Tobacco Documents Online

The Taxes of Sin Do 5rnakers and Drinkers Pay Their Way? uwuproG, venrunq, phD; Emmett B. Keeler. ahD, Josephl'P. Ne.vhcuse, PhD; Elizabeth M. Slose: PnD;,Jeftrey Wksserman;,PhD VYS estirnate the lifetime, tllscounted costs that smokers and drinkers iinpose~on aMios through collecttvey tlnanCed health lnsurance, pensions; dlgability i nsu r- enee, gtoup; Ift lneursnce;, firea, motor-vehicle' accidents, and the criminal justice syetem, Although nonsmokers subsidize smokers' mediaelicare and gr,oup Iifo ensur'BnGe, 6rnokere subaldire nonsmokars" ponsions and nursing homs'payenents; On balancit. smokere probably pay their way at the curnent isWN of.xciee tanea on cigarettes: but one may, nonethele sa , wi sh to fal Ce those taxos to reducethe numberof.dbiescentsmokers. in r,ontrast, drinkere donot pay the'It vreay: current excise taxetson alcohol cover only'about halfithe costs Unposed on'otftars: i JAVA : 1 WW;$61 a e04+1 et51 POOR h4alth habitai such as smoking aad heavydrtn;tins; carry costs not only !br rnoken aad `hea vy drinkera, but forr everyoni elee' ae wall. Concern about Lhese eosts has prompted not only. }kalth-pt~omotion efforti, but also pro- posals to incrsaae both fedrral and state' etcise taxes on cigaret'tes and alcohol. Fbr such ezxes to be at"an econottt[caUyy efficient level, they must' at lsaet cover the coats to others thatarise tyom smok- ing and heavy drinking: We term the co.ts to. otlfert cr1tirnW • roste, in Oon-traat to those borne by the', smoker or heavy'drinker, w•hich•we t'arm intsmal' coata. Some external costa, areobvious, for example, the'danage caused by drunk driving and p.eaive emoking: ot'hers are more subtl.e, for example, the higher medical eosts of'emokers that are fi. naneed by health uuurAnee premiums atd psysoll taxes. Such premiurpe and payroll taxas.re the aame for smokers and' nonsmokere (unlike individual lik instuaace premiunul- As a rwutt, non- ernolters =ay eubsidize smokiny: Uur purpose in -this artirJe sa to quan- tify externat costs. Earlier estimates of the costs of smoking and d.+tinking" (pf. Fpnl iTIM!LP*AISifr/ C1 MIC7:,Qen. ute4,pei (rjr Van- r.wy n+.axnWCiroorwron.Svt'awo,icaCsa'(O-s Nan•MwQ..Ko~ , NM.pOV" sbN...nd'.wqM^nr+):. IM 0..=sron.dF+eNI.~ a*y- itsseawla.d Etluc.FOn.. "a-.wd l.M+...hY Cr+,t,tlQs.,Masf ([Y, Nwnoun); . a+*o Sy.lantnot.~+CGrs.-~nr~ Srnts Be/Gars:. C."r . rvr wasee+/wl)i To ODpMed* Md kD'KtW,ys.>tDMMd ntLT i... . 6ot.N 1-c.o oen,+...n•,a'. 910 no.ea M . be eon«v.o t.'.'.D7feMlrq:1!`. DDU31ei vo oc1'1On. d -TM MW C. Gs~a r+ot vy p.nep a rs t15 onxnmert o~ ry, o/tM ~ndMS.~Ys ~.~.0 Mq/M'r AO',ptf tp.'MC.DMrFK Pd'NeVh S.'.. ACM..IJ.anaOn'eR ViO ftMGy. Tty Ul'ivlNtiNY tY MiGrv.. a.,. ,.2Q yai.ww.,pt.n r-hqMq:. Ann Aloes..rs..y:.Cp: (o, Mann+qt @ce of!T)tchnology, Assessment, unpub- llsited datal 19&6) are not suitable for analysis of'taxes beoause they do not always dlat3ngufaH between internaIl and externalcosts, nor do they calculate the lifetirne costs of poor health habits. MfTHOOS External Costs and Their Eatlm.tlon We Illustrate our conceptual frame• work in tetme af'amoking„butthe same principles apply to our analVses of dtdnking. Table 1 illuFtrntes the division be• tween the internal andlexternaiAo9ts of smoking. In the case of aleohol' abuse, we also consider the costsof mot'mr-yeh i- cleaccidenta and criminal justine. One goal of'an eounomicaily. efficient tax on smoking or tobacco •is to haw•e'the smoker bear the costs that he Imposes on othere when deciding, whether or how much to amoke.. Costa imposed on other f>amity members, however, are difficult to claesify as internal.or ezter= nal because it is not clear whether those coete would, in any event, be taken into account by the smoker. If'they would be, then they are internat~ costs. A1~ though our baae-case estimates claeaify such•costa as interna.l, we show the ef- fect;f of, treating certain costs borne by otherfami[y members as extennal. A eimple example'thet considers on1yy medical coete may elarifN the'division between internali andl external cost'. Suapose'a sa•orker, has a group health insurance policy'that pays 76%. of his medical bills, and suppoee that amokirtg a pack of agarettee per d ay raiaee merii- tal bills by 56000. The amount'the work- er patia. .f1hM (0.26 x 800Q=1500); ia a component of internal' costs. Secause. thte smoker does not pay higher premi- ums',that reflect hie or her• higher coats, the remainder of the cost, $4.500; is a component of external coats. To estimate extetttal costr, weshould not contrast the medical andlother ex- penses of Imokere to nonsmokers, be- cauae nonsmokere differ from amokels in other wa)tie-tiiat affect the various components ofcnsEauch as medlcaliax- penses: For example, according,tn~the 1989National Health Interview Survey (NHIS), those who never smoke are 1.5' times more likely than current smokere. to have more than a high school educa tion. Rather; we contraat emokers to•a' hypothetical group of "ttonemoking, amokere," people who are llke emokers i in age; sex, education, drinking habits, and several other ways described here- in, exeepu that' they have never smoked.' 