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Rethinking our tobacco follies: life and health insurers need to take another look at tobacco-use underwriting issues.

As smoking issues heat up in the public domain--dare we observe the high-handed extent of employers not only refusing to hire smokers but also having the gall to terminate currently smoking employees--what better time than now for us to judiciously rethink our own follies in tobacco underwriting?

Let's start by finally make a distinction between "current" cigarette smoking and "pack years" of consumption.

At this writing, any applicant who has smoked two packs a day for 50 years can qualify for "preferred" solely on the basis of quitting for 12 months.

What sense does this make?

It ignores the reality that long-time smokers who finally stop are unlikely to suddenly exclaim "egad ... what a filthy habit." They quit because they don't feel quite right, a fact that should raise our antennae, not cut the premium.

In truth, our present approach looks away from the fact that most of the adversity from cigarettes equates to cumulative exposure, not current use.

Going to "pack years" means asking a modified "tobacco-use" question. And let it be said that our success in doing so will be far greater if this (and every other risk-related) question is asked by a trained teleinterviewer.

For decades, cotinine (nicotine metabolite) screening has been a reliable antidote for "smoker's amnesia." Now, a timely adjustment in this regard would be to reset our "cut-off" for a positive cotinine test.

The typical cut point defining a "positive" urine cotinine test is 0.5 micrograms per milliliter. At 0.5, we decrease the test's sensitivity, thereby missing many diehard smokers who inadvertently (or otherwise) get tested at a time when their cotinine levels are transiently below this threshold.

The fastest growing subset of cigarette smokers is those who smoke only five to 10 a day. At the same time, the percentage of heavy (greater than a pack a day) smokers is in steep decline. As these trends continue, cotinine positive rates can only further decline while the actual number of smoker applicants remains the same.

That is, unless we lower our cotinine threshold to 0.2, whereupon we would surely detect many smoking prevaricators.

Volumes of epidemiological data assure we would not include passive smokers (defined as those condemned to breathe smoke from other peoples' cigarettes) among those we would be unmasking.

That's right. Using the 0.2 cut-off could not result in even one passive smoker being falsely accused!

What say we get this done now?

As far as this underwriter is concerned, the most important issue here is to avail ourselves of cotinine confirmation tests where they are appropriate.

Let me explain ...

The test we do for cotinine is a screening test, just like the test for cocaine. However, there is an important difference in terms of how we proceed in the face of positives.

When we have a cocaine positive, we religiously confirm it with the "gold standard," known as gas chromatography with mass spectrometry (GC/MS).

Why do we always insist on GC/MS?

Because no one would think of taking adverse action in this context without being absolutely certain the results were correct.

Every underwriter has had the uncomfortable feeling that some who deny tobacco/nicotine use but nevertheless test positive for cotinine are telling the truth. This is doubly so when the rest of the evidence at hand argues for a low probability of being a smoker.

Until now, we have not perceived ourselves as having a reliable remedy for this contentious issue. Not any more. We can use the very same GC/MS test we mandate for cocaine.

The labs that serve the insurance industry have studied the prevalence of cases where the insured denies tobacco/nicotine, the screening test is positive and a negative GC/MS contradicts that screening test. While their findings differ markedly, the only logical conclusion is that there are, indeed, false positive cotinine screening tests.

That said, be assured that they are few in number.

Still, no matter what that number happens to be, each defines a scenario where the proposed insured is being truthful.

I, for one, believe we owe it to prospective customers to go the proverbial "extra mile." Thus, I heartily applaud those insurers who insist upon cotinine confirmatory testing in these uncommon situations.

Better this than giving de facto embrace to the notion of "collateral damage" where our customers are concerned.

Hank George, a Best's Review columnist, is the principal in his own consulting and training firm, Hank George Inc. He may be reached at
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Comment:Rethinking our tobacco follies: life and health insurers need to take another look at tobacco-use underwriting issues.
Author:George, Hank
Publication:Best's Review
Geographic Code:1USA
Date:Jun 1, 2006
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