Focus 580; The Price of Smoking

In this hour of focus 580 we will be talking about the costs associated with smoking. And here's the question the basic question that we'll be talking about is it actually possible to quantify these to put a price tag on smoking to say something like for an individual young man or woman who starts smoking in their youth and smokes throughout their entire life what does it cost them. What does it cost their family what does it cost society. Can you actually put a price on that this morning in this part of the show we'll be talking with a scholar who has done that exercise. He and some of his colleagues at Duke University ad has come up with some answers and we'll discuss them this morning in this hour of the show. Our guest is Frank Sloan he's the Jay Alexander but man Professor of Health Policy and Management and professor of economics at Duke University he's also director of the Center for Health Policy Law and management at Duke. He's interested in a number of things including alcohol use prevention long term care and medical malpractise. And he and some of his colleagues are the author of a book that

presents their research. It's titled The Price of smoking. And it has been published by the MIT Press So if you're interested in exploring the subject in some depth including how it is they went about doing the work. How did they do. They did the study that some of the decisions that they made. You go out and take a look at the book and of course anybody who is interested in the subject can go out and look at the book here this morning on the program. The questions are welcome as always. The number here in Champaign Urbana 3 3 3 9 4 5 5. We do also have a toll free line thats good anywhere that you can hear us and that is 800 to 2 2 9 4 5 5 so at any point here people have questions can call all we ask is people just try to be brief so that we can keep the program moving but anybody is welcome to call again 333 W. while Al and toll free 800 to 2 to WLM. Professor Sloan Hello. Yes hi. Thanks for talking with us. Yes we certainly appreciate it. This is

something apparently that people have looked at in different ways before but perhaps not the yours as is perhaps the most comprehensive attempt to answer this question. And it seems it seems a perfectly good one I guess I wonder why it is that. It hadn't really been done before perhaps in the way that you did it hadn't been done before. Well when one thing is that we look over the whole life of course and we use a longitudinal data that is data which follows people over a number of years and typically the studies have been done looking at the cost of smoking at a point in time. So we're what we're really trying to do here is to say that you start smoking at a very young age usually before you're 21 and you basically nobody starts virtually no one starts after a certain age. So the

main of most of the action is in quitting yet. And so one can smoke for years and no no no adverse effects. You know it may be you buy it. Cough occasionally or something like that or your teeth might get yellow or brown or something like that but you don't get it. Your clothes might smell but you don't get the major health effects till you're well usually well over 50. And that's one of the problems actually that people could be smoking and say this isn't so bad. Well let's gets go to the bottom line here which is leaping all the way really to the end just because I'm sure people now are we. We've caught their attention they're going to be curious you do come up with a number do you say if we have a young a young man and a young woman and they begin when smoking when they're young and they continue into their adulthood we can look at. We can try and add up

all the various costs little things big things and talk about what it costs them just as an individual and what it ultimately cost society. And the figures are different for the men and women but they're both in six figures. That's right. That's right but there particularly in six figures for that matter I think could be a historical phenomenon because men back when we were looking at. At the data we've been looking it we're looking at people who are now old who started smoking a long time ago at that time. Men started smoking much before women. So the women are catching up with the men. In this regard. So the figures are for males and females are like one hundred seventy one thousand. And now what is that one hundred seventy one thousand represent. That is if a person is smoking at age 24.

This is the present value that is in today's dollars. What we would expect to be expended by that person or behavior on behalf of that person or over the person's life course takes in account that some people will quit after the age of 24 many people quit after the age of 24. But it's just saying that if you have a population say in Champaign-Urbana you know 100 people over age 24. Then we would multiply these numbers by a hundred. This is what you would expect. They will spend or will be spent on their behalf over the rest of their lives. This comes just one hundred seventy one thousand dollars figure comes to thirty nine dollars and sixty six cents per pack. It's almost 40 dollars a pack. I think that's a that's an interesting and and striking way to put it. When you put your cigarettes or are quite expensive now and certainly they're more expensive when I was a kid.

