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What Should We Do?

Posted by plosmedicine on 31 Mar 2009 at 00:19 GMT

Author: J. E. R. Staddon
Position: James B. Duke Professor, emeritus
Institution: Duke University
Submitted Date: February 06, 2008
Published Date: February 7, 2008
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

This fascinating article confirms what many people have suspected (e.g., in my book The New Behaviorism (p. 89), that in terms of medical costs, smokers are cheaper than non-smokers - lower not just in lifetime but in annual costs. (It would be possible, for example, that although smokers incur only a half, say, the medical costs of non-smokers, they live only one third as long, yielding a higher cost per year. Smokers die sooner, true enough, but not enough sooner to outweigh their lesser cost.) If the cost of state pensions are factored in, the disparity is of course even greater.

What might this difference imply for government policy? The answer is far from obvious.

Several other questions must be answered first. Does lower cost (per year or per lifetime - smokers are lower in both) imply higher (Darwinian) fitness? It is possible that a short life, a larger percentage of which is productive, is correlated with higher fitness, given the
well-known fact that lifetime affects, and is strongly affected by, natural selection (e.g., Reznick et al., 1996).

What is the proper role of government: is it collective - acting for the best interests of the community as a whole? Or should it be concerned with individual well being, even if that conflicts with collective good? More generally, should government only do for people what
they cannot do for themselves, as libertarians contend, or does it have broader obligations?

In our secular society, utilitarian considerations, the greatest good for the greatest number, usually carry the most persuasive weight. A utilitarian argument aimed at maximizing the collective good would say that since smokers cost society less than non-smokers, smoking
should be if not encouraged at least not discouraged. The Darwinian-fitness hypothesis leads to the same conclusion.

But what about the individual suffering that smoking causes? Here the conclusion is not at all clear. We all die and dying, whether smoking-induced or not, is rarely pleasant. A policy-maker urging abolition of smoking would therefore have to make the argument that a
smoking-induced death is more unpleasant than death via other causes. Perhaps - but against this must be balanced the pleasure that smokers derive from their habit. And smoking, unlike drinking alcohol, never leads to violence or death by automobile. So immediate harm to others (I discount the conjectural small, and avoidable, risk of passive smoke) is not available as a backup argument.

What seems to be left to anti-smoking advocates are two possibilities: a belief that longevity is an absolute good, or a taboo against smoking. So, is old age always a virtue? Not according to Jonathan Swift, who writes of the Methuselah-like Struldbruggs, eternally enfeebled by the infirmities of age: "the Question therefore was not whether a Man would choose to be always in the Prime of Youth, attended with Prosperity and Health, but how he would pass a perpetual Life under all the usual
Disadvantages which old Age brings along with it." And should the choice between a short and happy life and a long but perhaps less-happy one be up to the individual or is the government obliged to intervene?

The remaining possibility is to enforce a moral, faith-based prohibition of smoking no more tied to utilitarian arguments than the Hindu prohibition against eating beef or the Jewish one against pork. But is the promotion of such a belief proper for the government of a secular society?

However the political process comes out, we should at least be clear that the arguments for the prohibition of smoking rest on shaky scientific foundations.

No competing interests declared.