1b test how eensitive our esti- mates are to diffeencee between emok - ing and not'smoking; however, we also contrast medical andi other costs of' unokerm to thoseofactual nonsmokers. Our methods estimate lifetime' costs by tncking expenditures for two hypo- thetical cohorts o(ine:i and,w-omett from age 20, years to death. One' cohort emokas; the other doesnot. We develop life tables for each'oohort showing the probabilit7 of surviving to each age from age 20 yeare. Theas tables aome from applying estintateb oft.he relative risk of smoking to the 19$0ilife tables of the liS' population.' Relative risk was estimatsd!by applying fihe L989'Centera for Diaease Control health risk apprais- al program' to the ever smokers in our sample twice-once with their actual smok4lty statue and once with their amoldng, atatua i changed to "never emolted." Inijudginganypoliby'that has'long-term effectalitie itnportantto(liscountfuture costs, thereby trtakittg,costa that ocrur at different times'commensurate. A dollar received today is worth more' t-harn a dollhr receiti'ed'S'5years from mow (even witihoutinflation). A current dol• lar can i1e invested and'earn interest so that at the endlof 15 years it will he worth more then $2 tae54e). Because the proper rat.e of discount is oontroversial., we have comp:ited results for rates that apan the range betweenu% and 10%. , The expected net external co.ta per pacR are thesumrof t:he immediate ooEts 1QO4 JAneA,)JSrcn w; 1989-vo12@r, No 11 5- Tsr-AAann r,fl 6i a[ ' 2024719448 su t,y fej sn 01. lei na' ca: no tNl pa' wh finn ecf, eal' by am I sm re=, urn h3% t.KF por niu con : Ouw ber und a r T f {•

per pack andi the cumulating lifetime costs per paek: We assume that thF ccscs of fires, motor-%.•aiiiole accidenta, and oni'ninal justtce are imniediate; 1e; each cigarette or ounee of ethsnol f,aa a certain probability of caueing such,cost3 inahe immediateperiod atter purchaeec but once the cigarette ie smoked or the alcohoi consumed, the probability drops quickly to zero, For Nuch aoetB, we oli- vide eetimated,national annuaCcriete by the annual packs (or excess ounceia. T!h e' cumulative net lifetime external eonts are given by'the foliolwing: sb ~ a'*2D Y p;A?tll, x CtNI,. ,_V a -L b`10'x FtAINF>7, x CtvF~~. /-M rvh,ere b indicatea ithe annual discotmt. Eaetar tU[1'+ rl) if r ia the discount rate;', P(4lt): the probability of survivingg fremege 80 yeara to at least age tyear>s, condit,ional on ismOking; C(R),l the annu- al toats minue t.xee and'premiuma for smokers of' age t; Pl the probe- bility of aurvtvtng,from'aRi 20 yoarb:to at )eax age t'yeara, conditional on not smoiting; snd l the annual costs mious taxes and premiums for smokers dsge t p!ears if they had never amokedl The external eost+s cotrn fronT collea tioel,u financed progzams; including health ineuranoe, pensions, sick leave;; disability ineurance, and group life in- surance. Theee'programs'are 5nanoed by taxes land premiums that db not dif- ferentiat,e between smokers and non- smokers. Because amokere' havee ahorter iife expectancies, they will pay lesa of the taxes andtpremiumr that ti- nance these programs. Ib simplify the calculation of' how• much srnokers and nonsmokers pay annually to finance these programs, we assume that each pays the same'proportLon of. earninga;, trhere the proportion is just enough to tlne,nca these ptograma:' Tbe diecount. ed. expected lifetitne costs per pack are cakulated by dividing the lifetimecosts by the eapeeted, number of packs smoked nra lifetime: Ln eatunating,the external costs of smoking and drtnkdnR: we reliedan self- reported'conaaunptioni Because people underreport their oonaurnptioni we have corrected for the difference be- tween'acti:al and!reported use. The re- ported'numb.r of packs per dapy was multiplied by 1.5i ar.d reported aleohol! cousumption was multiplied by 215:' ' Our figures for pension inaome' have been corrected for a 21% rate of onderreporting:' Ou r eetimaf.es ore based on daoa from a number of sources:, The prunsry aource' for, those under age 60 - years ia The RAtiD Corporationh Heaith' In- Tade 1i-Co.uor,swil P.ewy14~. a1w/,. 5+•n04.•.M ta*Hf Cnwe•-eY'and o4hw.' Ps!nanAriMi4!g 5-al:wanyt[n+ny, CGMC•YaM.na.Otly^.• MMffrek'wel. CGqarWnu Inwre.w qlmburf4nMM. sICid IHw'. unCO.wdlekklee.A car.wdatd'b.er t7WYt11tMy. Fo/eQOPl intl norretJlaced. by da0bllYy 4yyt.r4! DMaa111ty mau+anc. droup O/hinew.f+el i Ne{ylo0y tfeein e.n.M atrvil ~ De1k.Wwaair,tx*ion plni Soea/5.cun1l.no.ae.n.a-0enMfD!.at. Wlgee FOreOen.a..po.able.lAcornf. Tereaanaa..we. o.'wooW: o•oitilty beeduao,Nr.epd~byRenl Irowr.apsp.rrtylop O4stokw Tobeaa~procUC4 Cfp...It.D4rrne.s . !~ . . •P,rnY4n me*lemy, eMW evRarlnO iemap qmly, nhna.m end eowoA.M:,.t cwe.dl byy pasN+..nbt'm0 vur . WtVielly.taels,tlcnry pyi ytnw Il m.mOMi'as !ntenyl'cof4 . ~WJlent. ~Or YKOt<1h~COMMQIM r?y COHntd4 we m0M1.Y0NOl1o al '.kNO 91 tE+eW l.ea a+ cqeneneeawq et coraider.d nepFnw..esrtub mas n iMV.n•.o tl.Be.d. we oW.d !d c„r .,,aw woua w lo d.UnAlf. e aftRW WeY N.wNe aMD: relfyl ANM e4Vl 10 iDM CSXreIM ..el11e 41f. rabte a.-E.r.rnat Cous per Pecu d Cpwltes" olweww n.r t+eaew eeses 0% ax TOk. Cdsta Ov pldr, a MoeleM e"t' 0 36 0A6 ~ 0.16 5ck 1qW. 0.0/ 0-01 0.0t' arouo w•uu.+o. 0 1/ o:Of' 0:08 N+a.elnaroM. -o2e -o,os aoa. 11~l1AemWntVensiont -t.a7 -0:2a. -Oi02. Rbsa 0.02 7 0;07' 0.02 ! Tuae on evRNZ 7o menee e0avspro0nrnel s' -o.eS: -o.Cb' -0.02 TdUneMam4spslpapt.6§ -OA1' 01d 028 tae.s.epeeerhruaps40Y'CnDark,mm -1s7 -ab -c 'TMnYn27MotpeGi..ON'clparelMe re COrryttedsru,1tlen.l Cwte:(In tias.eeNanJ W/0oll w c.Waled hrdivldnpt py, tne deaanqenlrnti.r at peou «ndcW., tMltlkM N but mwln f, wal, ,eM deroai tan: tldwlriM. daedsty kwn+c~; ~T~e wm at ~coeu n+~wa:w~ee on eeewy...