Talk is cheap: do smokers really want to quit?

Should the NHS bribe people into leading healthy lives? Should there be cash incentives paid out when people eat less junk food, quit smoking, drink less alcohol etc? In a BBC News Channel debate with Mark Littlewood, LSE health economist Zack Cooper rejected the charge that there was anything patronising about these proposals. He quoted survey evidence showing that the vast majority of smokers want to quit, but very few do it. So, far from forcing other people’s preferences upon them, this was merely helping them to act in accordance with their own preferences.

The mismatch between what smokers say in surveys and what they do in practice is a classic example of the difference between “stated preferences” and “revealed preferences“. Social engineers love stated preferences. Opponents of big supermarkets, too, always have a survey at hand, indicating that the vast majority of residents in their areas would never set foot in a discounter. But once it is there, it flourishes.

There is nothing schizophrenic about this behaviour. When asked whether you would shop in a big supermarket in your area, of course you respond something like “No! Small, local shops are much more charming and personal” – because that is the socially acceptable thing to say. When you smoke, saying that you want to quit makes you at least a repentant sinner.

Evidence for this effect can be derived by comparing expenditure surveys to national accounts. For most goods, the two show broadly the same pattern: with small errors, what people profess to buy grosses up to what is really being sold in the country. But tobacco is a big exception. Less then half of the recorded cigarette purchases shows up in the Living Cost and Food Survey. In the US equivalent, the ratio is not even 40%.

So whatever the arguments for healthy-living bribes may be, people’s “preferences” cannot be counted among them.

I’m not sure we need to argue about whether or not these proposals are patronising or not – that’s a subjective matter anyway. The real crux of the issue here is the absurd condition we find – government effectively subsidises people to smoke by socialising the healthcare costs of their doing so, then subsidises them not to smoke in this way. This is a typical government process – intervene then intervene further to correct the problems arising from the original intervention! Surely a better system would be insurance – private insurers already incentivise healthier lifestyles by adjusting premiums. This is just another indicator of the many failures of the NHS.

@Whig – does the government really subsidise smokers when they pay so much in tobacco duty? They also die younger, thus reducing the burden on the NHS, state pensions, social care and so on.

In general I would agree with the sentiments expressed here, but isn’t there one important point being missed? Speaking as an ex-smoker who tried several times to give up before managing it (no money changed hands!), I am all too aware that smoking is addictive and this means that we cannot say that people behave with the same level of rationality as with their choice of shop. It might, therefore, be rational to provide them with incentives in a way that one wouldn’t with other goods.

@Richard – 2 points. 1) I believe that 20% of cigarettes smoked in this country aren’t paid for here. Further, is it an accurate assessment that the costs of healthcare for smokers is outweighed by the amount that they feed into the treasury and that the costs of their healthcare is outweighed by their dying early? If your belief is correct, that would seem to provide a rationale for the government to encourage smoking, in the perverse world of intervention?
2) Such a condition, whatever it is, hardly justifies the deadweight and bureaucratic inefficiencies and costs of all that duty, customs, healthcare etc rather than just allowing people to choose themselves with a sensible set of…

…incentives. Unless you advocate the current NHS and the sort of problems (like this intervention) which it creates?

I should clarify: like von Mises I argue that bureaucratic behaviour and its consequences like Kris outlines is actually quite logical and justifiable if we accept the system as it is, despite the instinct to deride it as perverse. There’s little point attacking the results of the system, and often they are logical responses, or have a degree of logic. What needs to be attacked and abolished is the system itself – the symptoms are symptomatic of the disease. There’s little point merely treating the symptoms without a proper cure, to use a medical analogy.

@Peter – but people never choose anything based on pure rationality, be it their choice of shop or brand of cigarette or chocolate. The logical outcome of your argument is that we (ie government) ought to be able to decide ‘how much’ rationality individuals are making choices with in all instances, then correct each choice by supplying them with the correct level of information to make a ‘rational’ choice (obviously to do so we need to remember that we’re taxing and subsidising smokers or drivers and thus interfering with their rationality)! Clearly this is manifestly absurd, not to mention impossible as we can’t make such an assessment. So why is smoking different?

The 70% “I want to quit smoking” is frankly a push poll. Action On Smoking and Health (ASH) ask the question “Do you want to stop smoking?” 77% answer yes.However if you ask the question “Do you want to stop smoking within one month?” This figure drops to 5%.

