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Do penalties for smokers and the obese make sense?
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NEW YORK (AP) -- Faced with the high cost of caring for smokers
and overeaters, experts say society must grapple with a blunt question:
Instead of trying to penalize them and change their ways, why not just
let these health sinners die prematurely from their unhealthy habits?
Annual
health care costs are roughly $96 billion for smokers and $147 billion
for the obese, the government says. These costs accompany sometimes
heroic attempts to prolong lives, including surgery, chemotherapy and
other measures.
But despite these rescue
attempts, smokers tend to die 10 years earlier on average, and the obese
die five to 12 years prematurely, according to various researchers'
estimates.
And attempts to curb smoking and
unhealthy eating frequently lead to backlash: Witness the current legal
tussle over New York City's first-of-its-kind limits on the size of
sugary beverages and the vicious fight last year in California over a
ballot proposal to add a $1-per-pack cigarette tax, which was ultimately
defeated.
"This is my life. I should be able
to do what I want," said Sebastian Lopez, a college student from Queens,
speaking last September when the New York City Board of Health approved
the soda size rules.
Critics also contend
that tobacco- and calorie-control measures place a disproportionately
heavy burden on poor people. That's because they:
-Smoke more than the rich, and have higher obesity rates.
-Have
less money so sales taxes hit them harder. One study last year found
poor, nicotine-dependent smokers in New York - a state with very high
cigarette taxes - spent as much as a quarter of their entire income on
smokes.
-Are less likely to have a car to shop elsewhere if the corner bodega or convenience store stops stocking their vices.
Critics
call these approaches unfair, and believe they have only a marginal
effect. "Ultimately these things are weak tea," said Dr. Scott Gottlieb,
a physician and fellow at the right-of-center think tank, the American
Enterprise Institute.
Gottlieb's view is
debatable. There are plenty of public health researchers that can show
smoking control measures have brought down smoking rates and who will
argue that smoking taxes are not regressive so long as money is
earmarked for programs that help poor people quit smoking.
And
debate they will. There always seems to be a fight whenever this kind
of public health legislation comes up. And it's a fight that can go in
all sorts of directions. For example, some studies even suggest that
because smokers and obese people die sooner, they may actually cost
society less than healthy people who live much longer and develop
chronic conditions like Alzheimer's disease.
So
let's return to the original question: Why provoke a backlash? If 1 in 5
U.S. adults smoke, and 1 in 3 are obese, why not just get off their
backs and let them go on with their (probably shortened) lives?
Because it's not just about them, say some health economists, bioethicists and public health researchers.
"Your
freedom is likely to be someone else's harm," said Daniel Callahan,
senior research scholar at a bioethics think-tank, the Hastings Center.
Smoking
has the most obvious impact. Studies have increasingly shown harm to
nonsmokers who are unlucky enough to work or live around heavy smokers.
And several studies have shown heart attacks and asthma attack rates
fell in counties or cities that adopted big smoking bans.
"When
you ban smoking in public places, you're protecting everyone's health,
including and especially the nonsmoker," said S. Jay Olshansky, a
professor at the University of Illinois-Chicago's School of Public
Health.
It can be harder to make the same
argument about soda-size restrictions or other legislative attempts to
discourage excessive calorie consumption, Olshansky added.
"When you eat yourself to death, you're pretty much just harming yourself," he said.
But
that viewpoint doesn't factor in the burden to everyone else of paying
for the diabetes care, heart surgeries and other medical expenses
incurred by obese people, noted John Cawley, a health economist at
Cornell University.
"If I'm obese, the health
care costs are not totally borne by me. They're borne by other people in
my health insurance plan and - when I'm older - by Medicare," Cawley
said.
From an economist's perspective, there
would be less reason to grouse about unhealthy behaviors by smokers,
obese people, motorcycle riders who eschew helmets and other health
sinners if they agreed to pay the financial price for their choices.
That's
the rationale for a provision in the Affordable Care Act - "Obamacare"
to its detractors - that starting next year allows health insurers to
charge smokers buying individual policies up to 50 percent higher
premiums. A 60-year-old could wind up paying nearly $5,100 on top of
premiums.
The new law doesn't allow insurers to charge more for people who are overweight, however.
It's
tricky to play the insurance game with overweight people, because
science is still sorting things out. While obesity is clearly linked
with serious health problems and early death, the evidence is not as
clear about people who are just overweight.
That
said, public health officials shouldn't shy away from tough
anti-obesity efforts, said Callahan, the bioethicist. Callahan caused a
public stir this week with a paper that called for a more aggressive
public health campaign that tries to shame and stigmatize overeaters the
way past public health campaigns have shamed and stigmatized smokers.
National
obesity rates are essentially static, and public health campaigns that
gently try to educate people about the benefits of exercise and healthy
eating just aren't working, Callahan argued. We need to get obese people
to change their behavior. If they are angry or hurt by it, so be it, he
said.
"Emotions are what really count in this world," he said.
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