•e0, eoeu u 6YIG~ W0 16~ o!2e r 0.0, . o os -o o~ -o .aa:...0 cs -f-00.) surance Experiment (HIE), because of its detaIled information regarding hab- its andlthe medical reasona for the utili'- ration of medical csre:" Becaus4 per- sons aged 92 yearsor oltier atthe time of enrollment were ezcludrdi from the HIE sample of 5809 persons, we used data regarding persons greater than age b8lyears from a 188.'I eupplement to the N1:IIS. It' included information re- garding healtii habitei healtH6care use, and work lose in a sample of 22'418 pel eons. Inaddipona we compared!the 1983 NHIS resalts' for nonelderly persons with those from the HIE. We have in- flated all costd'ata to 1986 dollars using the eonsumerpriae index. We estimated differances in spending for medical care services between those with and withouteach'habit:,Suc}i dif- ferences, of'course, rne}^ or nuy not,be caused by the habit. We addressed this ambiguity, in two vway s. Firet,, we con- tcviled for the confounding, characterie- ticsdescribed; in,the next section. Sec- ond, although our baee-cttil estimates include allitnedical eervices except,,nr- teralty servi,:esand x-ell care, we exem- ined their sensitivity, to> considering. onlv costa that arise' from d'lagnoees thought' to be diroctjy related to smok- ing and excestive dttinking;,auchas can- cer of the lung and cirrhoeis of the li iver, In addition to medical expense, we estimated the differsnoe in daye lbst from work between persons with and't without eachihabit, eontrolling for the confoundi ng variables described herein. 11e eollectively financed oost' of days sost from work was computed'bymulti- plying the dailynage'by0:38, the'em- ployer.f average share of the cost of work loss through covered aiclt Ibave."' When estimating the cost ofdriniting; we controlled for smoking status, and conversely. Had we not done ao; we would have attributed aome of the wstY of smoking toldrinking if emokera tendl to drink heavil'y. We classified!persons ~y te former cigarette smokers, current ve e'sganette smokers, current pipe'or eigar N smokers, and never smokers bated on their reaponaes to a smoking hiatory A queationnaine filled out at thi time of' ~ enrolltnent' in the study. We classiRtd ~ persons as abFtainm~s, forunerdiirtkprs', (~ and current drinkers based on reapone• ~ es to the same questionnaire. We col- ~ Iltpaed infonmatibn regail the' cur- ~ rent, drinkera" consumption of tPeer, ~Ar+64'.'dartch~ 17. .1?89~-V3122b1, MO, ti+l Sim T~x-Nenn,npet 6' 1605

;itMtrW ossils d'pow nsa4e MtiRa,et attarnewe dlscaurnraua, %ela 3.-lMYMy rd Ee/.nnaf Coats (h 13ae DOllvs) per Paarc q AMUmQtlOnt at bM Ddeeaurrt AsM tLtoreNtosw s.s aser .aoia frem . wseew »saa+ s»ww.r.w.y caspaeoen . ww, Nwer: smoksp tmtiw, em."dt: Ttlw coaas' osawssr pert. s ss+aliesw oie oae 030' ons oas leaMrs: 0.0t 0:06' 004, O:Vt Q09 pp9 iM Yr.vw QQS 0103 0 06 0 0F O.Qs. NwY`e/ts.rs -0.03 -0.03 -o.a2 -o.e01 -a.03 : assr..rMprebnf -ox. -0.aa -o,W -o.:u, -caa fba 002 002 002 002 002 . 1YNaisr4ppr,pacM:S. -0:0l. -00e. -o.0e1• -0.06 -0-0,14 %W MlseM/asr.pa* ao 0.:a~. 020 olAt -015 71'. 'EeM d drqMa wrqM an0 Iortnr rnok.ra t0 nwer. vneKr...riM cmM.c~eradMafCS l41d bonRant . 1Ni.o. MaMfM ot unsekd dNa1, wttl+ no ankis ol arrwWlq an sanqr reElsnsrM. , :rneNd.. wa.a esNs ~.~eww ewsssry +,.w,e._1 pyin d1mis M eesNnak/q tnroisri Oxf•renhat: Mre sMOksneckutly a.y.t0d1 OMtm moN.sereiqs t1. MnaRpeara Osr pedr' Oscsufs. at'tYPer NrN~hp rpea Cut M rs a+iysusibts riaf.tttsk.Mlyyr samip nMSs aw n CKM..f. wlMSbb w.e~6~q. d wfi.w .rwn id.My~ an m1; rot su.a ew s,nngl. .suw 40 eoft w+Mw lws on w". -9toss a srsss qw+ ena aWw+q tirW„ok.r end tanrsy na ftudedl sss an wrune, and spirlt. Into a singlevarlable- monthly consumption of' ethanol in ounoss. Witldn the cateQqr-v of carrent: driaker., keaoy drirtken includt' those Mbo.repOrtan- ~aYerageof two:or n'InredrWa da4 (Q:z,or mone actual drinks daiq; with allowance for underreport- ing). 8ecause light drinkinQ maynot:bey harmful, we ealculate the eost per ounce In exeess of' two reported I drinks per daR"" Thue,the drinking enalogpe' of nonemoirin,`, amoketA are "controlled" heavy drinkern;,ie, we estimate the ef- fect of'hypothetically red'uc:ng the oon- eumption of those with more t)un two reported drinke per day to two reported dzinka;per day. Our base{sse analyeis also controlled forbealthiasurance eovera a, age, sex, nce, edueation; the use of scat' lielts, family iitcome; exercise, self-tasseased measurea of physical; mentsll and-gen- era7 heatth, and farnily siisa, We includtd'ed'ucation ,and seat belt use to measure attltudee thatmay differ betweel those with varying hea}th habiU-attitudes that may affect work lotte and use of medieal' senices independently of smoking and Icirlnking. Pensions and Other tyoate In addition to thecostsofinedical care and!work loss;,we cafcutated the other' components of cost shown in 'Dtioib I. Data regarding, pension and' disabilitv payments by age, sex, and educatiomstatua Qome from the Curren.G li6pula- Lubn Survey, That isurvea! irF also, the source of'earninga data„which 1we ude tio oalculate texes toilnancrthe programs. tlur estimate of annual property loss fc9m 6res that' ara associated with eigaL rebte smoking iu 1340i million (iin 1 1586 dollars).'''