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Chapter 8

Everything costs.

"Some people just let a cigarette sit" after they light it, she says, indicating disapproval. "Some people who smoke two or three packs a day, they'll light a cigarette and they'll let it burn." Ever since she started allotting herself only ten cigarettes a day, she's been more aware of the "value" of those ten cigarettes in her smoking life.

"I don't just light one and let it burn. If I'm gonna light it, I'm gonna smoke it, because I don't want to waste it, because now I'm smoking less. That would take away one of the cigarettes that I'm allowed to smoke during the day. I certainly can't afford to waste a cigarette.

"If I smoke half a cigarette and then I put it out, then, guess what, I've only used of half of something that I could've had a whole of if I'd waited until I had time to really smoke it. And now I have one less cigarette that I'm allowed to smoke during the day."

Because everything costs—and in her internal economic budget through which she allows herself only so-many cigarettes per day, wasting a cigarette she could've smoked is like wasting money, only worse. It's wasting what she could've experienced and felt.


Everything costs, and everyone pays. Often, we don't realize we are paying, and often we don't realize the thresholds of what we will pay. But we do pay.

Let's imagine that someone gives us a choice: Either we can have $100 now or we can have $100 one week from now. Most of us would choose to have the money now. But if we are offered $100 in six years, or $200 in eight years, most of us would take the $200. Our preference has been reversed as a function of the long time it would take to get either amount. Valuation changes as a function of time, and this then affects our preference.

"People figure it's such a long ways off, they may as well get the larger amount," explained researcher Warren Bickel, who has helped to do pioneer work in what is called the behavioral economics of tobacco use. He and other scientists have applied and expanded economics principles to the field of drug abuse.

The Cost of Being a Smoker

$3,650 cost of purchasing a pack of cigarettes a day for 5 years, not including inflation or lost accumulative interest
$310 — $520 annual cost of extra cleaning bills for a smoker vs. a nonsmoker
$3,963 added amount a middle-aged smoking male pays for a standard term life insurance policy over 5 years, compared with a nonsmoker
42% men below the U.S. national poverty level who smoke
30% women below the U.S. national poverty level who smoke
4% — 8% decrease in income earned by smokers, compared with nonsmokers
1 in 3 chance of dying of smoking-related disease

The currency or commodity can also be tobacco, rather than money. For example, a smoker can have a cigarette now or a better chance for good health in 35 years. While good health today may seem worth more today than a cigarette, good health in 35 years seems less valuable. Also, a smoker can pay about $2 for a pack of cigarettes now, or instead can someday use the money he or she would have spent on cigarettes to buy a luxury car or even buy a house. Given these choices, many smokers still opt for the cigarette now. This is one of many situations in which we "sell" a valuable asset today for very little, if the "delivery" seems far in the future.

These types of now-or-later choices are evident in statistics on tobacco use during pregnancy. An Australian study found recently that 21 percent of pregnant smokers ignored the risks of smoking and continued using tobacco during pregnancy. Some 45 percent of pregnant Australian young women who smoked continued to use tobacco while they were pregnant. The 1997 study by Patrick P.L. Wong and Adrian Bauman examined more than 85,500 births in New South Wales in 1994 and found that the women who continued to smoke risked obstetric complications, premature birth, and low-birth-weight babies. Their offspring also were more prone to respiratory infections, asthma, growth retardation, cognitive deficiencies, and even death.

Many of these women, no doubt, planned to quit smoking if they became pregnant, and many probably intended to quit all the way through the pregnancy. As one 38-year-old mother of four told the researchers, "I worry about it, but obviously I can't worry too much. I've always been aware of the risks, but I just haven't really taken it too seriously."

Such logical inconsistency makes sense—sort of—when viewed through the lens of behavioral economics. "The farther you are away from events, your behavior will seem more self-controlled and rational," Bickel noted. The farther away we believe that a cost will come due, the smaller the cost seems. As our time horizon changes, the costs and benefits of our present values change.

For example, if we have a looming deadline, such as a report due first thing Tuesday morning, we might decide on Sunday night that we need to get up very early Monday morning to get a good start on the work. The cost of getting up early seems less on Sunday night than it seems early the next morning, when we feel too tired to get out of bed. "We'll set the alarm to get up early and get a lot of work done," Bickel explained, "but in the morning we hit the snooze alarm." The present value of sleep has increased as the cost of writing the report has increased. "It's not a lot different than a smoker deciding to stop, but then walking down the street and seeing someone smoking a cigarette, and not stopping smoking."

Unlocking the secrets of human behavioral economics might help lead to better smoking cessation treatment. Adapting and expanding on principles from the larger and older field of microeconomics in the 1970s and 1980s, behavioral economists have identified some of the reasons that smokers make the choices they make.