@WhigIt is now getting to the point now where smokers are being refused treatment by the NHS. I have done some figures and what I have paid in cigarette taxes, income tax and NI (specifically the portion that goes to the NHS) over the last 32 years (I am 50) and you take away what I have cost the NHS including my 2 children I make a handsome profit of £150,000. So I would be delighted to have a refund and go private. Also the government should be obliged to sell me my cigarettes at manufacturing and marketing price (£1.50 versus £6.40) and we will all be happy.

Smokers on average die 7 years younger than non smokers at an average age for the combined sexes at 73.5. So we avoid costly nursing home bills for conditions such as dementia and alzheimers. The Dutch Public Health Ministry published this paper and we are 21.43% cheaper to treat over our lifetimes.“That’s according to the Netherlands’ National Institute for Public Health and Environment, which found that while “a person of normal weight costs on average £210,000 over their lifetime”, a smoker clocks up just £165,000 and the obese run up an average £187,000 bill.”http://www.theregister.co.uk/2008/02/05/healthy_tax_burden/

@DaveAtherton – thanks for the numbers and for subsidising us all. If the Dutch stats are correct the government is doing a fair job of redistributing from those who smoke (who are often poor) to those who don’t (who are often from more wealthy groups). But my point that the government is at the same time encouraging us and discouraging us from smoking still stands, whether the final result is one way or another. The problem is not merely the injustices of the final result but also the huge deadweight costs of all those transfers to and from smokers. Thus the whole sham is simply an argument for doing away with free-at-delivery healtcare systems and the absurdities and losses they cause.

Whig, smoking is different because it is addictive and harmful. The issue for those who purport to be rational is to ask why would someone rationally choose to do it. On the other hand, we might use the case of addiction to question the manner in which we use the concept of rationality as the basis for choice.My starting point for any argument is personal responsibility for one’s actions rather than focusing on rights or the mechanics of choice. I have no wish to ban smoking – other than in my own house, of course -merely to ask why would anyone rationally want to do it. Surely that is the question we should ask?

The cost of treating smokers one could argue that effectiviely we cost nothing in real terms looking at the figures above. However ASH quote the figure of £2.7 billion. The revenue obtained from tobacco taxes are £9.66 billion. Also we need to factor in the 7 years early mortality of smokers and save about £0.5 billion in old age pensions. The tobacco industry employs directly and indirectly 80,000 people who contribute income tax, NI etc. For an investment of £2.7 billion the government receives on my figures £20 billion. 1. http://www.ecancermedicalscience.com/news-insider-news.asp?itemId=3112. http://www.hmrc.gov.uk/stats/tax_receipts/table1-2.pdf

@Whig
That’s true, of course, and I’ve covered this more fundamental question before: http://blog.iea.org.uk/?p=269
But given that the NHS is here, and won’t go away soon: I still don’t think that every paternalistic act can be justified even within the present system.

@Peter
Agreed. I gave up smoking long ago and found it awfully hard, even though I hadn’t smoked for very long.
I’m all in favour of voluntary paternalism from competing, private paternalists. Essentially, it’s about changing the payoff structure that Zack Cooper describes: the cost of quitting are now, the benefits are in the future. So one somehow has to rearrange the intertemporal order. What I did, back then, was to give a banknote to a friend and tell him: If you see me smoking once, keep it. So I created a different choice environment for myself.
What I don’t want is the government using coercively raised funds, spend them in unaccountable ways, and with no discovery process.

@Peter – that just illustrates the folly of using rationality as the basis for choice. Use subjective utility like the Austrians. There are plenty of things around that are harmful and addictive to varying degrees and irrational but people still choose them. My point is, why ought the government have control over what we choose to put into our bodies – if I don’t have control over my body, aren’t I a slave? Such nannying behaviour as incentivising us not to smoke (or eat too much salt or take care crossing the road) is none of the government’s concern except that by intervention they have made it a problem.
@Kris – fair enough, although it seems futile to me!

Kris, in my case it wanting to marry someone who was an ardent anti-smoker! I agree entirely with your last sentence. My point, which relates to Whig’s last comment too, is about the limits of rationality. If rationality ought not to underpin choice what should? This is pertinent because it is a version of rationality that underpins a lot of libertarian economic arguments. So, on a more abstract level, why do no more libertarians argue on the basis of personal responsibility and self-constraints?