&cause:of fire insuranee; we have assumed these costs,are entirely external;:but our estimates are notsen. sitlue toths assumproion. Our estiinates of.oertain annual ex. teraal+costs of'tloohol abuee are as fel> lowi: property damage from motor:ve- hicle .ocident.; 3M billion, and from fires, VW million; criminal justice, 53.1. billion;,and'.-socia! programs, Sii4 mil. llon."' It is extremely difficult, and to some distastefUl, to place a dollar valueon the innocent divee lost due to fitra, passive smoking, or drunk driving,, Nevert.he- 1ess, it is often necessary, implicitiy or explicitly; to place a value on lives lost whenjudgttlQ the merita of'alt.rnative policies, bor exsmple; policies leading,to air potlutiion control or increased auto- mobile safety. For this analyais;, we in- elude an explicit value for the lost livee to avoid the systematic undereounting of the rostis to society that would occur if we included.onlythe differences in uee of inedlcai cana, sick leave: etc. 'Ib defiTe a value flir innocent liver lost because of fires, passive sntoidnQ, and drunk driving, we used a methodl based''on the willingrtess to pay for a small change in the pt'obability af.ur- viving:"'This yieldaa value ofS1.66 mii- lion per life (around $10 per hour, using years of'life expectancy discounted at. 556), considerably more thin the value of lost earnings. We believe earnings are'an inappropriate measurs of the val- ue of life, in part, because they attribute a relatively low value to those who are out of the labor foroe." FlfBllLTS'Smoktnp External @osta per Pack of, CiRa- rettee.-If coste are not discounted. each pack,of'eig(trettea increases medi- cal costa:by =4.19, but saves i1182 in public and private pensione due to a 1.3?'- minute reduction in life expectancy. Overail; tEere,ia ia net savings of t0:91 per pack in undiscounted coets (Table 2). Results change markedly if costs are discounted ar59i;, l'argelybecausepen- sioni costs changerfrom -3L82I(at Urle) to -3b;2& (at 5%) per pack. Penelons are recei4edliate in 1ife; so discounting drarnatAcally decreaaest'he differentiL7 between smokera and nonsmoking smoker5. Lsinga58i disrount'rate, the total r and',th discou t.ault ample Techrr pack c exclus ings fl coste: Sen tiona. subaid' sensiU below effect For cc peds ~ diacou nesulu We usF old pe) costs'I ered a pack; :: 30.15 t: Ti to dif;? scnokin ' smokerather 3;,twlu insenv ternal figure~ ooatt betu e~i~ exceptemohir differe retirer smokir• mediCa' noesti health (Table sccibec nonam. manne atnoket efl<ecte t;hat' th ranum as amc cafumn tims I -iA.ll per pac' Fine gives t, portion person. the coe sufferii appean table. Othe rnatea c do not teUe .YAMA'. tNarch,7. ,g09-vC.J 261 . No , i 2024719450 r:.u45:Ll ~ Sm Te,-tAanninp io1 ai JAMA' K ~ '

total exterua'..coate perr pack bre g~l:la, and they nise to 80:24 peYr, pack at a 167c discount rate. The main rausett:!Creer resultr are so,n:uch lower tF'a!:, fat ex, ample, the estimate frotn thr U;'fice of. Thchnology A'saessment of g2:17 per pack (unpubli.hed dato„ 1985) is our exc!euion of changes in lifetime earn- inp ftam unoking, which are internall cost8. Settsitirityy nf Costs to Aasump- tiots.-Clearly, the magnitude of any su!lsid5 from nonsmokers to smokers is serwitive to the discount xate, eepeciall.• below 5% (Figurel. Table 3 shows thr effect of wryirtg other assump't.ions. For comparison. the flrst column re- peats tlte't'+esuits ifrorn Table 2 for a 5& d5/countrate. 'Ib test bow sensitive tliee results are to the data source selected„ we used NHIS data for yowig ae K el l ass old persons (Table 3, column 2). Medical . costs per pack do not change, but co.- ered'aick laave eoste rise to-5Q.06 per pack; and the totalinet eoets rise from f0: 15 to $11:20 per psck, 'Ib:testhowsensidve the results are to different assumptions about how amoking affects- healfhi we contrast smokees with actual never mnokersi, rather t}ian rtonsntaldhg smakers. (Ta bl e 3, column 31, The results are relatively insensitive to thls modificatyon alio; ex- ternal coeta rise'to $0.28 per pack:.l7iis figure probably; overstates the true costa because ittreata all the differences between , smokers', and never emokers, except wages. as causa((y related, to amoking, whereas smokers may have different: patt,erne of'medical use and retirement for reasons unrelatedi to smoking. As another test, we reatrict.ed l' medieal costa to those ariaing from diag- noree thought to be related to poor health liablte; medical costa' ftsll,40.11 (Table 3, column 4). T}ie aatimates de- scribed herein assumed that a cohort of'f ntmsntokittr smokers would retire in a manner sitailar to people who never' amoked, However, we al.no computed effecte ontarroe and pensions, assuming that the pattern of retirement amongg nonemokittgsmokerawould be the same as among smokers; ie.- quitting would not affect age of retirement (Table' 3, column 4); Combining th'ette aranmp- tions leads to a lower boundary of -f0.15 (at a 5% dlscount rate) ion coFts per pack. Finally, the iast column in, Table a giirealtotallcosts: that is.,it incluc4s the portion of coats that are financed by the person. It,does not, however, indWde the coats' ofl premature mortality and suffering, which -is vrhyy a question mark app2ars in the'lower rigt:t:oorner ofthbf tabk:. Othoe t•;osta o(Smoklns.-Our eeti- rnates of the coste of'smoking in'Dable 2 do not inelude t,he, adi•erse effectE of Tabiao-.-fREe.•na%.6ostsor Nesv~•DYSnrsca pn Esceac'-0unce" nreeou"t nate, Ek:a•ntI Cq.tt 0'+. aR t6e1 r.y'Jr.a+ ara pensq++ cot+s o.r e.e.ci aur+c.: sMeeca, car+t 026 VC 005. skK r..w 0.08 0105 ~ nnc~~ O+o~~Di1e.