But this is in even the price tag is even bigger when you say to somebody do you know really what the cost of that pack of cigarettes is it's when you load up all the cost. Think about it if you continue smoking. It's $40. The thing though I think that that's really striking is that we think a lot about the cost of smoking to individuals and rightly so because obviously it affects their health and then it will it could well affect the people of health of people around them. And you know people that are connected with them spouses children and so forth. I think we do also have concerns about social costs and we think that in fact society perhaps will have to one way or another pick up a lot of the burden. And what I think is striking to me is that in fact the the the bulk of the cost of this approximately 40 dollars a pack of cigarettes. Most of that something like 33 dollars is ultimately borne by the individual. And the social costs are actually a rather rather small because that

the simple reason is that. Smoking kills people who smoke die off sooner. So this means that you're not going to have to pay the pensions you so Security benefits Medicare sort of benefits. So you've got some smoking related disease and grace but people are dying much earlier so in a way we could say that smoking improves the financial health of many of our large programs. I'm sure that some people would say that having this information would give you yet another argument to try to persuade people not to smoke or if they do to quit. On the other hand I suppose some people might say that this last point that you have made says that it throws the ball back in the court of personal responsibility ends and says something like Well if you want to smoke that's up to you. But there are

significant costs that you personally will bear. And in the end this does come down to you know you decide what you what you want. I guess I wonder what you think about the the usefulness of this kind of data in more than a purely academic sort of. Well hopefully that it will tell people. Who are smoking to say say for example the hundred 71000 figure say you know have you had that money that cash flow you could buy a house you could buy. You certainly could buy several cars. You might not buy a luxurious house but you could certainly buy a house now instead of buying this house you're spending it on this. So it seems sort of foolish I mean even though there may be some benefit. People like smoke and or they they feel stressed in the soap's them etc.. But but basically this is a very very expensive habit. There is also the $5 and

44 cents that goes to paying coverage because you know what happens to the family. And did the thirty three dollars this not take into account the fact that if a parent dies prematurely then the kids suffer the family suffers in some way that intangible way that we did not measure. Well we have one caller and we'd certainly welcome other people who have questions or comments you can give us a call 3 3 3 9 4 5 5. Toll free 800 2 2 2 9 4 5 5 the color here to start us out is in Aurora and it's on our toll free line. Hello. Yeah i m running I've got off. I just watched my friend die. Team of five months and all I could think every time I went into a room was I wish smokers came with me so they could see what I was seeing. I one of those people that can't smoke or

just can't. But I watched it for five months and that's to say it is fighting anybody who wants to see because there were so many saying that happened so many occurrences. Like the time she was taking a shower and the count came out of her no she wouldn't take a shower anymore cause she was afraid that the candle would come out of her nose and she could not breathe anymore. There was so many incidents like that. It's it's very sad but I do have some questions. Promised the body more out of your cigarette. OK that's a good question. Alcohol in moderation. The data suggests it actually is good for health. Now we the people hate to give that advice because they're afraid that people who might start out as moderate drinkers end up being

heavy drinkers but some drinking actually. Most all studies show. Those people live longer who drink a little bit versus the teetotallers and in some sense in some studies heavy drinkers aren't even that harmed and the difference is smoking any amount of smoking is bad. So I wouldn't want to ask. Right right. Faming right. A vote to tell somebody not to drink and do something about it but everybody tells me you can't tell somebody not to smoke. Why can't you. Well I think that we somehow have made smoking to be not an issue of morals and drinking. Somehow drinking. Some people have religious reasons for you know thinking that it's sinful to drink and and we haven't associated that with smoking. But that's one reason.