@Peter – I’m not sure I exactly get what you’re driving at? If you’re referring to some sort of ‘perfect markets’ theory, those kind of approaches are open to exploitation by interventionists and aren’t really libertarian at all. I don’t believe rationality underpins choice – choice is determined by subjective utility (or ought to be) which may or may not be ‘rational’ however one defines that, but it presents a far better argument for liberty.
Personal responsibility is always key to libertarians, but one constantly hears statists put forward the idea that there will always be those who abuse responsibility, which of course blurs the clear distinction between anarchy and libertarianism.

Peter – smoking (despite its addictive nature) is similar to many other activities: pleasure is instant and problems long term and may be profound (eating cream cakes, getting into debt, casual sex…). Some of these also lead to early death. Some people are also over-cautious (save too much, never take risks and so on). There is really no other way than allowing people to take the consequences of their own actions – something which government intervention tends to undermine. Also, we should consider whether restraints on contracting prevent voluntary paternalism. If I set up a business to take money from lots of people as a deposit which they lose if they smoke – is that enforceable?

Whig, we might be talking at cross purposes because I certainly agree with what you say about subjectivity. Personal responsibility may well be key to most libertarians as you say, but the problem, for me at least, is that a lot of libertarian argument is framed in terms of freedom from proscription, when it ought be based on self-prescription.Philip, smoking is only similar to other good before you start smoking, and this is where free choice can be properly applied as you state. I’m not sure the same applies once one is addicted. Do you know Jon Elster’s work on addiction and rationality?

Chaps the jury is out as to whether smoking is an addiction or a habit. There are some people who are affected by nicotine more than others. My evidence is two papers, the first is from Professor Martin Jarvis of ASH.”Hardcore smoking defined by four criteria (less than a day without cigarettes in the past five years; no attempt to quit in the past year; no desire to quit; no intention to quit), all of which had to be satisfied. Results Some 16% of all smokers were categorised as hardcore.” That is me. So that seems to suggest that 84% of smokers range from a casual take basis or leave it smokers to regular as opposed to habitual. The URL is from the BMJ.http://tiny.cc/li9f2

This Israeli study suggets it is a habit. “Surprising New Study Shows Cigarette Cravings Result from Habit, Not Addiction.In the new study published in the Journal of Abnormal Psychology, Dr. Reuven Dar of Tel Aviv University’s Department of Psychology found that the intensity of cravings for cigarettes had more to do with the psychosocial element of smoking than with the physiological effects of nicotine as an addictive chemical.“These findings might not be popular with advocates of the nicotine addiction theory, because they undermine the physiological role of nicotine and emphasize mind over matter when it comes to smoking,” Dr. Dar says.”http://www.sciencedaily.com/releases/2010/07/100713144920.htm?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed:+sciencedaily+(ScienceDaily:+Latest+Science+News

@Peter – yes, but as libertarians are advocating freedom from (government) prescription or proscription as a necessary precursor to self-proscription or prescription, they are then hardly like to start telling people what they should and shouldn’t do once they have such freedom. As such free choice is absent in the status quo I think that’s quite reasonable.
Of course, we could posit ways in which such self-proscription could be encouraged (avoiding government action in doing the encouraging, I’d not a ‘nudger’), and I agree that personal responsibility is key, but the necessary first criterion is that government stands aside and allows free choice.

Whig, I take your point. But just as it is only a smoker who can decide to give up – it must, as it were come from inside – the same ought to apply generally. We can’t surely wait for government to move first.On the debate between smoking being an addiction and a habit, where does the compulsion come from? I am in the habit of reading the daily Telegraph and keeping up with the IEA blogs – but I wouldn’t if I knew it would kill me and I would be quite certain I could stop. Smoking is still different if one can’t kick the habit.

@Peter – I wholeheartedly agree. But we have to get government to move out of the way first. The ‘big society’ or whatever one terms it will never flourish until government crowding out or prohibitions are removed.
The fact that one can’t determine whether it’s a habit or an addiction (which really is the difference between mental and physical addiction) and at what point it becomes so points to the individual nature of such issues – it is a clear sign that procrustean government efforts will prove ineffective and the right incentives are not being applied anyway (because we are at once rewarding and punishing smokers). Individual will is crowded out in such circumstances.

Whig, its a bit of a chicken and egg situation, isn’t it? How do we get government to back off? Can it only be done by government?

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