If there are two cigarettes of equal amounts of nicotine but different cost, the buyer's income could affect preference. If a less desired cigarette costs one-half or one-third of the more desired cigarette, persons of lower income tend to choose the less desired cigarette and persons of higher income to choose the more desired cigarette. Having a choice between these two cigarettes might result in this scenario: If our income increases, we would use the more desirable cigarette that costs more and would use the less desirable cigarette increasingly less. As we get wealthier, we would be buying more expensive cigarettes, or perhaps cigars, and smoking fewer generic cigarettes.

How does this analysis relate to stop-smoking treatment? Bickel explained that in economic terms, tobacco products might be considered preferable to nicotine replacement products that do not provide quite the same experience as smoking. The irony should be apparent, since nicotine replacement products undergo exhaustive development and testing before being marketed, and are "inferior" only in that most smokers perceive them as less desirable than tobacco. Work by Bickel and his colleagues indicates that smokers do tend to perceive nicotine replacement products as what economists call an "inferior good," or one for which "demand" falls as "income" rises.

"What this suggests, if this is representative of how nicotine replacement operates in the real world, is that the only way to make it a viable alternative to cigarette smoking is to radically increase the price of cigarettes and to radically decrease the cost and increase the accessibility of nicotine replacement," Bickel explained. "You can demonstrate that people consume fewer cigarettes when they have nicotine replacement, but the important question is, under what conditions will they use the products?" Smokers are not electing to quit en masse, and only a minority employ the harm-reduction strategy of using nicotine replacement. Perhaps smokers would attempt to quit in greater numbers if nicotine replacement were available in smaller packages that were available at convenience stores, or if the price differential favored the replacement product over cigarettes. "Those are the conditions under which you would engender the nicotine replacement option," Bickel noted.

In laboratory research with human smokers, Bickel found that some smokers would perform considerable "work" (i.e., tasks in the study) for a puff on a cigarette. His all-time hardest-working research subject was willing to engage in 2.5 hours of computer tasks for two puffs on a cigarette. Amazingly, the same subject could have waited only 3 hours for that segment of the study period to end, without engaging in the computer work, and then could have gone outside and smoked.

"This suggested to me that indeed the temporal horizon into which cigarettes are integrated over time is pretty small," Bickel said. That temporal horizon apparently is one of the key factors at work in the decision to use tobacco.

To understand how this process works, it helps to consider some monetary examples. If, for instance, we are given the option of taking $1,000 now or $1,000 a week from now, the choice is fairly predictable. But what if we can have $980 now or $1,000 in a week? Researchers find that as they manipulate the amount of discount that someone will accept, they can detect a direct measure of how much a person will discount $1,000 in a week. The same question can be posed and the same calculation made at many different time points to provide a picture of the rate of discounting. "It's almost a psychophysical procedure," Bickel explained, comparing it to measuring such physiological phenomena as heart rate or brainwaves.

"When people keep doing things that are bad for them, it may be because their temporal horizon is short," Bickel stated. "Things beyond a certain point don't matter to them." If comparable questions are asked of heroin abusers and of research subjects who do not abuse drugs, nondrug users will perceive that the $1,000 will lose 60 percent of its value in about five years; for heroin addicts, $1,000 loses the same amount of perceived value in one week. When the commodity becomes heroin, no amount of heroin tomorrow is worth any amount of heroin today to a person dependent on heroin. Behavioral scientists studying smoking now are attempting to examine similar questions in relation to tobacco and alcohol use.

Up in Smoke

$2 amount of hidden health costs associated with each pack of cigarettes sold
$47 billion annual loss from sick leave and loss of workers to death related to tobacco use in the United States
33 cents amount per pack of smokers' net loss to society
25 cents amount per pack of net loss to society related to secondhand smoke
24 billion number of packs of cigarettes purchased in the United States annually
$50 billion annual U.S. cost of health care for smoking-related illness
$47 billion annual U.S. cost of lost productivity and forfeited earnings due to smoking-related disability
one-third proportion of world's cigarettes used for smuggling
quadrupled increase in tobacco smuggling from 1989 to 1993
$16.2 billion annual amount governments lose worldwide because of tobacco smuggling
154,000 number of fires started each year by tobacco-related smoking materials
$416 million annual damage from fires caused by smoking-related materials

The work of Bickel and others has shown that virtually all self-administration of drugs, whether by humans smoking tobacco or by laboratory primates self-administering cocaine, fits the same shape curve. When the amount used is plotted against the timing of administration, the resulting graphics look similar, whatever the drug. The shape stays constant, although its parameters vary according to the specific drug. This fact has given behavioral economists an empirical, measurable model on which to base assumptions, "which is a useful contribution of psychological science to economics," Bickel added.