You know that's much more it's much worse to smoke for your health it's much much worse. What about laser treatment I hear advertised as a way to stop smoking is that. These are treatment. Is that something that should be looked at the paper. I don't know there are many different ways. There are many different interventions. And the problem is that not all of them are going to work as well with people you know going back to your emphysema point. We just done a study another study where we interviewed people who have emphysema and chronic bronchitis and it's part of that study. I went to the center here where they're doing rehab for people who have had onset of emphysema. And it is amazing in one case I spoke to a couple and the demand actually was awaiting a lung transplant and they're having to live in an apartment here in Durham because they come from out of

town and so their whole life is being dislocated. And yet his spouse continues the smoke. I know I know I mean I had seen and then you just look around and and all these people you know the people are you know the all with you know oxygen tanks and the whole thing because young people don't have never seen these oxygen tanks. So maybe in a way if we could have show pictures of what it's like later on but we behave on TV we even have an oxygen there's some an ad for some oxygen tank that actually makes it seem attractive. I mean you see this guy carrying around a tank and playing with his grandchild and it doesn't even it doesn't seem that bad. All they had to say might go what my friend they say my friend. Oh absolutely I'm sure I am letting you but people just don't. So actually what we found in some of this work is that people fear death less than they fear

disability and dependence on others. So what they think is well yes I'll die early but it will just be like an instant heart attack. My heart would just stop and it will be painless and there will be nothing you know that happens before them when in fact they will be disabled earlier and they are not necessarily longer. But we find that certainly earlier they're younger when they get this disability. I have another friend who retired from the area. To warm climate and had to go back to work to support her smoking because she has been in and out of the hospital E.R. room for three weeks now. So the costs do mount up but they do make a terrible dent in your life when you retire and then have to go back to work to support your habit. Right. Even with Medicare that doesn't take care of everything. The other thing I think is great. I have since my friend died

if I see some young children in an appropriate setting I talk to them about not smoking. And they tell me that in school they get told all about not smoking. The lungs fill up like and I thought to myself Well isn't that a great thing. It is but they think a lot of them think that they can quit anytime they want to so that they can be in denial and figure well that's what happens if you smoke all the time. But I'm just smoking now whenever I want to quit oldest Kazim I learned I had looked new. Then I met a few young people who were at war bots in college and they were outside the door smoking and that was just about when my friend died and I guess I just was so so hurt by the whole thing and to see these pretty young girls 20 years old smoking and I stopped and I asked them may I speak to you about

smoking and they just look at me. So I told them and then I said this. I went on to the next generation. I said if you don't do it for yourself when you get pregnant will you at least do it for your child that's coming at that. Then I left. I felt like I was an evangelist of some kind. But I guess I was so tormented by having just seen my friend die that I just had to voice my you. What we have annually four hundred and thirty thousand tobacco related deaths in this country. Now I mean well 9/11 was terrible and all that you know we were talking about 3000 or something like that. You know and it was absolutely terrible. But for some reason we can't get national publicity around the 430. That is happening 2000 is happening every year and I didn't believe those numbers and so as part of this research we we really did those numbers we did the calculations ourselves and we came up with the same numbers the Centers for Disease Control.

So I mean this is a phenomenal number of people I mean the biggest some sticky in the country. I mean people dying every year. Well thank you for the populace. Thank God giving. Thank you I have thanks for the call we are talking this morning in this hour of focus 580 with Frank Sloan He's professor of Health Policy and Management also professor of economics at Duke University. He's the director of the Center for Health Policy Law and management at Duke and is interested in a number of subjects among them alcohol use prevention long term care medical malpractise also has a longstanding interest in hospitals and health care financing. He and some of his colleagues have researched this question of the costs of smoking to individuals and society if you're interested in reading the results. It has been published as a book form in a book form and it's titled The PRI. Smoking and it's published by the MIT Press questions are welcome. 3 3 3 9 4 5 5 toll free 800 to 2 2 9 4 5 5. We talked a little bit at the beginning about the the

