Obesity spending and the long-since diminished marginal returns of anti-tobacco spending

“In our reaction to the obesity epidemic, sometimes we have taken our eye off other issues.”

There has been quite a bit of sound a fury in the popular press lately, about the supposed battle for funding between researchers and health practitioners focusing on obesity and those focusing on smoking.  The press is generally best at reporting on sporting events (people who only read the sports section and ignore the rest of the paper are often criticized as being out of touch; but perhaps they just are just aficionados of top-quality reporting).  Playing to their strength, reporters try to cover everything – elections, political struggles, environmental catastrophes, and now public health spending priorities – as if it were a football rivalry and a series of matches.

Today’s New York Times included one such report.  The report began with a fundamental flaw, focusing on how the Robert Wood Johnson Foundation had scaled back its spending on anti-smoking (really anti-tobacco – they were not on the side of effective harm reduction measures) and was moving toward anti-obesity efforts.  Even ignoring the fact that RWJF’s shift away from anti-tobacco funding occurred several years before obesity became the thing, this does not demonstrate what the reporter wanted to pretend it does.  The suggestion is that RWJF should, or does, just keep pouring money at a single issue.  But that foundation has always focused on following the judgment of smart people and swinging resources toward where they are most effective.  It is not the U.S. government or Gates and Bloomberg, who decide to own an issue and throw billions of dollars at it.  Indeed, with those bottomless pockets pursuing anti-tobacco, there is little room left for the clever contributions of the likes of RWJF.  (Disclosure: RWJF paid my salary for two years and for the costs of me becoming educated as a public health expert.)

The quotation at the top of the page is from Terry Pechacek of the U.S. CDC, one of the most hard-core drug warrior types in the anti-tobacco industry.  In fairness, that statement may have not sounded quite so ridiculous in context rather than as a soundbite in the aforementioned NYT article.  But it is hard to see how any context could make it other than incredibly ironic.  The Big Anti-Tobacco Money guy worrying about one over-emphasized issue taking away attention from other issues?  That was not even the most absurd quote.  Steve Schroeder, who ran RWJF during its anti-smoking days (the foundation’s emphasis also is influenced by who happens to be in charge, of course), complained “The sad thing is, smoking, despite all the harm it does, is left pretty much an orphan.”  Seriously?  I never would have guessed that the RWJF retirement package for ex-presidents was so good that you could spend the ensuing years yachting around the world, cut off from the news.

Have they truly not seen what the marginal dollar spend on anti-tobacco is used for?  It pretty clearly has low cost-effectiveness, and arguably actually does more harm to the world than good, even apart from the money (which is to say, we are currently to the right of the vertical line in the graph that is shown, which I hope many of you will recognize from introductory economics).

Therein lies the fundamental lack of understanding by the press and other commentators.  When someone pretends to lend substance to arguments, they talk about only total number who have a particular behavior, what fraction of them die and other average or total values (almost always this is by way of pointing out that these numbers are still worse for smoking – it is pretty clear that this “controversy” has been engineered by those worried about losing their unending supply of anti-tobacco funding, taking advantage of their current power and influence, including with the press, to defend their empire against anyone with another priority).  In the same article, Stanton Glantz is quoted, “Given that tobacco kills four times as many people as obesity does, why is the government putting more money into obesity?”  Since he seems to be believe that passing exposure to second hand smoke causes 1/3 of all heart attacks, I can only assume that he actually thinks that is a valid argument.  But sadly, most others seem to miss the point also: What matters is the marginal effect of additional spending.

This is a very simple economic principle:  For most decisions, what matters is marginal cost and marginal benefit.  You cannot justify spending $200 on a restaurant meal by saying “I only spend $10,000 per year on food and without food I would die, so how can you suggest I reduce my budget?”  The average spent per day does not matter, and what would happen if you dropped spending to zero obviously does not matter; all that matters is the marginal (additional) benefit from that meal compared to the big price tag.  Similarly, when assessing spending priorities, it does not matter how many people smoke or how many total disease cases will result from the exposure.  What matters is whether the last dollar spent is doing much to improve that (and what harm it might be doing too), as compared to what another dollar of spending to try to help people not be obese will accomplish.  Apparently the smart money is on the value of the latter.

I do not really know where anti-obesity money is going, but you could imagine that a bit of spending on some basic education and life skills – akin to telling people in the 1960s that smoking kills, a very effective intervention – could be very effective.  Compare that to the marginal spending on anti-smoking:  yet another study that shows that smoking causes lung cancer (but very little to learn to better treat lung cancer – we would not want to reduce the incentives to quit smoking); hundreds of ad hoc school and community interventions and the studies that show they are incredibly effective (apparently we actually eliminated all smoking years ago); and they even have to start making things up (third hand smoke, etc.), damaging the integrity of health science, just to pretend to have something to do.

It is pretty clear that basic education about risks works wonders, but that has been completed for smoking (in the West) and probably does not even require any spending to make sure each new generation picks up the conventional wisdom.  Also seemingly effective is torturing smokers (I think they use different terms for it, but I forget what they are right now) by restricting their behavior and imposing punitive taxes, and now the FDA trying to lower the quality of the products.  But these do not cost much either, except when it is necessary to fund a propaganda machine to convince a generally sensible public that these are a good idea, and that is pretty hard to justify spending on from an ethical perspective. 

A massive education campaign to encourage switching to low-risk alternatives (and more research on those alternatives) would be a great use of funds.  It might be almost as cost-effective as the original education campaigns about smoking.  But since this – the only proven method to dramatically reduce smoking prevalence once the “smoking kills” message is generally understood – is opposed by the people who want to keep the money flowing, it is difficult to imagine that anything of value will be lost by switching money from anti-smoking to anti-obesity.

I cannot wait to see their reactions when a paper funded by the anti-obesity initiatives comes out that shows that smoke-free nicotine products seem to be an effective way to reduce obesity.