~nwr.ncs 002' 002', 002 ' rruesMp'taTe -oA't 1 t. Ratlr.w,eM pensqnS - O q= C C3 0:02'. raussoneamtr+Os:S' -0~15 -0.0e -dI02' amM7icale•+dD.r•.t«+tcx+'.Dh^exceaaource.s oe3 029 o~,s. Malmrrrttloa taeN1lta arna onrnrs nastlee aosn OMr,eaaas.pu•ee, f Llhs 0t nondmNtma o se 0.58 056 M/b0"Iarcos'iit d.2i oJS 035 ~- TW'at n!t RtF! Daf e10/H ou't0a. Y +.se 1119 ~ oe uK awetrxy .t aas 30 r par aaai ouncs. Tn -20 - e -• •COlft (.f t9ee dbllarS) pK taCM OlresY. caltuUtk'ot.div-elnq by IN d,tCeut•1sd nurnbe• a o.Oa.. ounca. 1Ea[MSanunltn3y, rH, s~e dtntal iCay: aed.m.di.arCaM teflc~ta othis iuatM'ordkrrxd*Anp ihdreaus pasre N r." tne. 0 0os:"uas iowbttly hsuKa•te. 1150 0 3S~ca% 4Quw a+cwaes ,.cenap ntrwu. cotas. .uc^ as tna Cpopv-0 Cerups,in rro¢w-oency . accbana ! Rtld ey t/le alp)b0t en.e, nCaCuctwaa ie+atM"~eoDay-mmESa.'^d nipha• lyarrtY.»+$ but etaluGN t YIwA.•na, cosn!asaaurea.np, ev.s^act! o+'akot+oliarnan tpnutar ana cMd•en (ap. Ainruse olrn7uqa n)arnat 0eun.erNMS) Vtl tAO.e MpCV/N Mtthtn• InC7a"tlrlek or ~akfNOhtrn n7r Mleie OeDfnWnla . ,Swn at ODl1& mlnus taxN Cn aa^'Mipa passive smoking on those outside the' smoker's family. Passive emoking, causes an estimated+2400 lung cancer' deaths per year, and it hat also'been linked to redizced lung function among ehildl•en of ssnokers. a higher incidence of respiratory problems for children and others; a! well as'the di!pleasure of oon= suming unwanted cigarette smoke:" Mostof theGe costs are u•ithin the familk and are internal i or external I costF de- pending on the extent to, which the emoker considers the welfare of others in his.family when he'smokea. The fig- ure.s inillAble 2'asaume that sueh costs atx internal- Ifl, hower.-er,we'treat the, costs of the:240fi deaths as entirely ex- tetnal and use an esttmateof willingness to pay for lower mortallty of $1!.66 mil- iion. per life," external costs per pack would rise $0.14. Because deaths in smokingrrelated fires are also -almost entirely, within the family; we hacv treated the costa as interna! and did inot' inciude Chem in our estimates. However, lf we were to treat t,he eostb of such deathn' as ext.ernal,, some 1fi00'people in 1984 (J. Hall, orall communication„ Aug, 13, 1987), we %muld inorease the external eosts of cig- arettes;byg0.09 perpaek c+f cigarettes. The smoker loses 28 discounted min- utes of life expectancy (ata'55h discount rate) for each pack smoked (Table 2), which accounti for• S0.981of'discounted wagps (many of t.he loat minut.as occur when notvorking). L'eing our est3mat- ed'wi llingness to pag•, for lower mortality' of ELO per hour, the 2t:,minut'es'is worth approximatel}' $o. Although we consid- er the fG an internal cost„it may none- th._loss be nelevant to rn economicaliy. e.fFcient thx„ a p,~int we will come to laten. Hsvy'Drfr,kiny External Medical and I'ension, Costa per F.xcees Qu nce of Alcohul. - Gsing undiscounGed values, each excess ounce of alhoho6;,ie, t'hoae conaumed'in excess of two reported deinka per day, haq external medicaliand pension costs of 50.63 and causes a loas of29 minutes of life expectancy (Table 4:.columr. 1): At a 5% discount rate, external rnedical and pettsion-costs per excess ounce fall', tu $0.26. Iat contrast to smoking, heavy drinking increases all kategories ofcoeta (at a 6% discounCrai even pensions, because the large effects of early retire- raent, which tligp'et-s pension and dis- ability payments. outaeigh the,ahorter life of drinkers. At a 1l??b rate of'dis- count, medical and pension costs fail~to 30,16 per excess ounce. Before diecuning the'other costs of drinking shown in''I'able 4„u•e describe the sensitivity of our estimates of medi- cal and pension costs to different: as- sumptiona (Table 5)r ~ For convenience, the first column of'Pable',5'repeata the results from Table 41 for a 5% discount rate. ;ledicaband pension aoets are not sensitive to tlte sourceof data (Tlable 5; oolumn 2);, nor do they change much if tve'compare heavy'drinkers with actual, ahstainers and light drinkers rather than hypotheticall controlled drinkei . (cutting back to two l eported drinks per day among those',co:auming more than that amount) (Ta3le o, coiumn 3); nor do they change:a•hen drinkings'not treat- ed as a cause of dirsabilitl' reurement (Table 5i,column,4). Reatricting medical cortn to thn.ee arising, from diaRnoees thought to be reiated to poor health'tiabiu makes vir- tuallv no difference 1o our estamat.ec (Ilable o, calumr. 4);, impl, :ng', that the .f4!thG:.lAtan'7.,.*989-vc.,28'I No 11, S,c'a,_txanr r.~aly' 1607 t

TOWS-SSas" .oiF,/Mediand Mmitm Costa ph.leas Wkn)'pm.l.cess.0una e1.ElnenoV.19Aeewncoar. 6% d.oount aas. -- - ttew A6Da7apnoen Br... NMisn.! Neate+ esN-tm.rrYsw auhnry, MsawnWY. .nd Llpht L1.IIt4.c. CO+.n' 9oa:ndt 101Ut 1 e6sta'. . . ra.ettaa and :DSrw" cosu: f'I bKebsro.,..tw.-unwro._§ Oat. O.OT. Otn o:16 gkt4....s. 005 r 0.to 005 '. 0nJ orourx••rww" - 0102 - 001 _ oa - 002 _ 002 hory 1 o', ftfr-nwMp.negrc a00; ocs -o:+s -0.OS 0.07. wseone.akn~.,a -o0a -0oe -tc1ar. -0.03 ho.rpyfti asd CoMb+ POSb an . deNSOUbe.lM 0.26 023 020 0!6 O UM.pslsrqr elOpsffiY:I>M ebesseUw.nur -s- -7 -ro: -e -I 'EMeOt of dNnqrq A.w+y drww bmrwrau0 d"a.. wm onw cno.aMhea ndd oonranttNatroe etMi•oon et e+.mwt'6Meets. ve ro...cr o0 wrnr..el.ws.nu ta~are.. sknr ooMS.