Psychologists and others engaging in this work can learn much from economics, particularly its concepts and terms. "Other concepts that may be particularly useful include the notion of reinforced interactions," Bickel explained. "In economics, reinforcers can interact as substitutes. For example, if we increase the price of seeing a movie in a theater, its consumption will decrease, but there will be an increase in the use of videos even though their price remains constant." Another type of interaction is the complement, in which consumption of soup would decrease as the price of soup increased. The consumption of soup crackers would also decrease, even though their price remained constant. Lack of interaction would indicate independence; for example, the price of a theater ticket would not affect the consumption of soup crackers.

"This way of thinking provides a useful framework for understanding events that interact with cigarette smoking," according to Bickel. An increase in cigarette prices will decrease coffee consumption along with tobacco consumption, for example, but an increase in coffee price will not affect cigarette consumption. "Those events can be confusing when the effects occur together," he admitted. Studied carefully, however, this behavioral economics approach can "provide a conceptual system for studying how tobacco interacts with other drugs, and also with social interactions." Additionally, it raises valuable questions and provides a useful framework for quantification.

"If you could create an analog of an ideal smoking treatment situation, you would like to have a world in which you would have few complements for smoking, and many pro-social substitutes," Bickel stated. "You can test that in a laboratory and test it in the real world." Behavioral economics provides a conceptual system for understanding how elements go together. An example of the kind of statistical puzzle that behavioral economics can help solve is the use of multiple drugs sequentially, concurrently, or both. Some drugs are used together, some are used in lieu of each other, and some are used together even though there is no relationship between then. "How do you put that quagmire in functional categories?" Bickel asked. "This is a potential way of doing that."

Many baffling aspects of human behavior, including smoking-related behaviors, can be studied through the eyes of behavioral economics. One of the most puzzling, the "loss of control phenomenon," is readily analyzed through this means. It is a phenomenon many of us know well: We make a decision to do something, but when we are confronted with the reality of it, we find ourselves choosing the direction we had not planned to take. Bickel and others have studied this "preference reversal" situation in terms of "discounting." In other words, what looks like a good idea from a distance of time no longer seems as appealing when we approach the situation. The closer we are to paying a price, the higher the present value of the price. Our resolve to diet was strong a week ago, but instead of choosing to lose weight today, we find ourselves eating an ice cream cone. Such a choice can feel as if it is out of our control. When the concept is applied to drug use, it becomes a diagnostic criterion for the misuse of many substances, including nicotine. Researchers have not yet determined whether behavioral economics can be applied directly to smoking cessation treatment, to lengthen a smoker's horizon or to manipulate preference reversals.

"Studies have looked at time perception of drug-dependent people," Bickel explained. "People in treatment have a longer time-perspective than those not in treatment. Hopefully that means that treatment can induce a longer time perspective." It is also possible that persons with a longer time horizon are more able to value treatment. For many substance abusers, including many smokers, any inducement toward a longer time horizon would need to be attractive indeed. Bickel found that when most people think about the future, they view ahead an average of nine years. Heroin addicts, on the other hand, view the future as being four weeks away. "And those are the ones who are in treatment," Bickel explained. "God knows what it's like out in the street."

Adolescent alcohol and drug use presents a particularly poignant example of this concept. "Do adolescents get bumped into drugs when they should be expanding their temporal horizon?" Bickel has wondered. If so, maybe adolescent drug use is a different sort of problem than it previously has been considered to be.

One of the leaders in applying behavioral economics to substance use is Steven R. Hursh of the Johns Hopkins University School of Medicine and the Science Applications International Corporation. In the early 1970s, as he started his career in science at Walter Reed Army Institute of Research, he noted inconsistencies in baboon behavior. Scientists taught baboons to give themselves heroin and studied the primates' patterns of use as a way to develop a possible model for human use of heroin. Hursh noted that if he wanted the baboons to respond at a higher rate, he had to make them "work" harder to get the drug. "This seemed counterintuitive," he recalled. "It turns out, though, that it wasn't at odds with what economics would predict."

To understand the baboons' heroin use, he referred to the concepts of elastic and inelastic supply and demand of commodities. The demand for a product that we need to buy, whatever the cost, is inelastic. "This concept opened the door to realizing that the factors that control our overall output of performance for a commodity can be better understood from an economic perspective than from a simple reinforcement perspective," he explained. "Reinforcement is part of a process in which the subject is trying to defend some level of consumption, and that consumption has some benefit, such as enough food to maintain health, or enough drug to ward off withdrawal."

