Sin tax bill: According to the eye of the health secretary

This is the message of Secretary Enrique T. Ona during the senate committee on ways and means hearing on the excise tax reform bill for tobacco and alcohol products or sin tax bill.

As your Secretary of Health, it has been my honor and privilege to be given this opportunity of overseeing the health of our country, in much the same manner that your honors craft enlightened laws that will help us fulfill that goal. In this role, conflicting interests sometimes intersect our responsibilities as I’m sure it will, today, as we look at the effect of smoking and drinking alcohol on health, economics, jobs, the greater public good and ultimately on life and death.

My 50 years of medical practice, both in the private and public sector has exposed me to occasionally delve in the innermost strengths, but also on the weaknesses and frailties of us, human beings. I say this because smoking is admittedly a comforting habit. It relaxes us and as every smoker claims, it allows him to think better. It is essentially, however, more than just a habituation. It is an addiction and it almost always leads to early deaths! And we know that today, in our country, smoking starts when one is still young! And so thus drinking! And moreover smoking is highest among our poor men and women.

Admittedly this is a (sin tax) bill that will affect the immediate comfort of smokers and their pockets; will affect some farmers, some manufacturers, maybe some of us here today.

Let me just show you a few slides detailing where I am coming from, why I believe that regardless of where we come from or where we are looking from, this is a bill that needs to be passed for a healthier nation, a longer life expectancy for many people and a chance to rapidly modernize our health system – meaning our public health interventions and our hospital system.

Although I will leave the discussion of the economics of this bill to Secretary Purisima, let me articulate its health implications.

The Constitution, legislation passed by Congress such as the Clean Air Act of 1999 (RA 8749) and the Tobacco Regulation Act of 2003 (RA 9211) as well as the Framework Convention on Tobacco Control (FCTC), an international treaty passed by the Philippine Senate in 2005, recognizes the need to protect and promote the health of our people.

A large study by Omran et al in the 1970’s predicted that communicable diseases or infectious diseases will go down with time due to improvements in medical technology: vaccination, newer drugs, sanitation, and others. However, non-communicable diseases or lifestyle diseases will surge as a function of urbanization, globalization and other harmful habits. And thus, adapting to the change in environment is key to a good health care system.

We now know that tobacco use is a risk factor for six of the eight leading causes of preventable deaths in the world. What is disturbing is that these diseases are predominantly present in low to middle income countries. In the Philippines, the top 4 killers of mortality are the following: ischemic heart disease or “atake sa puso”, cerebrovascular disease or “stroke”, chronic obstructive pulmonary disease such as emphysema and bronchitis and cancer of the lungs, bronchus, trachea or windpipe, and gastrointestinal tract or “bituka”.

It is alarming that the Philippines is now the number 1 smoking country in Southeast Asia. The next slide will show you a comparison of the smoking rates of the countries in Southeast Asia.

Three studies from the World Health Organization show that in our country, every Filipino smoker consumes 1,073 sticks every year, the highest in Southeast Asia. And we have one of the lowest prices in cigarette and cigarette taxes.

What is just as disturbing is the high prevalence of smoking among young Filipino girls and boys. Of tobacco users in the Philippines, 17.5% are girls and 28.3% are boys aged 13-15 years. This is the highest in Southeast Asia. Consequently, early smoking will lead to earlier onset of smoking related non-communicable diseases.

The second thing I want to emphasize is that the poor suffer the most deaths from non communicable diseases. Based on the Lancet article of Dr. Dans in 2011, the poorest quintile or the lowest 20% of the population (represented by the red bar) smoke more than the richer quintiles or upper 20%. This makes them more vulnerable to smoking related non-communicable diseases.

Additionally, smoking does not just cause cancer and lung diseases, it is also the number 1 cause of stroke and heart attack (about 50,000 deaths per year). In fact it causes more stroke and heart attack than diabetes, hypertension, obesity and high cholesterol. This is based on the National Nutrition and Heart Survey, 2008.

Today, the total annual cost of the four leading smoking-related disease: lung cancer, chronic obstructive pulmonary disease (emphysema), coronary artery disease and cardiovascular disease is a staggering P 177 billion. Yet, this amount is still an underestimation, considering that there are 39 other diseases related to smoking.

What have other countries done? 

From 1991 to 2007, Thailand, a country with similar economic level as ours, increased the tax rate on tobacco in a series of eight steps, which increased the retail price of the most popular brand by nearly 400% and nearly tripled Thailand’s annual tobacco tax revenues. The increase in cigarette excise taxes was more rapid than the inflation rate, decreasing the relative affordability of cigarettes. Adult smoking rates have decreased from 30% in 1992 to 18% in 2007, a period of 17 years. This gradual decrease in smoking rates proves that the increase in tobacco excise tax will not kill the industry. What is significant is the number of lives saved: It is estimated that in 2006, there were 31,867 fewer smoking attributable deaths that resulted from this policy. It is projected that a total of 319,456 fewer deaths will result by 2026.

This (sin tax)bill, despite its higher taxes will not kill the tobacco industry, much less the alcohol or spirit industry, as shown in the Thailand experience. Every cent removed from this bill is a life placed in jeopardy and lesser funds for the healthcare of our people.

Using a simulation model predicting the fiscal and public health impact of a change in cigarette taxes, we can see here that in a period of 10 years, a higher increase in excise tax will result to a larger number of deaths averted and lesser smoking prevalence – translating to more lives saved.

On the other hand, the effects of alcohol are dose related. Intake of more than 40 grams per day in men (3 bottles of beer, or 2 glasses of wine or 1-2 shots of distilled spirits) and more than 20 grams per day in women is a risk factor for diseases such as liver cirrhosis, dilated cardiomyopathy, neurological and psychiatric disorders.

There is therefore moderate drinking but there is no such thing as moderate smoking. Smoking causes early deaths, regardless of consumption. Moderate drinking, on the other hand, can actually decrease one’s risk of dying.

I will end my presentation with these following slides, which best highlights why we must pass this reform bill.

This is a ward in the Philippine Orthopedic Center, supposedly our specialty center for bone and joint diseases. Note the rusting beds and IV poles, the use of balkan frames, the overcrowding of patients.

This is a shot taken at the Fabella maternity hospital. Two or three babies have to make do with one bassinet. Indeed we now have plans to modernize these facilities.

To reiterate, House Bill 5727 and Senate Bill 3249 are both health bills that will:

• Insure the financial sustainability of our program of universal health care for all the years to come
• Pay for the premium of the poorest and poor segment of our population – the 10.5 million families listed in the NHTS
• Fund the immediate upgrading and modernization of all our government hospitals and other health facilities
• Allow us to hire the needed number of doctors, nurses, dentists, and other health workers such as our thousand of barangay health workers who have toiled as volunteers through all these years.
• End the perennial practice of our poor people running to our legislators for your PDAF assistance whenever they contract a major illness
• Fund the expansion of all our immunization program
• And allow us to finally eradicate malaria, rabies, schistosomiasis, and other public health diseases as what other countries around us have done

Honorable Senators, as Secretary of Health, I wholeheartedly thank you for the two years that you have supported our DOH budget to a level never in our memory was ever reached. Never have we ever had a President who has clearly articulated his commitment to improve the health of our people, and identifying precisely how and where the funds will come from. Today I ask you to help finally seal that financial gap that has kept us from giving all our people the kind of healthcare we all aspire for and dream of. This is also what our good President, President Benigno S. Aquino III aspires for our country.

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