We were musing the other day about how to deal with smoking, pondering matters like:
- If an applicant says he or she smokes x cigarettes a day, can you believe that?
- How do you deal with cigar and pipe smoking? Should you ask about inhaling?
- How much does size of cigar count – for example cheroot or cigarillo versus fat Romeo y Julieta?
- What about ‘rolling your own’ (possibly a mainly British working class thing)?
- And what is the equivalent in loose tobacco (for pipes and ‘roll-ups’) of a pack of 20 cigarettes?
Of course some brands of cigarette are supposed to be low-tar but stratifying risk according to brand would be ridiculous, as would differentiating tipped versus un-tipped (in our opinion).
The guidance on smoking risk in the underwriting manuals is often hazy, with guidelines like ‘up to +25’ or ‘consider rating up to +50’, especially where the form of tobacco is not cigarettes. What do you do in the real world? Which side of the fence do you come down on?
Historically cigar and pipe smokers have exhibited lower mortality than cigarette smokers, maybe because they inhale less – although there is a view that nowadays cigar and pipe users are more likely to be ex-cigarette smokers and thus more likely to inhale. But there is still an increased risk compared with non-smokers – seven to nine times for developing and dying from lung cancer and 1.5 times for total mortality.123 Even non-inhalers are at risk from oral and digestive tract cancers.
There really are many factors to take into account when evaluating the smoking risk, for example smoker/non-smoker differentials in the basic premium rate. How much smoking does the smoker or preferred smoker rate allow for? Anything in any quantity? Up to 20 or maybe 30 cigarettes a day? And if you fix a threshold beyond which the basic smoker premium rate is loaded, how do you do that fairly without verifying the tobacco consumption declared (which raises a feasibility issue)?
While it is theoretically possible to grade smokers according to cotinine levels in blood, urine or oral fluid, there is arguably a strong case for the simple approach of putting applicants into two groups: those that use tobacco or tobacco/nicotine products (including chewing tobacco, snuff – are there still snuff users out there? – and nicotine gum) and those who don’t. The basic smoker rate covers all types and heaviness of use and if there is a combination effect between tobacco and another risk factor, then there is a single, standard addition to cover it. So no spurious differentiation based on dubious, unverifiable information from the applicant and probably relatively flimsy background statistical evidence. Highly practical. Would it be fair? Fair enough under the circumstances and no less fair given the weaknesses inherent in current approaches. (And it’s worth a reminder at this point that, except for large face amounts for which specialist evidence beyond an APS and a medical is required, the Brits don’t bother with cotinine testing, taking the applicant’s word on trust.)
Now, is there a better way of dealing with alcohol risk…?
- Boffetta P, Pershagen G, Jöckel K-H, Forastiere F, Gaborieau, V, Heinrich J et al. Cigar and pipe smoking and lung cancer risk: a multicenter study from Europe. J Nat cancer Inst 1999;91(8):697-701
- Peto R, Darby S, Doll R. Smoking, smoking cessation and lung cancer in the UK since 1950: combination of national statistics with two case-control studies. Brit Med J 2000;321:323-9
- Shaper AG, Wannamethee SG, Walker M. Pipe and cigar smoking and major cardiovascular events, cancer incidence and all-cause mortality in middle-aged British men. Int J Epidemiol 2003; 32:802-8