As of roughly 5 or more years ago, half of tobacco consumed in the US is by people who are mentally ill and/or substance abusers. For example, people with Schizophrenia are heavy smokers and 90% smoke. Those with clinical depression 60%. They are self-medicating for their underlying illness. We need to ensure that they are getting proper treatment.

Income Disparities in Absolute Cardiovascular Risk and Cardiovascular Risk Factors in the United States, 1999-2014 https://www.ncbi.nlm.nih.gov/pubmed/28593301

This study shows that in the 15 years studied, only the smoking rate of high income individuals has decreased from 14% to about 9%. Those at the poverty level or below has remained about 36.5% who are smokers (some of those will be the mentally ill and/or substance abusers) and middle income is about 24% who are smokers.

Former NYC Mayor Mike Bloomberg with his latest donation of $360 million in December, now donated a total of $960 billion to combat tobacco in low- and middle-income countries (e.g. China, Russia, Bangladesh, but also Turkey). Bill Gates added another $125 million.

The plan is to implement the World Health Organization's (WHO) MPOWER program which has been implemented in NYC since 2001. Raising the cost of tobacco has over half the effect of getting people to quit or never start. Also very important is banning smoking in public places and hard-hitting, scary, advertisements spending about $1 to $2 per capita. Clinical interventions such as doctors speaking with patients about quitting, providing nicotine replacement therapy, and telephone counseling support are also important. But most of the gains are from the public policy initiatives.

A frustration I have with the healthcare system in the US is that too little is sent on public health interventions such as MPOWER compared with the spending on clinical interventions. If you want to lower healthcare costs, ultimately more effort has to be put in public health interventions which is much more scalable and more effective than clinical interventions.

Under ObamaCare, smokers can be charged premiums 50% higher than non-smokers because the healthcare costs of smoking are so high, yet most insurance plans don't charge the premium nor does the ObamaCare let insurers really verify if someone is a non-smoker.

If you want to lower the high costs of healthcare, nationally implement MPOWER in the US as well as other public health interventions. ObamaCare made a huge mistake when they did not implement the tobacco tax policies of Canada, UK, France and other nations which have universal care which is pay for the healthcare partially with high tobacco taxes in the range $5 to $7 per pack or more. Our federal tax is about $1. Raising that of these other nations would result in tens of billions of dollars for paying for healthcare while helping people, especially the poor, to quit smoking.