bottom line numbers that you have come up with and the fact that before you find that over or over a lifetime you have someone who starts smoking young and continues to smoke that the costs to that individual are considerable. That the private cost of smoking for your your average female smoker is a little over eighty six thousand dollars and for the man its a little over one hundred eighty thousand dollars hundred eighty two thousand dollars more than that. Part of that is simply the cost of cigarettes but thats certainly not the biggest small thing thats a relatively small but 13th out there spend about $13000 over that time on cigarettes but most of it. Thanks. Can we take that apart a little bit and taught her a bit about what with the various costs are they now the one that the medical care is a cost. OK but it is not the major cost. Here because of the longevity shortening because we know

that if somebody were to live to a ripe old age they would be a lot of spending on medical care costs. And so that isn't or isn't the big what is B is the mortality cost and that is maybe a little controversial by mortality cost. I mean the decrease in life years that the person experiences and what we're doing and this is based on a lot of other research we're valuing a life year at $100000. So if if your life is cut off by six years because you smoked that is approximately 600000 out of that number so big and the the aggregate number is so small the thing is we use a discount rate of 3 percent. And so the 24 year old for whom we're making this calculation will be

dying earlier but probably. Five or six decades later and that just gets discounted to a much smaller number. So a chunk of this is is mortality cost. Then there is some cost of disability as well. We we say that if somebody is seriously disabled we value that it fifty thousand dollars in value a life here rather than a hundred thousand for somebody who is fully able. And so some of it is that then some of it is medical costs. But that's really not at the very top in terms of the driver. And some of it is work loss. And we take in account and the external calculation sickly because when you're absent. Presumably your coworkers are really bearing the cost of your absence rather than you. If you have sick leave and so that that is considered as well but those are really of smaller

magnitude. The big thing that happens with smoking is it shortens your longevity. What does that mean in terms of lost productivity too. The economy and how does that balance against the fact that if that person does die younger than we expect then that also means that they there may be potential benefits that they will then not draw because they don't live at all that's the main thing. OK the thing is the death occurring. This substantial increase in death in the 50s that the base do with a mortality rate base of a never smoker is not that high in the 50s in the 60s. The base is substantially higher in the 70s much higher still in the 80s still much higher. So it's really in a lot of the people who are dying probably not dying during that time in which they would be most productive in the labor force.

Some of them many of them would be retired already so they're at that time in which that's why the social cost isn't greater. They're dying at the time that they typically would be getting Social Security and getting Medicare and getting public assistance if there if their income were very low and that that is eliminated by smoking. So I would lecture to cardiologists not too long ago and I say to you you know you guys are doing in this post security program piece. They're keeping people alive keeping people alive longer. Yeah right and so from the standpoint of the health of the security program keeping people alive is bad. What would be good from the Social Security programs perspective obviously that's not the perspective we want to take. But but would be there for people to pay into Social Security at least more people to pay into Social Security for years and then they die at 66 and not leave a surviving spouse. Yeah I mean that would you know. So the program would be collecting all this money and then the

payout would be very limited what. And so that's why the security program is in trouble now because for example smoking rates have declined substantially especially for men. We did a talk at the beginning about about how you did you add up all the numbers and then you break this down in a per pack basis and you conclude that the combined price is paid by individuals by their families by society is about 40 dollars a pack for cigarettes and that most of that cost is is borne by the individual smoker that bad spot 33 dollars for them it's about five and a half. Dollars for their families in about well under a dollar and a half for everybody else. Can you talk a little bit I'm most interested in having you talk a bit about how the ex Turnell costs breakdown and what it is that that goes into that dollar forty four that the society pays. OK some of that is a

neonatal you know sort of birth related problems. Some of that. OK. Another part of that is a small piece is due to the effects on Medicare and Medicaid. You don't know when the Master Settlement Agreement will settle with a look at the back of companies they came up with a huge huge estimate for Medicaid costs that triple or smoking were WAY lower than attorneys general were in. And you know and there's assessments of that cost. And I suspect the reason is that we're considering the fact that the Medicaid you may be more likely to be on Medicaid if you're alive but if you're you're more likely to be dead. Even with Medicaid certainly with respect to long term care costs. You know like a nursing home costs which are a substantial part of Medicaid. That piece you're not going to see as nearly as much with the smoker.

