by Ed Straw

Governments can be quite sophisticated in the thinking. They can also suffer from tunnel vision or, if not a tunnel, then a deep gorge. The tendency is to take a problem, analyze how to reduce it, and focus hard on its solution. In many circumstances, focus is what is needed to deliver change, but only when the analysis has looked at the wider landscape. What is over the other side of the ridge? If we do this, what are the knock-on effects? From a system wide perspective, this paper examines the widely supported, applied, and successful policy to reduce smoking. It finds a policy based on an insufficient grasp of the human condition, with five factors contributing to its limitations.

Smoking is undoubtedly bad for us. Many have thankfully and successfully given up for good. But, would you rather be fat or smoke? It seems that this might be the choice for some. How so?

Here is a table of smokers and the obese using accessible data for adults (16+) in England, 1993 to 2012

All data sourced from Health Survey for England – 2012, Trend Tables: Population number estimates tables: http://www.hscic.gov.uk/catalogue/PUB13219/HSE2012-Pop-no-est-tbls.xls Accessed 7th August 2014 Ed Devlin/ Ed Straw www.treatyforgovernment.com

Whilst many have given up smoking, in the last 40 years the “pandemic” of obesity has gone the other way. From 1997 to 2012 the number of smokers decreased by 29% whilst the number of the obese increased by 34%. The absolute numbers of smokers quitting and the obese arriving over this period are not the same, but the point is made. The top line is the combined number of smokers and the obese, which shows remarkable consistency from 1995 onwards. Some double counting is certain here in that some are both obese and smoke, but these numbers are thought to be small and not material to the broad point of this paper.

Obesity has similar morbidity, health costs, and productivity costs to smoking:

“In both the US and UK, the rise in obesity is expected to be associated with an extra 6 to 8.5 million cases of diabetes, 5.7 to 7.3 million cases of heart disease and stroke, and between 492,000 and 669,000 additional cases of cancer. In addition, the increasing prevalence of debilitating disorders such as osteoarthritis would affect the duration of the person’s healthy lifespan.

“Medical costs associated with treatment of these chronic diseases are estimated to increase by £1.9-2 billion per year in the UK by 2030. Regarding economic effects of lost work productivity, the researchers say that the shortage of consistent and high-quality data prevents comparisons between countries. However, using estimates from the US 2008 National Health and Wellness study they estimated that by 2030 there would be a loss of 1.7 – 3 million productive person-years among working-age US adults. This would be associated with an economic cost as high as $390–580 billion.

“Unlike other major causes of preventable death and disability, such as tobacco use, injuries, and infectious diseases, there are no exemplar populations in which the obesity epidemic has been reversed by public health measures.

“The degree of political difficulty for implementation of policy and regulatory interventions is typically much higher than that for programme-based and education-based intervention. Reasons for this reluctance to enact affordable and cost-effective policies include the powerful lobby force of the food (and allied) industries against government regulation of the food market, and public reluctance to change environments to which they have become accustomed (such as car access and cheap parking in cities, and high fat and sugar food choices in canteens). Nevertheless, the experience with trans-fatty acids in Denmark, where legislation was introduced to restrict their use in food production, is an example of a cost-effective government food policy that was successfully enacted for population health benefit.”
The global obesity pandemic: shaped by global drivers and local environments The Lancet, Volume 378, Issue 9793, 27 August 2011

Much hand wringing here and an unwritten policy presumption that the behaviour of a population should be controlled, in this case to limit self-harm. It is almost a perfect media story too, as it contains fear plus outrage: an almost alien growth of fat enveloping the world. The story has legs too: it will still be running when most of today’s editors have retired. And of course, why isn’t the government doing more.

But, let’s stand back and think. Smoking is addictive. The “foods” causing obesity are also addictive: refined sugars and fats. Smoking is a pleasure, and nicotine temporarily increases levels of dopamine, the ‘happy hormone’. Eating is a pleasure. Both are drugs of solace – smoking at times of stress, and food for comfort eating. People were dissuaded from smoking by the health consequences. But the causes in terms of the need for some solace or support were never addressed. Along comes addictive “food” marketed as hard as tobacco ever was, as the best alternative crutch.

The correlation and the underlying rationale for postulating that to some degree obesity has substituted for smoking is there. It is certainly an hypothesis. In The Super Size of America: An Economics Estimation of Body Mass Index and Obesity in Adults (National Bureau of Economic Research Working Paper No. 11584, 2011), the authors conclude that the rapid increase in obesity in the 1980s is partly an “unintended consequence of the campaign to reduce smoking.” But the relationship has not been properly tested, so remains just that until it is. If it is proven the point will be that a singular objective has been pursued by governments, medical specialists, and individuals with considerable success, but because it ignored the significant underlying cause – the emotional consequences of low self-esteem and stress – the society-wide results have been largely similar in mortality, morbidity, health costs and productivity.

