Cigarette Makers’ Never-Ending War : Federal rule related to secondhand smoke is blocked

The thick cloud of lobbying and subterfuge around a federal decision on secondhand smoke earlier this summer has left behind a strong odor. Indeed, the smell is so bad it should compel quick completion of a federal review of the complicated coding scheme that the government requires for payment of Medicare and Medicaid claims, including for tobacco-related ailments.

Central is whether cigarette smoke can cause cancer in nonsmokers, a question with huge implications for cigarette makers. The threat to that industry takes a seemingly innocuous form: a request by the White House Office of Management and Budget (OMB) for a bit more information from physicians on the possible causes of patients’ illnesses. The makers have temporarily blocked collection of data pertaining to secondhand smoke, much as they have deflected efforts to tighten controls on cigarette manufacture and sale.

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SYMPTOM CODING: At issue is a highly technical and bureaucratic requirement. All hospitals and doctors use a set of federal injury and illness codes when filing claims for reimbursement under Medicare, Medicaid and other insurance plans. Health care researchers and government officials use the coded data to track injury trends and design preventive measures. The codes--the International Classification of Diseases, 9th Revision, Clinical Manifestation--allow physicians to assign numbers to distinct symptoms, injuries, illnesses and medical treatments. One section pertains to external causes of injuries, including environmental causes.

Early last year, in an annual review of the coding system, experts from two federal health care agencies decided to include a new E-code, or external cause code, for secondhand smoke. Physicians are not required to fill out E-codes and many do not. Nor are they required to prove that the external cause they coded contributed to a patient’s problem; rather they are simply asked for a medical judgment. Nevertheless, the panel’s adoption of E-code 869.4, the secondhand smoke item, was a small bombshell in the growing controversy over scientific consensus that secondhand smoke can cause cancer and heart disease. That consensus was bolstered by the Environmental Protection Agency’s 1993 report concluding that secondhand smoke causes lung cancer in nonsmokers.

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LOBBYING ATTACK: The new E-code went into effect in October, 1994, permitting physicians to indicate whether they suspected secondhand smoke in an illness. But adoption of the code, asking for one bit of data amid a sea of federal reporting requirements, frightened the cigarette makers, which apparently fear even a little more knowledge on the risks of tobacco. The industry took immediate action by retaining Multinational Business Services (MBS), a Washington lobbying group. In meetings and correspondence with federal health officials, MBS argued that the code would generate unreliable data because chronic illnesses have many possible causes. To the OMB, the lobbyists argued that the agency was required by the Paperwork Reduction Act to review the data on all federal forms for “practical utility” and that such a review was overdue. MBS snowed the agency with studies and reports about the dangers of inaccurate statistics.

The pressure worked, as it has so often when cigarette profits are at stake. In late June, the OMB directed the Department of Health and Human Services to bar use of all codes adopted since 1994 pending a study of their practical utility. Curiously, the only code affected--and thus suspended--was 869.4, on secondhand smoke. Subsequently, OMB also ordered a review of all E-codes adopted before 1994, but they were not suspended.

Only prompt reinstatement of E-code 869.4, along with the other E-codes, will preserve integrity of the agencies involved.