Some commodities do not maintain that kind of inelastic demand. For instance, monkeys "working" to obtain nonnutritive saccharine will work for it when the flavoring is easy to get, but when the price is raised to the level of a food price, the monkeys do not increase their work output. This is also true of laboratory rats taught to press a bar to obtain food, or laboratory pigeons taught to peck a certain spot to obtain grain for food. If the task is made more difficult, the animals will reduce their rate of response.

"This led to a study that showed that this occurs because rats and pigeons are kept in an open economy, in which they don't get most of their food from the experiment," Hursh said. "So the food from the experiment is a luxury good. But if you study monkeys or rats in an environment in which the only food they get is from the experiment, they show that the demand is inelastic."

"All of this is part of a unified process, but you have to understand the nature of the economy that they're working in. If the food outside substitutes for food within the experiment, the demand for experiment food is elastic," Hursh explained. The continuum between elastic and inelastic demand for tobacco and other consumed substances can be controlled and manipulated. By altering "price" (cost and availability), one can make a substance so expensive in money and in effort that regular users will use it less and less frequently.

This approach has been applied, with mixed success, to the problem of adolescent tobacco use. Tobacco use by minors is illegal virtually everywhere in the United States, yet sizable percentages of youth use tobacco. Governments and municipalities have tacked substantial taxes onto tobacco to make it less accessible to young persons. The theories and evidence indicate that this approach ought to work in reducing tobacco use by children and adolescents. Even so, the results of altering prices or decreasing accessibility of tobacco have been mediocre.

A 1997 report in The New England Journal of Medicine by a team led by Nancy Rigotti of Massachusetts General Hospital indicated that tightening enforcement of laws prohibiting tobacco sales to minors did not reduce consumption by minors. Rigotti and colleagues examined enforcement of tobacco laws in three communities by having minors who worked for the investigators attempt to purchase tobacco from retail vendors. In addition, anonymous surveys of more than 22,000 students in grades nine through twelve assessed tobacco access and use among adolescents.

At the start of the study, some 68 percent of 487 vendors sold tobacco to minors. When local health departments distributed written information about tobacco sales laws and began testing and enforcing compliance (these tests were separate from those conducted by the study investigators), compliance increased to 82 percent, which did not quite meet the goal of more than 90 percent. Concurrently, the same measurements were taken in communities where law enforcement agencies did not go to any extra lengths to enforce tobacco sales regulations. Those communities maintained a 45 percent compliance rate. The change in compliance rate was significantly different in those communities with more rigorous enforcement, but the change failed to affect minors' access to tobacco. Teenagers reported only a small decrease in their perceived ability to purchase tobacco in the communities where enforcement was enhanced, and they reported no decline in tobacco use.

The problems contributing to the disconnection between tobacco- control efforts and reported use are probably manifold. The goal of reducing young persons' use of tobacco is a hallmark of tobacco-control legislation and negotiation, yet evidence does not support the efficacy of the standard approaches. As Rigotti and colleagues stated, "Empirical demonstration of benefit is critical to justify the resources being expended on this new effort." In addressing the question, they concluded that typical tests of compliance with tobacco laws tend to underestimate young persons' access to tobacco. Potential reasons include the possibility that underage smokers attempting to purchase tobacco may lie about their age or use false identification, or may enlist an older person to buy tobacco for them. Also, store owners might sell tobacco only to youths whom they already know. Teenagers also might buy tobacco in neighboring communities that enforce tobacco sales regulations with less rigor.

Defining Values

Howard Rachlin, a State University of New York at Stony Brook researcher of human behavior, wrote that behavioral economics sometimes is seen as the "study of error—of deviation from rational behavior." Such " 'psychological' good" as approval, satisfaction, and avoidance of negative feelings can translate into "subjective value," and value is precisely what human decision making seeks to maximize. Which is to say, if someone places greater value on the sensations associated with smoking than on physical health, smoking may have more value for the person than jogging, or than quitting smoking.

Rachlin stated that he prefers to look at behavior (such as smoking) from within the framework of the overall pattern in which it is performed. Someone looking at smoking from Rachlin's point of view might see smoking not as an isolated act, but as one of several mechanisms for maintaining emotional equilibrium. He equated what we might call rational behavior with self-control, and equated irrationality with impulsiveness. The same act can be either rational or irrational, depending on its context. For example, smoking a cigarette is neither rational nor irrational in and of itself. But the smoking of a cigarette by someone who has quit smoking would be considered irrational, while the smoking of a cigarette by someone who is cutting down on smoking as a prelude to quitting would be considered rational. He insisted that the study of what might be considered anomalous behavior should not end with its mere discovery and classification, but should be examined in terms of its "functional base in the environment."