They're less likely to be in a nursing home. So that would say Medicaid is the major payer for that and that that is saved. Also we're netting out of the social contributions that those people are making in terms of excise tax smokers. So that keeps it down a little. Let me ask that we're putting that in the private but we're not double. You know we're not double counting so we can't put it in twice. There's a section early in the book where it as you're going along through the book that you're looking at talking about your methodology. Looking at what it is that you're hoping to find out in the holidays you hope to go about that and and again going to this issue of what the costs are and who bears the cost there's At one point here where the in the text you pose the question Do smokers pay their own way from a social perspective do they. Well they do to a large extent. OK but I think you know we are great believers in our free society that people should be able to die.

The way they run our allies himself I mean that that is the belief that we that most of us share. And you know people want to spend money on the Cadillacs or going to Hawaii or whatever. That's their own affair and it's really not the duty of the state to tell people how to spend their money. The big question that we have here though is are people under the age of 24 which is the year we're doing the calculations from 24. Are they really able to make these rational calculations. And we heard from the last caller where you know she's trying to tell people about the dangers of smoking but there's a lot of rejection of that. And so that really raises the question as to how private are those private costs. I mean it's one thing if they are right if they are right that there was some rational calculation. It's another thing if they're arrived at because of advertising

or peer pressure or whatever. And these are choices that the people would rather not make. Looking back on their lives obviously at the time they made them they were happy about it. But looking back later in life this thing would see why in a world that I do that that was a terrible error and wouldn't be good maybe if the state did something to prove either information or make cigarettes less accessible or do something to make it not as easy to make this choice. So I mean in that sense the private decision isn't quite as private anymore because we're saying we would be better off as a society if we made cigarettes less accessible especially to young people. We are a little bit past the midpoint of this. Our focus 580 Again our guest for the program is Professor Frank Sloan he's an economist. He's also professor of Health Policy and Management at Duke University. He is the director of the Center for Health Policy Law and management at Duke and he and some of his colleagues had been working on this

question for some time and the results of their study have been published in book form so again if you're interested in looking at. And it goes into the subject in great detail. The title is The Price of smoking and this book is published by the MIT Press. It's out now and the questions are certainly welcome 3 3 3 9 4 5 5 toll free 800 to 2 2 9 4 5 5 and we have some callers Cyr will go to champagne. Next line number one. Hello hi. I wonder if you're doing this sort of work in the field. I'm thinking of asbestos and red and often. Preservation people are accused of being unduly concerned about those hazards and people who can down buildings being overly concerned with. I wonder is that easy. Costigan I'm

thinking of a factory that I think is not too far from you if you look at that at that moment closed out industrial factory. And the question for me is do you pull these down or do you add tremendously. Energy consuming to pull down and recreate. Ed do you have. A system for questing after items like lead an asbestos I think we could use the same method of calculation. The problem is that it's much more difficult to measure the exposure. With cigarettes if you're a 50 year old and you're smoking we can easily make an assumption that you have been smoking for 25 years or more. I mean we can you know that's a very safe assumption. Yes with exposure to asbestos and lead you may be exposed at a site and then not exposed and so it's very hard over the life course to measure you know exactly what that exposure has

been. Yes it's much harder. Right. Care that diesel fuel had sometimes seventy five rigs that cannot and and produce and fizzy and I wonder if that is a measurable device. I don't surrender to what extent if education comes into this if you know if there's a cost to the nation of educating a person could set an age and I across t'ing in Maine and there are the educational value of that person is a certain amount and that person dies five years younger than me and serach a cross-tab education it's just needed to account if their earnings are higher we have taken that into account in our calculation. We have not taken account the fact that since you go to school you're more you know you like poetry better and you're more cultured person and five years of that is

lost in terms of earnings we have measured. So I think that part is OK. Then these two different exposures you're talking to are maybe somewhat different. If we're talking about a bunch of trucks and we we could measure for champagne. In terms of the environment and we knew but then we will see what we have to know as well. More or less how long has that person lived in that environment but we would also need to have measures as to how many trucks were coming through over time and that is just a toughie. I mean I think I picked off the easy one. I thought I thought you were trying to say. You know smokers rights people will say Why are you picking on us. You weren't saying that but nice now you know why you picking on us. Glad you picked on lead you know. Yeah yeah you know that that's bad too but you always come back to smoking to the disadvantage of smoking from from their perspective.

