Author: David Kuneman
Position: Director of Research
Institution: The Citizens Freedom Allliance
E-mail: sharz28hus@aol.com
Additional Authors: none
Submitted Date: August 31, 2008
Published Date: September 1, 2008
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

Time-trend analysis can be a powerful tool, especially when testing a public health policy within a jurisdiction which has adopted the policy because it is less subject to selection bias, but unfortunately, more subject to confounding bias. In my own experience, (1) I was able to detect lowered laryngeal and lung cancer rates, in response to our nations declining smoking rate over a 25-year period, but not the anticipated decline in vascular disease rates expected.

Therefore, I was surprised these authors had identified healthcare cost-savings due to the California Tobacco Control Program, particularly since prevalence of vascular diseases would be expected to be the first and major healthcare savings benefit of any program lowering smoking rates. The American Heart Association, in a comparative "states" study covering almost the same period (1991 to 2001) (2) ranked California below average in improvements in Total Cardiovascular Disease deaths (27th) Coronary Heart Disease deaths ( 33rd) and Stroke deaths (34th). ( "1" was the best.)

The study claims the per pack cost of healthcare in California is $27, but that is in sharp disagreement with Library of Congress findings of $0.33 per pack with an upper bound limit of $0.53 a-pack in 1995 dollars (3) Due to the Library's much lower findings, the possibility other factors might be the true causes of the reported healthcare cost decline is likely.

California was the first state to launch a hospital performance improvement program, (4) which itself leads to immense healthcare savings over time. That program reported 37,850 AMI's admitted through the ER in California hospitals in 1993, compared to 404,371, ( first year of data for the USA) for 1993 (as reported by a nearly identical national program called the Agency for Healthcare Research and Quality. (5) ) Later California submitted the same data to (5) and in 2004, California reported 42,273 heart attacks through ER's when the entire USA reported 446,100.

In 1993, California's percentage of our nations heart attacks admitted through the ER was 9.4, and in 2004, it was 9.5 , which is evidence incidence of California's vascular health did not improve over the study period relative to the USA either. Again, as with the American Heart Association study (2) hardly suggestive of cost savings due to improved vascular health of Californians, which are exactly which health improvements should have materialized early on, during the course of the present study.

The Library of Congress findings and the lack of relative vascular disease improvement in California indicate the present study grossly over-estimates the investment return of the California Tobacco Control Program and that the observed declines relative to other states healthcare costs are likely due to other factors. These authors need to identify exactly which smoking-related age-adjusted disease rates declined in California more rapidly than the rest of the nation, to add causal plausibility to their study.

David W. Kuneman
Director of Research
The Citizen's Freedom Alliance

(1) Kuneman, D.W. TIME TRENDS ON SMOKING AND HEALTH AND THE VALUE OF THE WAR ON TOBACCO. The Smokers Club, 2004.
http://kuneman.smokersclu...

(2) Heart Disease and Stroke Statistics- 2005 Update. The American Heart Association
http://www.americanheart....

(3) Gravelle, J.G. The Proposed Tobacco Settlement: Who Pays for the Health Costs of Smoking?. CRS Report for Congress. April 30, 1998. #97-1053E
http://www.law.umaryland....

(4)California Office of Statewide Planning and Development http://www.oshpd.ca.gov/

(5) Agency for Healthcare Research and Quality http://hcupnet.ahrq.gov/