California’s Proposition 56 May be More Curse than Blessing: Our Obligation to Prevent Unfair Burdens to Low SES Populations

On November 8, voters across California preoccupied with the presidential race may not have given Proposition 56 much of a second thought. The ballot proposition, which moved to increase the state’s tobacco tax by $2.00 for a total tax of $2.87, may have seemed like an obvious gesture in the war against smoking. However, the subtleties of tobacco taxes have a sinister twist: the most impacted populations tend to be low-income individuals who can’t fathom how to quit—and can’t afford not to. Now that Proposition 56 has passed into law, we need to find ways to support these populations and prevent already at-risk smokers from becoming even more marginalized.

California has one of the lowest smoking rates in the country, but most remaining smokers are adults with a high school degree or less. Most want to quit, but have not yet managed to determine how. This begs the question: even if this tax will provide the final push remaining tobacco users need, at what cost, and how can our society ease the process?

Although studies show cigarette taxes are highly effective—with a 10 percent rise in taxes contributing on average to a 4 percent drop in smoking—these taxes are economically classified as regressive. In economic terms, this means those bearing the burden of taxation are lower-income individuals with less disposable income.  Across the United States, rates of smoking tend to be much higher in lower socioeconomic status (SES) subgroups, and constant stressors in their lives often make it even harder to quit. Furthermore, these already marginalized individuals may face further discrimination and marginalization as their battle with addiction forces them to flout increasingly strong social norms against tobacco usage. Such a tax is therefore inherently inequitable, and may cause significant damage to lower SES populations by limiting ability to purchase food, afford housing, avoid harassment, and otherwise provide for themselves, their families, and their children.

In California, these economic and social costs could be dramatic—both to those who do quit successfully but struggle along the way, and to those who still can’t shake their nicotine habits. This presents an ethical dilemma: whose lives are we fighting to save with this tax, and at what price?

From the perspective of a human right to health, we should fight for all populations by providing opportunities for low-income smokers to find increased taxes offset and cessation support provided. Two ethical concepts inform this obligation: a belief in a right to equity, and a belief that health and human rights are fundamentally intertwined. From a social justice perspective of promoting equity, this tax largely impacts an already hindered population, so we should offset this imbalance to provide as close to an equal starting ground as possible. From a perspective of health and human rights’ entanglement, a right to equal treatment is not only an ethical concept, but in a practical sense will likely improve overall health of the lower SES population. Lower SES smokers who are supported in cessation and not excessively hurt by extreme taxation are likely to have stronger mental health and feel more empowered to fight against addiction.

On the ballot, California’s Proposition 56 promised to use expected revenues of $1 billion to $1.4 billion in 2017-18 “primarily to augment spending on health care for low-income Californians,” and even dedicated 13 percent (an expected $130 million) towards tobacco-use prevention and cessation measures. Although this may seem like a significant contribution, when distributed between the over 3.8 million smokers in California, the program would amount to a per capita contribution of just over $30. Compared to Medicaid’s estimate that “cost per quit” ranges from a few hundred to a few thousand dollars, this promise feels woefully inadequate. Negative impacts to low income smokers who are not fully supported in this measure may still be drastic, and the state should work to find ways to create a stronger movement for cessation assistance and provision.

Policy-makers must now consider new ways to reduce these external impacts, both by providing more support and education programs that assist with smoking cessation and by working to offset the tax burden felt in lower SES populations whose greatest sin is an inability to break free from the throes of nicotine addiction. Ways in which California can provide additional support measures include increased awareness of smoking cessation support groups and improved coverage of non-tobacco products such as nicotine patches. California could also engage in other forms of financial assistance targeted at lower SES smokers. Some of this funding can come from the 13% donation granted by Proposition 56, but if necessary we must exceed these means and find other ways to support struggling populations in their smoking cessation efforts to ensure that this ballot measure’s enactment as law does not become more curse than blessing.

—Katie Glockner