`ffp/YAYwylw~Ry. wntS, o^Id AYNY CM. sr,ete.rs typ* r tw rWo oos: +nrk+a. w tiiwr«+cs. /V/e /IeYS 1M/ ft M1T7r" ,Ot aDAlnf~l vq epM OrlnkMf p LMftuINtClN ,TMN ~srrt+Mjf Ye W4d6rapy "S/W VY+ w sr+rew,,.wn 4rt.r oartralrpg a+.o.,c.eon. To~tir ~99014 ?a.r ~av.e MmYlrp dtWsnc.a .n -jot awW66d'bp OAn14n0 r~ MdA6. uM delrtksrr ssemnpr: N nnat Ws.. ON ~-o ~, i equn veud t». -A 03:. ^E.e~ na ws a+ wMMas Ttswe oi oow mrus tu.s m a.rntrqS medica! coete shown in the GrsG column srs laraely dus to differencen in medical esa tba'are related to habits. In con- trust, theaxterna3 mste oGrmoking are senaiti.e, to tlie definition of relevant iisediead ooats. suggesting that the bro.der del4trition of ateoking effects, may overatate, medieal' coste and& total externalcoata: pthee External Costs:-Although oar ertimates include the adtlitional probability that..Llriker w(11'.be +ultedl in a traffic accident, they do notacsount for the dea'.hs of innocent byetanders and tf4ndrlnicing passengers inauch,ac- cidentq. The Department of Transpor- tation estirnatea that,about,7404'of the 22 t00peapie who died,in alcohol-re3ttt- ed trafflc aecidenta in 1985 were not drinktag;' Based on a willir.gness to pay.. for a hmnan tife cr<E1.66'miliion andlthe esthnated'voltune of drinidng from the 199 NIIIS, the value of the 7400 lost lives isti0.6g per excess ounce of ethanob (Tabie 4, botto.n)., This 5gtre is low seeawe it does not include medical, dia- abliity, and suffering ooets of surviving nondririltittg victims of aloo}iol-related aceidettta.' (}n the other hand, the figure is high to the extent that'noL:all drixk- bng-related accidenta! are eaused by, aloohoi. In!addition, there are annuaAy'57.2 hilli+on of other eosta described previ- ously herein,, pr(nciyally, costa of the criminal juatice syetsm and property damage in alcohol-reiatodi motor-velti- o1e aeodenta. These coets add another $0.35 per excess ounce. B.nsRtvhy of Aesultr Although i0:16 per pack of cigarettea and 31, 19 per excees ounce of a3cohol are our best eadinatea of'the external eco- norniceosta of smokingand heavy drink - ing, the oalues are sensitive to four fsc. tore; discount rate; valite assigtted to lives lost ia drun[tdriving-related aeci- denta, amount of'underreporting, and treatment of persons who die of causes related to pesaive stnoking tnd fi>•es.. Discounl Rate,-The: sensitivity to the discount rate ia.more pronountxdi with smoking, where the estimated sx- ternal co4tg }p0131fi ha alm oat 30.~0 lawer pv pack if we used'a 3% rather than a 696' discount. The sensitivity of drinkfng, costa to distrounting,is muzh, less. fbr smokingy conaumption'starta early;,but deathexome much later than in the case of drinking. The shorter the time be- tween consumption and'deat'h, the less sensitive the estimsteR are to d(ecounting: Doltar Value ofLife.-8ecauss tha assumed value ofdife is on the low end of estimated values, our estimates of drinltnng eoeta are eonsercative. QttderreDorting.-Assum»ng that the reported level of consumption were closer to the actual level of eonsumption, would'ra9ae our estimates of the, exter- nal coat, because we woulit intlate the level of repotked packs and ounces ~bya smaller factor when computing eosts. per pack and ounce. For examp,tie,, had, we assumed rsspondents reported 60% of their actual alcohol consumption, cre would only hava multiplied'& reported ounces by 1;67• (d00160Jrather than 2:6' (1001A0) to~eatitnate acttutl ounces; andd the estimated aost;pet excess ounce would be 6t196-(2.6Y1167- 1.6) higher. In the ease of alcohoi, our cost estimate ie conservative because the40% tigure we used,is at the low end'of the estiraatea, found in the Ilterature:' Within-Family Coste.-We~ ignored; costs o4'SG.23 per pack assucii:ted wnYh dEaths caueed- by'passive smoking and fires because we assumed,they vrere.in the(itmiiy and taken!into account;by the amoker. 13efining, these costs.as exter= nal u•ould more ttiandbublp our estimat- ed external cost of smoking: Our estimates are rel2tively insent+i- t'ive to other aSAumption.. Because the extecmallcosts ofdrinking are dominat- ed by costs aseoaiated with idrunk driv- ing; such costs are relttiveIy inaensitive'~ tio, discuuntinQ tFigure): The choice of deta usedlto estimste effects (HIE vs 2.'HIS) has little effect on the results, Our estimates of the external eosts of• aleohol were madeperexcasa ounce. but excise,taxea apply' per ounce, not per excees ounce. Forty percent of total consumption,represents ounces in ex- ce se of two reported drinks per dky '(t+•e actual' dr.nks per, day, gluen our estiL mate of' undsrreparting). Tb convert our Rgures per excess ounce to Agurss per ounoe, one'should multiply,them,by 0.4, reducing the estimated cost of $1. 19 per excess ounce to tD. 48 per ounce. Our estiinate of the externaltcost of smoking, SU.1b per pack,, is well beloww t,h'e eurrent average (state plus federal) excise and'salea taxes of $0.31 per pack (i0:32 of the $0.8'7' are exdse taxa•),° I{ovrever, the S0.