prevention purposes. The implementation of Proposition 99’s tobacco education program has led to decreased consumption of cigarettes approximately 1.57 billion packs, worth $2.1 billion in the first few years. Notwithstanding, under the pressure of California Medical Association which joined tobacco industry, the tobacco education fund was cut down to 10 %, and research fund to 1% in the 1994-1996 fiscal years. The fund was then appropriated to subsidize direct medical care. It was estimated that the failure to entirely fund the Health Education programs, as it was originally designed, was expected to lead to 234 million additional packs of cigarettes being smoked.17
“The overturned cart ahead is a warning to the carts behind.” Looking at the lessons drawn from California tobacco control program in 1989, we realize the important role of health education, which is a part of preventive medicine, in reducing smoking. Appropriating more money for direct medical care seems to resolve short-term financial crisis and help the poor, it would not reduce smoking and free the society from the burden caused by continuously increasing consumption of cigarettes in the long run. Therefore, we should even allot more proportion of the revenue drawn from tobacco sin tax on health education and promotion.
There are several measures we can adopt. First, when we determine how much proportion of revenue should be put in each intervention, we need to look at the cost-effectiveness of these interventions. Comparing with numerous interventions in reducing smoking, school-based health education program is highly cost-effective, and do prevent more youths from becoming permanent smokers. Second, clinically based smoking cessation is effective as well. We can provide subsidy for physicians for spending extra time on one-on-one smoking cessation education and also subsidy for the poor for free nicotine replacement therapy, for example. Finally, after preserving the portion of health education and promotion, we could use the rest of the revenue on direct medical care to offset the medical spending caused by smoking to some extent.
In conclusion, tobacco sin tax is a win-win strategy in reducing tobacco use, saving medical costs incurred by smoking, promoting health, and at the same time increasing governmental revenue. Nevertheless, it is crucial for policy makers and governments to properly tax tobacco and utilize the revenue. When consumption of tobacco reduces gradually, governmental revenue from this sin tax may probably reduce accordingly. But is it not the ultimate result we want? That is, the elimination of smoking and the health of the public.
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发表于 2006-11-22 15:16:39