Paul Campos writes:
Probably the biggest public health success in America over the past half century has been the remarkably effective long-term campaign to reduce cigarette smoking. The percentage of adults who smoke tobacco has declined from 42% in 1965 (the first year the CDC measured this), to 12.5% in 2020.
It’s difficult to disentangle the effect of various factors that have led to this stunning decline of what was once a ubiquitous habit — note that if we exclude people who report having no more than one or two drinks per year, the current percentage of alcohol drinkers in the USA is about the same as the percentage of smokers 60 years ago — but the most commonly cited include:
Anti-smoking educational campaigns
Making it difficult to smoke in public and many private spaces
Increasing prices
Improved smoking cessation treatments, and laws requiring the cost of these to be covered by medical insurance
I would add another factor, which is more broadly cultural than narrowly legal or economic: smoking has become declasse.
This is evident if you look at the relationship between smoking rates and education and income: While 32% of people with a GED smoke, the percentages for holders of four year college degrees and graduate degrees are 5.6% and 3.5% respectively. And while 20.2% of people with household incomes under the $35,000 smoke, 6.2% of people with household incomes over $100,000 do.
All worth noting. Anti-smoking efforts are a big success story, almost such a bit story that it’s easy to forget.
The sharp decline in smoking is a big “stylized fact,” as we say in social science, comparable to other biggies such as the change in acceptance of gay people in the past few decades, and the also-surprising lack of change in attitudes toward abortion.
When we have a big stylized fact like this, we should milk it for as much understanding as we can.
With that in mind, I have a few things to add on the topic:
1. Speaking of stunning, check out these Gallup poll results on rates of drinking alcohol:
At least in the U.S., rich people are much more likely than poor people to drink. That’s the opposite of the pattern with smoking.
2. Speaking of “at least in the U.S.”, it’s my impression that smoking rates have rapidly declined in many other countries too, so in that sense it’s more of a global public health success.
3. Back to the point that we should recognise how stunning this all is:
20 years ago, they banned smoking in bars and restaurants in New York. All at once, everything changed, and you could go to a club and not come home with your clothes smelling like smoke, pregnant women could go places without worrying about breathing it all in, etc. When this policy was proposed and then when it was clear it was really gonna happen, lots of lobbyists and professional contrarians and Debby Downers and free-market fanatics popped up and shouted that the smoking ban would never work, it would be an economic disaster, the worst of the nanny state, bla bla bla. Actually it worked just fine.
4. It’s said that quitting smoking is really hard.
Smoking-cessation programs have notoriously low success rates. But some of that is selection bias, no? Some people can quit smoking without much problem, and those people don’t need to try smoking-cessation programs. So the people who do try those programs are a subset that overrepresents people who can’t so easily break the habit.
5. We’re used to hearing the argument that, yeah, everybody knows cigarette smoking causes cancer, but people might want to do it anyway.
There’s gotta be some truth to that: smoking relaxes people, or something like that. But also recall what the cigarette executives said, as recounted by historian Robert Proctor:
Philip Morris Vice President George Weissman in March 1954 announced that his company would “stop business tomorrow” if “we had any thought or knowledge that in any way we were selling a product harmful to consumers.” James C. Bowling . . . . Philip Morris VP, in a 1972 interview asserted, “If our product is harmful . . . we’ll stop making it.” Then again in 1997 the same company’s CEO and chairman, Geoffrey Bible, was asked (under oath) what he would do with his company if cigarettes were ever established as a cause of cancer. Bible gave this answer: “I’d probably . . . shut it down instantly to get a better hold on things.” . . . Lorillard’s president, Curtis Judge, is quoted in company documents: “if it were proven that cigarette smoking caused cancer, cigarettes shoudl not be marketed” . . . R. J. Reynolds president, Gerald H. Long, in a 1986 interview asserted that if he ever “saw or thought there were any evidence whatsoever that conclusively proved that, in some way, tobacco was harmful to people, and I believed it in my heart and my soul, then I would get out of the business.”
6. A few years ago we discussed a study of the effects of smoking bans.
My thought at the time was: Yes, at the individual level it’s hard to quit smoking, which might give skepticism about the effects of measures designed to reduce smoking—but, at the same time, smoking rates vary a lot by country and by state, This was similar to our argument about the hot hand: given that basketball shooting success rates vary a lot over time and across game conditions, it should not be surprising that previous shots might have an effect.
7. To us, though, the most interesting thing about the stylized facts on smoking is how there is this behavior that is so hard to change at the individual level but can be changed so much at the national level.
This runs counter to currently-standard individualistic theories in social science in which everything is about isolated decisions. It’s more of a synthesis: change came from policy and from culture (whatever that means), but this still had to work its way though individual decisions. This idea of behavior being changed by policy almost sounds like “embodied cognition” or “nudge,” but it feels different to me in being more brute force. Embodied cognition is things like giving people subliminal signals; nudge is things like subtly changing the framing of a message. Here we’re talking about direct education, taxes, bans, big fat warning labels: nothing subtle or clever that the nudgelords would refer to as a “masterpiece.”
Anyway, this idea of changes that can happen more easily at the group or population level than at the individual level, that’s interesting to me. I guess things like this happen all over—“social trends“—and I don’t feel our usual social-science models handle them well. I don’t mean that no models work here, and I’m sure that lots of social scientists done serious work in this area; it just doesn’t seem to quite line up with the usual way we talk about decision making.