$7 tax' rate approxi• mately equals the, estimat,ed' extemal coetof 50.88 if we werc to treat all lives lost to passive snioking and Ares sa t;- tat,.al wete. Dy'contrast, our ettintatef oUthe external cost of alcohol, f0:48 per ounce, is well above the current'average (ltate plus federsl) excise and sales taxr esof 541.23 per ounce:n Chhe average excise tax is taken acrosa distiUed spir- ita, wine, and t»er, where the exclLe taxes uv 90.26, 10.08, and130:09 per ounce of ethanol, respectively.) Thus, emekere probably pay enoughi taxes to cover the neteosts they impose on oth• era, but heavy drinkere do not. We noted in the introduction tltateco- nomioally efRctent e.xtxse taxes should at least covrr ezternall cost., By this criterion, taxes on alaohollltre too,low; whether cigarette 4xes are high, enough depende on, oneb appraloall of three other arguments far tauation of cigarettes and,alcohol. (E)ach of these argumente wrou)d further st'rengthrn thecase for increasittgaiaohol taxe.. ) 1 The first argument tikes cognizanoe of the regret expressed bymoet smok- ers and their attempts'to qtltt: Smoking tends t'o start irvad'oleseence or early adulthoodi at a time when•individhale are not.vvell informed'and mey not ap• preciate the consequences of their ac- tions.' Cigarettes(and alcohol) are ad- dictive, so it is more difficult to quit Lhan to avoid starting the habit. Because over 65% ofamokers begin smoking be- fore age 20 years"and sornR, evidence 6llM itnder sitiw••6 crease beconi, Som nalisti, t8ste6 quit; t the ecv in life e is rele~ cause ( efficien perr p,ac minutel Ase, dg+trett epYreci ing labe adult sn risks of deter in pet1eattir A thu modit~et ;: ,= : lead!to r'. havior.a Sappooe, external gretaasc point of', , etill be w is preter~ havlor d~ lnduC4d couid'al'sc [hanaLin IDe6p:tq ing our e! , thr differ audeater vEew, a it Snerea6ei tax increa level, not boot ieggir fs especial beer and • ously here of etftanol; !u. Stratej ing or pro may be'coa Tb tiie d alcohol ab+ drink in ba drive home cam lorsn: by the drinl tain what l, stern from a restauranteo hnmes: Ideally, n, ers°to-fonc,tcoetb of dr,, aic4lic,1: To 6 ~th fines, cenFee,juil~ Jrh.1A 1,14•.n 1603 JA ti1.1. Merc* 17. 1069 28 r. rta, " S; n Ta c- k4a n n., , e a r'

euqgedts that tHe' praportion: of tfiose tlnder 20 years of AKe who 2lnoke ir rel:- Fitive to taxes,"°` higher tnxee /ha?- de- cr+eaeethe number r,f ~ridiv.ial:nls tt'ftn become'addlcted- Some may.cee this angumentas llater- nnil!tic, liut it in not, i8 jiidget! by the tastes of the indtvidual a'ttempting, to qtntt those tastrr aryrtlably determine the~:etonomicallyefficienttax. [fthelossin lifeexpecWcy of28 minutes perpack is rele.ant to economic efflciency be- catfse of latar ixgret, an ieconomically effac'lenttax wiluld be on the order of Sii per'psck; the estimated %-alueoftre 2R minutee.. A'set:ond and'related reason to tax cigarettes Is that many adults do not appreciate the i riska. Deypite the w'arn- ing labele tm'cigarethz.. 205E to'?Stlr of adult smokere eayF they do not knota'the riaks of gmoking:e A hig#ter'tax would doter initisdon of'smoking, thus com- pensating fornrty undervalued risk. A third reaaon'to itnt addictive com- fnodittea isdhat'such taxes are likely to lead to a nlativelyunall change in be- havior among those already addicted. Suppoee, for example, there were no external costs; no ignorance, and no ret gret assoeiatrd with smoking ; From tJn point of•vieµ• of raiaing,revenue; it may' still be wise to tax cigarettes becauee it is Preferable to tax iteme for which be- havior does not ehange: there is less induced ineff'iciency.° This argunient rnuld'also justify'higher cigarette taxes than at present. Despite the: uncertainties eurround, ing our estimates, in the'case:of alcohol, the difference betx•eeo the actual tax and external eosta is ao large that, in our view,:a strong caae can iie'made for an increaee in federal alboho3' t•ances: The tax inereaae should''occur: at':the federal Itve1, not, the stat. levell to prevent bootiegging across state lines. The case is eepecially strong'for raising taxes on, beer and I wine, which, as noted previ- ously herein, are mueh lower (per ounce'e oCethanol) than taxem on distilled spir- its. Strategies such as banning advartis- ing or'ptomo•.ing negative advert9sing' may be complementary,e Tb'the'degree that e_xt.err.al'costb ef' alcohol abuse stem from people who drink in baxa and reataurants and then drive home whi:e intoxicated', there is a' case foran additional tax on alcohol sold bythe dsnnk: Ws have not'tried to oscer- tain what proportion' of externia] costs stem from alaohol''consumed in barsand reataurante relative to that congtuned in homet, Ideaily, society u•olildta:c drunk driv= en to force them to pay the external eosts of drunk driving rather than tax alcohol. To eometztent'• society does so with flr.es, suapeneion of driving li- ren9es, jai: ser.tencea, and civtl liablliqy. How•ever, thc, pl•trsent il gfia ;p5tem dDed not make;,nor could itl-eaaonably make' drunk drivers beer fidlv tne' exltrnal ctiste of their actinn " r>pecli":1•. ia ith.lse caBeBlwhere:'there Ie a !0ssGt•,Inllocent lives.°'Fbr example, liAbility insurance pdrtially ettleldn'dtvnk dtivers: We' eltrse by considering, ta-o srgu- mcntF' against hiSHer, exciee' taxes Fir.it, tobacco and slbohol taKes consti- tute a Ihl-ger proFortion:nf the income of the poorthan of,thewelf to-do."" How- evet;, alcohol and x/bacco taxee eaeh, eupply only 19koftedera! revenues. As a, reault, ratlierentall changes in the iildi- vidual dncome Wx stru cture'could ireAdi- ly compensate for the effect of increased exeice't.axes on the disnibution of in- come, if that' were deetned desirable: Drinkers and smokers would atill pay more,,but low-income individuali, als a group, needinotpay molY. Seoolxi, light drinketi ' may argµe that they impose few ol•r no external costa, but would unfairly pay a higher tax burden. There, are two responses. First, suppose, ttiat a: given