An example of this "functional base" could be a behavior that does not serve its obvious purpose. A "wider interest" or long-range interest, such as maintaining relationships by smoking with friends, can interact with a more immediate interest, such as the pleasure of smoking and the alleviation of withdrawal symptoms, to dominate an interest that is somewhat mid-range, such as quitting smoking to improve health. Personal maximization based on one alternative or another "is strictly relative and conditional," Rachlin stressed. "We cannot presume to know what an organism (including ourselves) values. Rather, value must be defined by choices."

1,000 Tons, and What Do You Get?

$2.6 million added economic value from 1,000-ton increase in tobacco consumption
$5.6 million estimated direct costs of medical treatment related to consumption of 1,000 tons of tobacco
$29.8 million total cost of death and illness related to consumption of 1,000 tons of tobacco
minus $27.2 million benefit-cost difference of consumption of 1,000 tons of tobacco
650 — 1,300 average number of deaths per 1,000 tons of tobacco consumed
25 — 30 years time lag between processing of tobacco and the related deaths
(Barnum, 1994.)

The choice that most of us make to have something now rather than something else of value some time in the future may reflect our impulsiveness, but it is not an anomaly, Rachlin insisted. He refused to treat such choices as deviations from the standard rules; instead, they are behaviors to be studied, so that more accurate rules can be discovered. Turning this approach inward toward the individual ex-smoker's attitude might involve not labeling a lapse back to smoking as an anomaly, but rather as a situation to examine in view of the individual's values and choices. Why does someone who knows the value of a healthy diet consistently overeat? Why does someone who knows the dangers of smoking continue to smoke? Those questions are not examinations of anomalies in the stream of rational behavior, but are case studies that provide an opportunity for understanding the behaviors within their larger framework.

"Self-control is difficult," Rachlin stated, citing two reasons. First, as behavior patterns become more abstract and extended over time, perceiving them is more difficult. The common outcome of patterns is weaker and more difficult to spot. Second, even if we can perceive them, their elaborate patterns require maintaining a wider view of the events, or a broader "temporal horizon" in the presence of immediate "reinforcers" such as the sensation of smoking, or the relaxing or stimulating effects of nicotine. A successful quitter who indulges in one cigarette faces what Rachlin called "an awful conflict," with haunting questions: Is the immediate reward worth risking slipping back into regular use of tobacco? The smoker thus, in a sense, is "tossing the dice with regard to the future," to apply Rachlin's terminology.

What will happen? Will the lapse cigarette be the last, or will the ex-smoker become a smoker again? What is behind the door in the arena, the lady or the tiger? We won't know, Rachlin explained, "until future behavior settles in."

The economics that apply to an entire population of smokers might not explain the behavior of an individual smoker. Economics may need to be applied differently at different levels of analysis. It might not be accurate to assume that the methods by which a behavioral economics researcher might analyze the behavior of a group of individuals would be useful in studying the economic impact of a cigarette tax or cigarette regulations on a larger group chosen randomly from the population at large. And what is valid for one segment of that population, such as adolescents, might not be the case for the rest of the population.

Analysis of cigarette taxes and cigarette consumption in all 50 states in the United States over a period of 40 years indicated that cigarette taxes effectively reduced cigarette use, but that federal taxes had more impact than state taxes, presumably because federal taxes provided no advantage for "bootlegging" cigarettes across state lines. The report also noted that cigarette consumption declined as health warning labels were added to cigarettes. Reducing consumption by large amounts required large increases in taxes, Kenneth J. Meier and Michael J. Licari of the University of Wisconsin-Milwaukee concluded. Increases in excise taxes are associated with reduced tobacco consumption, even when other factors are considered statistically. Interestingly, they discovered that the rise in tobacco-related health concerns of the 1960s actually diminished the effect of taxes, because "individuals have reasons other than economic ones to stop smoking." They recommended substantial increases in federal excise taxes to reduce the demand for cigarettes.

Harm Reduction

To quit or not to quit? That is a question smokers face. To help mitigate the risk of tobacco use, some experts have developed an approach called harm reduction. They view it as an alternative that might help save lives, even if purists might not approve. Millions of smokers who find it too difficult to quit smoking completely might consider other alternatives. Experts have debated the benefits and risks of helping smokers cut down how much they smoke, or find safer ways to smoke, as a way to reduce harm among those unwilling or unable to quit smoking completely. Some 16 million smokers try to quit every year; of these, only about 1.2 million succeed.

Strategies for harm reduction can include the extended use of nicotine replacement such as nicotine gum or nicotine patches, switching to alternative nicotine delivery mechanisms such as smokeless tobacco, or even using cigarettes that are less toxic, such as a smokeless cigarette or other smoking device designed to minimize harm. Another strategy for harm reduction is smoking fewer cigarettes per day.