Referred to in the Lancet research as the most comprehensive in the world, the Foresight systems model of the causes of obesity does include self-esteem and emotional reinforcers. Smoking does not appear to have had the same quality of analysis when its “solution” was in the tunnel many years ago. Similar limitations could lead to the provocative counterfactual that individuals and society would be better off “solving” obesity by persuading people to take up smoking.

Some effective government action is possible for obesity itself. The addictive qualities of fats and sugars could be taxed to the same extent as are those of tobacco. An apple should be cheaper than its calorific equivalent provided by addictive foodstuffs. Pricing has some affect. There is no point in allowing harmful rubbish to be sold so cheaply.

Welfare benefits are used to buy addictive foods for babies and children, starting them early on the escalator to obesity. This is one of the strangest uses of public expenditure. Government is funding obesity. What would be the advantages and disadvantages of conditional benefits in the form of vouchers, that could only be redeemable for healthy food? It feels uncomfortable, but far less than the discomfort the to-be-obese child will suffer.

But governments are often impotent in matters of human behaviour. Education, education, and education is the best they can do. As with recreational drugs and young people, the most effective strategy is to ensure the effects of each drug are well known. Prohibition does not work. Nor does the war on drugs. Adding addictive foods to the class A banned drugs list and making their possession a criminal offence with punishments up to X years in prison would be a consistent policy for harmful substances. But it also raises the question as to whether and how policy should seek to control behaviour.

In the way public policy debate is framed in some countries, human vices are not allowed. The widespread pretence, even in our own heads, is that we should live by some higher calling or superior morality, which excludes vice. Thus, anything that alters our consciousness such as alcohol or cannabis or magic mushrooms, or potentially damages our health is wrong. These are bad things, to be avoided, banned, government must act now.

But, in an otherwise hard and unfulfilling life, in a low paid job and poor housing, with a lost or stressed family life, the only pleasure for some is alcohol, cigarettes, and recreational drugs. The consumer is quite aware that alcohol and cigarettes are “bad” for him or her, but consumes nevertheless as the better option. Their choice is to have some enjoyment in a shorter life or little in a longer one. A no-brainer surely. Is that the “wrong” choice? Who am I to make that judgement? Is it a judgement for government? The anti-smoking policy has been making it for many years.

An alternative basis for policy decisions is to accept that humans do have vices, as in “what’s your poison?” and to enjoy them. For all of history, humans have sought out so-called “mind-altering” substances precisely to alter their minds. Is this a “vice” or a fact of the human condition? We know that flying, driving, most eating, drinking other than water, sleep shortage, sitting, watching television, and fossil fuelled heating are all bad for us. Indeed, I have never come across anyone who is not doing something bad for her or him. Our society is not so upright as to possess any authority to demand that personal behaviour should be “vice” free. Educate, persuade, offer, prevent the wild excesses of capitalism, and do not dole out money for negative consequences. Do what you can. Otherwise accept a “flawed” society. All societies use stimulants. Perhaps this universal human tradition should be acknowledged.

A more general word on policies aimed at stopping people dying, a policy pursued by governments keen on life saving. Whilst understandable, the war on dying may be as useful as the war on drugs and the war on terror, and as costly and destructive.

Everyone dies. Some die before they want to. In the modern world, many linger on for a slow and miserable decline and would prefer to die more quickly. The purpose of living is not, not to die, as some policy makers seem to believe. We are all trying to navigate life by finding a balance between what is good for us and what we enjoy, between prevention and cure, between duty and freedom, between ecstasy and boredom, always aware that good and bad luck may be around the corner, and conscious that we will never know whether our life choices have given us a better or worse life than our neighbours.

We may also want excitement, challenge, adrenalin rushes, laughs, binges, hangovers, outrageous acts in the small hours, recklessness, risk taking, alongside our remarkable medicine and sensible safety measures. We pursue high-risk actions like crossing the road and driving a car for their convenience and pleasure. We chose childbirth, despite its death rate, for many reasons. We pursue stimulants for their stimulation. Smoking and drinking for some people may be the only pleasures they have. The narrow pursuit of not dying represents a narrow understanding of life.

In terms of lessons from the insufficient grasp of the human condition, five factors are in play. Smoking is bad for you and we all got caught up in believing it was right to reduce it and by whatever means. Groupthink, on a national scale, is the first flawed decision process here. The second is the fatal attraction of simple policies (I wonder what is the psychology of this?). The third is the psychology of the moral high ground. Some people are strongly motivated by moral superiority over others. Saving lives, especially saving people from themselves represents high moral worth. The fourth is the felt pressure by government to do something, even though it may be ineffectual. Fifthly, governments are free to take decisions in any way they want. Political pressure is the only restraint. Decisions can be made on no information, flawed analysis, prejudice, or an anecdote on the 10.47 from Pitlochry ¹

In our system of government, no disciplines exist to ensure the decision process is based on evidence, that the evidence represents real lives, the analysis is comprehensive, and the objective clear. Is the objective to save lives through stopping smoking? Or to save lives in total? If person X lives longer by stopping smoking but dies prematurely through obesity, is that a result or a waste of persuasion money? The scope here to spend and fail is considerable.