It is that it's easier to measure. I mean you know so yes the survey didn't exactly say when did you start smoking but if we're talking about 50 year olds which we used a part of the analysis of 50 to 60 year olds we know that they started when they were teenagers and early 20s. You know I mean we don't you know the few few people started age 45 and we can get some we're just taking average effects we're not looking at the intensity of the smoking. So it's an easy one to pick off. Drinking is harder because drinking varies over the life course in very unpredictable ways you may be a tea totaller for 10 years and start drinking and then tea totaller again and you know I think it's very much worth the temp. I think I can you know improve the statistical model. And and it's very encouraging. Thank you very much. Thank you all. Let us go to another caller this is someone north

of champagne line number two. Hello. Yes. I don't listen to Rush Limbaugh occasionally and one of his arguments is it cuts down on nursing home costs because people who are smokers die sooner. However we had an aunt who broke a bone. She recovered very well from that and would not have had to go into a nursing home except that she had been a smoker so she would not have been in the nursing home and incurred those costs in the first place. That's not been a smoker. OK well Rush is correct in a statistical sense. But that doesn't mean that it never happened. It bein said if you go to a nursing home the average person in a nursing home. It is a very advanced stage and it's just going to be some people who are smokers because their genetic makeup is such that they could smoke drink and do everything

else you know and they still are survived. But if you interviewed people and said Well when did you you know how much smoking do of your life course. They would be less of it. Among those survivors in the nursing home. So Rush is right but I don't know what you do with that because you really have to look at all the other numbers too he just picking the number that does him some good. Fred I've noticed that there are also American Vera increased health care a Cochrane employee I believe it or in Michigan who want to be able to not hire people who are up for a job because of her health care. Right because he's and he's only hiring people who are alive. He's not hiring dead people so if you hire somebody who's alive by definition they're going to have higher costs during the years that they live. So my calculations are looking at. You're taking to account the fact that the smoker dies earlier and then of course there's zero cost during the

years their debt for the employer the employer is looking at it's smack in the face and is saying now this person gets on the job that person is going to be absent more that person is going to have more health care costs. And we do find in this study somewhere it's deeply embedded in the study that smokers holding a bunch of other factors earn less money so they are a little less attractive in the market marketplace as well as we could control for other factors. And that's probably because they do have more experience with work absence. So far what about your concrete mixer for that car. Are borne by the individual marker. However what about crack and where there are people who record in there too that's $5 and 44 cents a pack of four four members of the family we did not consider the workplace. Should be an important consideration.

All right you know it is health care a car for all go up because the smokers running rivers wrong but they don't. River healthy live and then clear over one day. Caraway incur a great medical issue that all of us. I mean it would be nice if that were not the case but if all of us sort of toward the end of our lives we all incur costs where the other is and you know where our hard knockers wrecker or RL But they don't they get sicker and all that and they don't get all Simers as much because they're they're dying before they get Alzheimer's. If all of us any of us I mean we hate to think that we would ever get Alzheimer's I mean terrible things but if we lived a hundred twenty hundred thirty we probably get it so you know so. So if you so there's certain diseases that they're getting less. It's not all getting more. They're probably breaking their hips less because they're just don't get to

that age. But very complex. Yeah. Well thank you for the call I appreciate that let me just I guess I want to be clear about this is professional Sloane if we do if you do one thing we know is that the vast majority of the spending on people's health comes right at the end of their lives. If you exclude However the cost of long term care and then you compare the amount of health resources that people consume and you compare smokers with nonsmokers do the smokers do they in fact consume more health care resources than nonsmokers they do if you look at the Medicare benefit. OK but if you put in long term care that runs the other way. Let's go to another caller in the champagne line. In number three. Hello. Hi. Yeah I was and I decided when I was in high school it was the partnership between the teenagers and there were no Department of Public Health