Even though smoking prevalence has leveled off in the United States, tobacco experts are faced with the problem of finding more options for hard-core smokers who are not likely to quit. The approach could "complement, but not replace" efforts to prevent smoking onset and aid current smokers in their attempts to achieve complete tobacco abstinence, said Johns Hopkins University researcher Jack Henningfield, who has publicly debated the issue with other experts.

"Medical and public health experts are considering reducing smoking as a goal of intervention for those smokers who are presently unable or unwilling to completely quit smoking," Henningfield said at a 1997 symposium where harm reduction was debated. This "exposure reduction" strategy could lead to eventual smoking cessation, but the goals are more immediate. Smokers who are not yet ready to quit may gain some health benefits from reduced exposure as they cut down the number of cigarettes. This would reduce their exposure to the harmful carcinogens and tars in tobacco smoke. In addition, reduced exposure to smoke can raise their chances of quitting smoking.

Results from three teams of researchers who presented findings at the symposium indicated that exposure reduction might help reduce the death and disease associated with tobacco use:

One researcher, David M. Burns of the University of California at San Diego School of Medicine, estimated that if 100,000 two-pack-a-day smokers reduced their smoking to fewer than ten cigarettes per day at age 50, they would cumulatively gain an additional 284,000 years of life. This is based on an estimation model for calculating public health benefits from smoke exposure reduction.

Another approach to reducing tobacco use is to limit the amount of nicotine, which is believed to be tobacco's primary psychologically effective (psychoactive) agent as well as its addictive component. Proponents of this approach recommend gradually reducing the legally allowed amount of nicotine in cigarettes until the amount reaches a virtual zero. The rationale is based in findings that nicotine is the primary tobacco constituent that drives the intensity of smoking. In an effort to get all the nicotine possible, smokers will commonly puff more, inhale more, and hold the smoke longer in their lungs when they smoke cigarettes with lower nicotine content. Recent research has shown that this particular smoking style carries the additional health risk of a type of cancer seen in those who inhale very deeply, as is common in the use of low-nicotine cigarettes. Also, those who smoke low-yield cigarettes tend to smoke more cigarettes and to get more puffs from each cigarette. All of these actions combine to compensate for the lower nicotine available from each cigarette.

Some experts claim that it is unlikely that gradually lowering the amount of nicotine in cigarettes will reduce overall smoking. It may, in fact, increase smoking as nicotine-dependent tobacco users strive to maintain the blood levels of nicotine required to avoid withdrawal.

The Bottom Line

U.S. News Online, an Internet production of the weekly magazine U.S. News & World Report, related this tale by Matthew Miller: A tobacco-control crusader asserted at a Canadian conference in the 1980s that the United States was spending more than $50 billion per year in smoking-related health costs and lost productivity. After the presentation, an economist insisted that the amount couldn't be right because it didn't account for savings in Social Security and private pensions for smokers who had died prematurely. The crusader snapped back, "You know that, I know that, and the tobacco industry knows that. The tobacco industry can't say it, because it means admitting they're killing their customers. Are you going to say it?"

It is, indeed, being said these days. A frequent consideration in the overall picture of the economics of tobacco use is the down-the-road cost of using tobacco. For the individual smoker, health risks decrease when tobacco use stops, with the decrease growing in magnitude the longer the ex-smoker stays abstinent. Not only has the ex-smoker saved money, but the smoker's lower tobacco-related health costs are savings as well. It sounds so simple.

But it isn't. A recent report by Jan Barendregt and colleagues of Erasmus University in the Netherlands studied the effects of smoking on health care costs. They compared a mixed population of smokers and nonsmokers, a population of smokers, and a population of nonsmokers (population being a research term indicating the larger group under study, of which the research subjects are a representative sample). They used a "dynamic" statistical method to estimate the effects that smoking cessation would have on long-term health care costs. They determined that at a given age, health care can cost as much as 40 percent more for smokers than for nonsmokers.

The picture, however, was not that simple. Increases in longevity contributed substantially to the overall increase in long-term health costs in a society of nonsmokers. Smokers have a life expectancy at birth of 70 years for men and 76 years for women; nonsmokers' life expectancies are 77 years for men and 82 years for women. More nonsmokers than smokers live to old age. For example, 50 percent of nonsmoking men are still alive at age 80; 21 percent of smoking men are still alive at the same age. Younger smokers have higher health care costs than their nonsmoking counterparts, but over their respective life spans, nonsmokers' health costs are greater because they live longer. The health problems nonsmokers face in old age may be unrelated to their status as a nonsmoker.

Ironically, a society could greatly diminish its health care costs by not encouraging public health and by allowing disease and death to run rampant in people of all ages. Health care costs would be low, but quality of life also would be low. As with the choices made by the individual smoker, a society's choices reflect its values. Barendregt and colleagues posed this question: "With respect to public health policy, how important are the costs of smoking?" Their response was that public health policy should be concerned with health, and that "whether or not smokers impose a net financial burden ought to be of very limited importance." Whatever the bottom line, they said, "Smoking is a major health hazard." Consequently, smoking should be discouraged. Period.