amount of revenue to-t5nance government expen- diture'muet be raised from various tax- e5::iitcludingCxcisrtaxes on alcohol. As a group, persons whose conaumptdon of alcohol is lielow•'tlse population srerage o€1.7, reported drinks (over four actual drinky) per day will'benefttfrotn shift- ing more of the tati burden to alcohol taxes and away from other taxes (eg, payroll taxes).1 ln fact, of' adults who drink, three fourths drink less tHanthis amount• Seeond; to tlie' derree that hlgher taxes deter alcohol abuse, the resulting decrease in external costs will offiiet increases in the tax butdEn' of light drinkers• Because excite taxeg imuat be propor,-' tional Go•conaumption and because the external costs of'smoking and drinking are' not proportional to consumption,. there wil] not be, in practice, a tax that' does not kave' aomeorto subeidit:ing someone else. The',taek of,determining how'such subsidies will flow falls to our political institutions. tiGe hope our esti- mates conttibute to more informed decisions. Thu w•nrk wsaupported by grent RQI-H ti•'tM2~ feom~ the'.* allons! Center for Health Ser.icae Rp. erv+di end Tlchnoloay Aan.soratt We tnaxrK'THom,u Vogt,.liD; Rol>ort't•au. PLD. and'Rerwd Friedecan. PMD:,forsugyeetivm and g+riddnce;: RatlPrt Attitr, .11D:. for help ,kith the HuttaRiek.AppnfWmodet; KennsthWerner,.. PI:D: Charip.Phelp.i PhD..Janeaxahan, PR~D,' Btidger Mltchell. PhD, and Jim :rnlth, PhD, far cereful',rev/ew*;.$emedatteHer(iannln and JtnetHanle.,IFtS, for•progrartmrt'Jeg,and1 detamanagbe ment: Joyce Pelerson• PhD: for edltorial a.yta- taace; . er.d ~. Stet7lfen, 6lareus, P?iD;, and', . Se}w+m. Viaingre.n• ror th.v suppnrt,, ccmmtnte; and sdveou Ratpencaa0 li L'S. Dept ofTh`srapcrtanan:: Pntn4' Ihxctno, Pieeou Nuiorial HiFh.•q 7tisffc Suity.Admirt;r•tratfen, 19e6. :- Lu:rRRl Sth~aritxr+RU.Rm~;+.l„kanda<cioi• ta+ureA. a>mpanron of thkrre:ca,rnrmlr. corer q,teroe.; , V b*qlJXrd'187N,I`.43atf•:S'I:. Y: Leu RF..i'Antr.ew,cktnEpub7,crt'v: t.~M•an ~-r, c'ne# dernud forr cirarMtee. J, NMlxb E'rc,r 1Gaa, 3 19'1'•1tl6:, t. lrr(dtSlot.utineaJ'!hei.aarnf'Srofn:', :D.KO H•. avv.ttk. tta,Natlnr,allr',emertnr:H+altfPtuV•. ttro. 1991. ~~ CLrG.HMld,RieL:.Apprmtor Urrr. ~ta-„nnE1 At!. la,nur, Centenfor 1lc.eaee Cont rol. I tiSJ 61 Pothnnan JA: FYdn+v! T~rrlirliry..eA Y. cYishIntrton.~lx; Btrbkingt Ihetltutloa, GF777, L4uner: KE s Fbssible inereue+un the v ndrrrt . tprti.ngetelgarette eonsumqtion. J ilnr Stnl,q!.tor 197A:75JS11-3S8' S. FtfGt $p.paf R!rfirt.to /he !'S:C~np+ear un iN.coAo1 and H.nif AFnae t.he Set'vterry oF H.etftb a na Hw+Kaw S.nuet UrS Dlpt of:Heslth ,and llirnsn S~ervic0l; JSAO. 4:. UlontrltKatna o('~Aar.Ntolda,. t.millhd end yer, wEa in the llnited Statr.-1 sty1, In i('Roreuf fbh+ln. rlon lteporf., Co.Ittnur lrtcv~, Spria Pdo.' US D.ptofCammae.:BW~teuoftiit':Gtneue. tttlF', ~b: 151, pp,16SdR9. I9. \'euhwe.JP: AAe.IRnfaraheallh'iinauranreax perimeat l.Qtriry 197k t 1 b27. 14. Brook RH, Wer.JE;.Dwlee.A-erv A. eU all Owrvleref.dult health ata8aa rnaanursa nblded in RA1:Db: Heaith Ineuranre Study. Med Cere 1l7a;17tetlp}t) -1,1I1: 12.. Px1tt DN"Qash benefn. der'short=ternt':pok- txns: 2liirtl-6ce year. af data; . i 6i&&l8ei. Soc Se. eur 8ru ttt86:6b4& 13, MIarntM111G: Rne:G; Ship4v W; Rt .1 Alcohol andmorWttl•: Au-aEap.d: curve.. L,rnrst 1aell. 1:6witeB: id!,Dy-ar AR, StlmterJ, Pe4liLn, et al; Alcoholl eonawmpUan.and 1T-year martalitr iattht'Chic.go liesttm Elattrnc Company, rtudy. Med tt>HO e:.bso:. 13: tGr.Nty'AL, Fnedtnan,GD. 8le«laub ABr AI• enitJand fieRafits-'A' t.n•yearr xaiser.Mnns~l- •ntsenperttmn. Axrnlrtts+xMtdlEIRla+EaBD 11;: 10. Harw'c.ut HJj Nsqollta.ro t)M. taiatfaneen P L, etel: Eronomu Coau to'Sorwty rdAlcnkof and D,~x+4A5r+.a>d~M/enfellt/nea Reesat•ch~TotanglaPark, 1G: Reanrch 24irtgie direktrbR 19+51. 17; EheprrdlDS,,Laekbaueer RJ: Sut+ri+ali~onua' aoneumyli0[t:Ata+tapantaxMSci 1ata4~3D:a2S.~2B: 1S: Rovrard ~RA~: .Late nyt death dsdpon ~sxulywa, . Irr-Proreedf%VSetiro.4 Lw.race Strnr;wtiuet en SYMeew,ard Lhrintm A+tdfyeit Bak'elcy, Utif. .r,nuv of~Ctl/fonnie Praea: ,1978. ID'- 7}.r. Hmltk CowaeqrmcwqIl~tetr~mr'• S++nl:x,p. A':Slyers to tke SLryMn Gcne+vl (,rC. Dapt ef Hwl th and Hmnan Seyteet,14a6: 20. TNe Thr BrrWa on Tb6ecco: W.asbltlgtaR, DC.. Tott.edo f ludiute,lai;: Si: fMDIiC Ret.rane,t Fnrot' Alenroi 8a.rayett wsair;n",tx, DiaiAed aplrttsCowtei:l at theUnited Butes,1fl6a:. E4: Wamer RE: SatHep S.r,ohu Cipnac Adt~- etli r<p and Pahtk /l/a1tA'. Waehingtan, DC, Ameri- ean PublicHqlth Aaaeclatlen.:19N1:.. 27. Ce.ntl:)t; Coetk D: Grosem.n lf: The eff.ets of gwarnmmt regttlation an teenagp amolMg: I Laur'Eran 1aS1;Le:o166l0. 24. R'qreernxanJ: Ercl.. 1Yases. ILpnlation: aad tAe Dernawd Jor Ct'poretto. publteat I on p-744R-RG : Senra I:vnics. CaH: The RASh'D Corpcraslon; i48d 26: Rareaer,r- A eontnbution t,o the Wxeorr oftu- atian. icon.11t127~ie7-B1. 26• Ddaull Jt1. ltannfn4:L6; Htokman J K: Culyahil- rtT and aoeoentatifl tv ,of:heepitalltad . ixtj ured alra hol iimtwlred'dn.ren: A' pro.pectl,v study. lA?fA t4Ge252ae110.1963 21, TbCer'&1: lssues'!n t.he twt.ton of c'q' arKtee. in - lAe ClyanrtlEtcire ftis:. Cambriqa, M4t, Hrrvsrd U hh,vrsitv Pru.; .19015, pt., 664.. 29. P.oek 95t: Mauurement o( taa'progreesivity A't,ptuation. Pu81u ft r>ente Q 1t193:11 L lt>tLl @ft• !9. . HarrisJE~ Im~reaain;,thn fHtenl ~eacrae u.:an ~ agaretus. 17JKLUr Caun 19g2tLi 17. i2ti.. JA':NA~ 11ar;pt 17' 19dB.-1k-M~251..td0~ 111 S^ TaK-NrennrnJeliet Sao9