and some of the stuff I've heard kind of made me think of one of the factoids I learned. They said something like the Czech Republic saved about twelve hundred dollars for every person who dies early from smoking. Have you done any sort of research to figure out how much the American government saves or anything like that. Well you know that's what our study does. First of all that that check study was I think paid for by Philip Morris of one of the companies. Yeah I wouldn't be surprised. You know and we have we reference that check study but I would we didn't I take it that seriously. The government saves the Social Security but it doesn't say on Medicare and it doesn't save on Medicaid it pays a little you know extra. So who knows for how they did that check study but I think it was even embarrassing for the cigarette company at this point to be putting out a study like this. Yeah it really surprises me that anyone could be that sort of crass because maybe they save money

but I'm just thinking about the families who lose their mother or their father or whatever. Well that's why you don't want to just consider the medical cost. You don't want to just consider as the last caller said the nursing home because the only way you want to consider that losing a parent or spouse early is costly to society we have something you know we spend a lot of money extending life in extending the quality of life I mean phenomenal amount of money and that's going to go up. So obviously we value. I mean aside from the religious reasons we value life you know where we're willing to pay to extend life. And we have all kinds of interventions that are that take place because we want we hold life dear. There's a sometimes sorry just sometimes I wish I was but I want to be like a crusader. But it's really hard to do both my grandfathers personal game. I had an Uncle Win that when I was a baby and I don't even remember him he died from sulking and I just really want to do something to stop people and it's so hard. I actually can see I actually

convinced one person high school to quit smoking. She is like the only one and I just wish there was something I could do it's just something that matters to me. Well I appreciate that I thought with what the thing is the average young person even their grandparents are healthy you know when they start out to be say oh my grandma I'm a grandfather healthy you know. And I you know so I mean might be anything. You know I mean I don't smoke either but then you know. So when they see them there's still hope that you the stuff the bad stuff starts later. Well I appreciate the comments of the caller once again and I want to go to Urbana for our next line number one as well. Yeah. Real sad good man recovering from a cold. Commentary. I think it's Mississippi where it is. You know these settlements are made in terms of against the tobacco companies and smoking among you know the youth by half. Now they're trying to get that money it's

set up in a separate fund and they're trying to get the money. Then you look at other states that have actually squandered that money. So I'm actually going more for a comment and from your ok the vast majority of states the word squander. Maybe that's a good characterization. If it's one that I have not used in my writings but I have used to the where did they have not allocated that money for tobacco control or even for health. And so you have states that are. Solving their budget deficit problems with a tobacco settlement money so what by the one hand what they're saying is you know this whole smoking is bad to sell smoking as cause Medicaid is costing us state a lot of money. Then on the other hand when they're given money and have the opportunity then to spend it on cutting the problem down further they decide not to do it and so they're really two faced in this room in this respect. You know the irony I think again in Mississippi the irony in that one is that they want to use the money to prop up their Medicaid costs. I mean to cover their Medicaid costs go up.

I mean very very sad. Thank you very much. Well I'm glad the caller raised the question it was something that I wanted to raise with you too because we came across one paper and I'm sure you've probably done other writing on this very subject that is how the states have spent the money they got from the tobacco settlement. And I was certainly curious because there has been a lot of criticism there's been criticism here in the state of Illinois and I'm sure other places by people who say that. The that that only small amounts of money have been spent on anything having to do with health much less smoking prevention is is that is that a true story on Alderaan only a true story overall. We've published two papers over published one and another one will be coming out on this very issue of the month papers in Health Affairs in the January February issue. And we looked at six states in depth. One of them being a neighboring state of Michigan and Michigan

and spent the money on scholarships for college. And I argued that that was justified because of education and it contributes to reductions of smoking. Another state North Dakota spent the money on water projects and the argument was that water sanitary water is safe water is good for public health. California through the money not only through the existing payments but through their future payments into a pot and just spend it on deficit reduction. They they securitized their debt so that means that they essentially what they've done is that all of the income payments in the future will go. Most of them will go to pay bondholders. So I don't know exactly what's happened in Illinois but it is just.