The Smell of Success

Perhaps the least predictable extension of private values into the public breathing space has been the recent explosion in cigar popularity. Did the trend start with the photo of U.S. President Bill Clinton chomping on (but not inhaling) a cigar? Was it the many heroes and antiheroes who puffed on cigars in the movies? Was it the parade of famous faces on the cover of cigar magazines? Was it the magazines themselves?

The long-term cigar slump that half-heartedly peaked in the 1970s reversed dramatically in the mid- to late 1990s as cigar use became a trend, even among the health-conscious. The cost of cigars increased along with the demand. "High-end" cigar brands, which have larger profit margins and faster growth rates, now sell for between $10 and $20 apiece. Sales of premium cigars have shown a compounded annual growth rate of 35.6 percent, according to the chief financial officer of the largest cigar manufacturer. At this writing, the cigar boom shows no sign of slumping.

What price does a cigar smoker pay, beyond the actual cost? Are these particular nicotine-delivery devices as safe, nonaddicting, and charming as their proponents claim? Consider a few facts:

Cigars range in weight from about 1 g to 22 g (cigarette tobacco weighs less than 1 g). Their nicotine content ranges from 6 mg to more than 300 mg (cigarettes range from 6 to 11 mg, with the smoker obtaining 1 to 3 mg). It is not yet known exactly how much nicotine a cigar smoker typically obtains from each cigar. A cigar's nicotine concentration ranges from about 5 mg/g to 22 mg/g. In other words, there is little consistency among cigars. Their pH ranges from about 6 to more than 8 (cigarette pH is 5.5 to 6.5). This more alkaline product results in harsher smoke and a unique odor. Higher pH cigars can provide a more rapid nicotine delivery than other cigars that might have more nicotine. Size alone does not predict nicotine content, since nicotine content varies among cigars. Smoking style also varies, with some cigar smokers inhaling cigar smoke directly, others inhaling little directly but inadvertently inhaling environmental smoke, and some cigar users not lighting up at all but still absorbing nicotine from the unlit cigar.

Cigars differ from cigarettes in several other ways. A cigar is wrapped in tobacco leaf or in paper soaked in tobacco extract. A machine-made cigar could be produced in a process similar to that used for cigarettes. The larger, more expensive premium cigars are rolled by hand. The nicotine content of a cigar varies considerably from puff to puff, with nicotine delivered differently at the beginning of the cigar than at the end. The tobacco used in cigars is higher in nitrates than that used in cigarettes, resulting in greater concentrations of nitrosamines in inhaled and sidestream smoke. Although the risks of cigar use to the smoker are difficult to quantify because of the wide variation in usage, the environmental smoke from cigars is another matter. A cigar smoker produces about as much environmental or secondhand smoke as seven cigarette smokers, and the smoke from a cigar is believed to be more physically irritating to nonsmokers than cigarette smoke.

It can take a cigar smoker an hour to smoke one large cigar. As Henningfield explained in a 1996 report, "[T]he consumption of a few fat cigars could produce the daily burden of smoke exposure produced by the consumption of a pack of cigarettes." Henningfield and his associates reported in 1998 that the smoke acidity of larger cigars changes as they are smoked, which affects cigar users' ability to consume these cigars without experiencing nicotine-overdose effects.

Additionally, those who first smoked cigarettes and switched to cigars are more likely to inhale cigar smoke than are those who never smoked cigarettes. Therefore, the reduction in health risk by switching from cigarettes to cigars is likely not to be as great as the smoker might want to believe.

A 1996 U.S. national tobacco survey by the Robert Wood Johnson Foundation found that among students ages 14—19, an estimated six million had smoked a cigar during the preceding year. Of these, an estimated 1.7 million were female smokers. Having smoked a cigar increased by three times the likelihood of also smoking cigarettes. Among those 69 percent of students who did not report smoking cigarettes, males were more likely to have reported smoking at least one cigar. Students using smokeless tobacco were more than three times as likely as nonusers to have smoked cigars. Curiously, cigar smoking among these teenagers did not vary by locale, ethnicity, or race.

A 1996 Massachusetts Department of Health survey of students in grades six through twelve found that 10 percent of sixth graders had smoked a cigar; of high school students in grades nine through twelve, 28 percent reported smoking a cigar in the previous year, with half of those reporting smoking during the previous month. As with the Robert Wood Johnson study, a strong relationship emerged between cigar use and other tobacco use.