The states have just been irresponsible. We have some other callers here and again our guest is Frank Sloan. He's an economist. He's professor of health policy management at Duke University and he's the one of the authors of a study has that has come out and been published in book form looking at the social individual cost the the total cost of smoking that the book is titled The Price of smoking is published by the MIT Press. We have about seven eight minutes left we'll try to get some more callers here. And I believe the next person should be in Savoy line number two. Hello. Oh hi how you doing. Good. Yeah. I'll tell you a lot there's whatever you want to look at information that are really shows that smoking's bad news. You have to go all the way back to the 50s and the 60s and and read some of the initial papers and reports that were coming out by the researchers that were starting the study of this. And back then you know they

used some you know by today standard they use a really crude but very effective method to show that it was really bad. And it convinced my father whenever it came across his desk that hey you're poisoning yourself and you're setting yourself up for you know. Lung cancer and ordinals wot. Those pap those papers are very graphic and they and you know they they couldn't gather. You know the kind of information and they didn't have the database that we have today and everything but they came to the conclusion immediately using in very blunt terms it was bad news. It kind of surprises me why this information is not resurrected and put in front of people. Tell you why it's very convincing. Well we of course I've looked at those studies now that I'm an adult. I grew up in the tobacco producing state of North Carolina and actually I also found among some of my materials a little notebook that I wrote when

put together when I was in the ninth grade and it has a newspaper clipping and some comment by me where I talk about the so called evidence or something like that yeah. So in other words this was 1957 a 58 57 I think of 56. I was saying yeah that stuff is out there but that's just. Good there was a lot of people well you know my father was highly educated and whenever it started coming across his desk. I'll tell you what it really got his attention. Right but he was I was more at the kid age. Yeah. And so I was we were so apparently I put that in my notebook and there's no comment from a teacher you know. Now this was seemed sort of not as a communist plot but similar. Hey I got one other thing that's kind of my hot button too. And it's called creative accounting. And we do a lot of capital you know capital capital work for customers it's mainly in the industrial area. And I'll tell you what no one no one will let us take credit for intangible value or anything that we can't prove

or show it's going to show up in a bank account. And and we do it. Yeah. Now it seems like there's two parallel counting systems here. Whenever we're dealing with public and private. Have you been able to reconcile that. OK well actually I do a lot of work in malpractise. And in the toilet the courts do recognize intentional values and that's what this whole thing about pain and suffering awards and all of that is about. But you've got a debate you know ever you start getting to the intangible area people say this is squishy this is not these aren't real numbers but yet we know that people by their actions are putting some value on this. I mean after all we take pain killers if pain was not worth anything why would we spend so much even on Vioxx or on aspirin. You know I mean this would there would be zero consumption. Obviously we take it because because it hurts and that's worth something to us in the marketplace. But there is always around these intangible

values there is some debate. You know people could say well you can't prove that the cost of a life years 100000. You know that's just arbitrary So I say OK you say it's arbitrary Let's then just do sensitivity analyses and let's assume that it's worth one hundred fifty and worth 50 and 40 and see what numbers we get you know and see how sensitive the calculations are to that. You clearly any one value is difficult to defend where you know we've used our time and we're going to stop and I should apologize we had a couple callers who wanted to offer additional thoughts and we just didn't get a chance to get to them. So I appreciate the comments of everyone who called in if you interested in further exploring the subject you can look for this book that we have mentioned the price of smoking published by the MIT Press one of the authors the lead author. Our guest Frank Sloan from Duke and Professor Sloan thanks very much. Well thank you.