A third 1996 survey of ninth graders, this one conducted by the Roswell Park Cancer Institute in New York, corroborated the findings of the other surveys. Some 20 percent of boys and 6 percent of girls responding in Erie County reported having smoked a cigar in the previous month. In Chautauqua County, 24 percent of boys and 5 percent of girls also reported having smoked a cigar. As with the other studies, students who smoked cigarettes were more likely to report smoking a cigar than were nonsmoking students. Among those students using smokeless tobacco, about 63 percent also reported smoking at least one cigar during the previous month.

It's Not Your Father's Cigar Anymore

1992 year Cigar Aficionado magazine started publishing
100 million total cigars sold in the U.S. in 1992
176 million premium cigars imported into the U.S. in 1995
294 million premium cigars imported into the U.S. in 1996
4.5 billion total cigars consumed in the U.S. in 1996
700 million projected annual premium cigar sales by the year 2000
6 million teenagers who have smoked a cigar in the last year
22% teenage boys who have smoked a cigar in the last month
11% teenage girls who have smoked a cigar in the last month
14% cigar-smoking teenagers who had never smoked before
up to 40 times more nicotine in a cigar, compared with a cigarette
up to 40 times greater maximum carcinogenicity of cigar tobacco, compared with cigarettes
famous cigar users Demi Moore, David Letterman, Michael Jordan, Tom Cruise, Madonna, Wayne Gretzsky, Denzel Washington

These reports, published in the Massachusetts Medical Society's Morbidity and Mortality Weekly Report in 1997, were the first to estimate cigar use among U.S. young persons. Although the three surveys were consistent with each other, they did not include nonstudents of the same ages, and therefore they might not represent all adolescent cigar use.

Where are these young people buying cigars? They are buying them in most places where cigars are sold. Not only are cigars apparently readily available to youth who want them, but at this writing, they carry no warning labels. The Surgeon General's health warning that is legally required to be on many tobacco products does not cover cigars. Public health officials have expressed concern that many young users of cigars might not be aware of the health risks. The 1997 report citing the three surveys emphasized: "Immediate efforts should be made to publicize the health risks of cigar smoking; deglamorize the product in magazines, movies, and television programs; and protect nonsmokers from secondhand cigar smoke."

As for those risks . . .

The daily use of cigars increases the risk of oral cancer, lung cancer, chronic obstructive pulmonary disease, and heart disease, with risk related to the frequency of use and the degree of inhalation. Also, cigars contain nicotine, a substance with considerable potential for dependence. These risks were affirmed in a 1998 monograph released by the National Cancer Institute.

In apparent defiance or ignorance of the health risks, the fad is booming. For example, a video is now available to introduce women to the basics of selecting and enjoying "fine cigars." Marketed by an attorney in Seattle who with her husband owns a cigar store/smoking lounge, the video provides information about flavor, ring gauge, price, and brands, as well as cutting, lighting, holding, and smoking cigars. It also discusses wines, ales, and coffees that complement and enhance the cigar-smoking experience. It is a follow-up to a previous video aimed at educating cigar novices; unlike the first video, the second one is aimed specifically at women who want to smoke cigars.

Michael Erickson, director of the U.S. Centers for Disease Control and Prevention's Office on Smoking and Health, referred to the cigar craze as "a phenomenon of the 90s." The next few years will tell whether this fad has the momentum to build its own little bridge into the twenty-first century.

Donald Nelson, editor of the Puget Sound Business Journal, explained the cigar phenomenon this way: "Every generation celebrates its independence from its predecessors by lapsing into a kind of momentary lunacy that, on reflection years later, seems shallow, silly and pretentious.

"That's my take on the 20-something crowd's current wretched fascination with cigars. There's no other defensible explanation for the faux sophistication and phony elan that are part of the laughable cigar ritual.

"They're doing it to show us old geeks that they're the smart set, that they're really something." What Nelson said he "gets" is the rebellion part; what he doesn't "get" is the cigar part. "Cigarettes are intolerable, but cigars are—vile. They stink. They offend. And despite the hype about the exotic pleasure of a fine cigar (now there's an oxymoron!), a cigar is just another death-dealing tobacco stick that people have been hoodwinked into paying a lot of money for."

And yes, he conceded, his bias did show, for which he made no apology. And he did remember his own days of rebellion. He remembered wearing bell-bottom pants himself. "They were dumb back when I wore them, and they're still dumb."

So why do people smoke cigars? Evidently, the reasons people try cigars and keep using them are similar to reasons for cigarette use: marketing, nicotine, marketing, sensory experience, marketing, images of prosperity and well-being, marketing, keeping your mouth busy, marketing, being "in your face," marketing, relaxing with your friends, marketing—did we mention marketing?

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Copyright 1998 National Academy Press