The Tragedy of Tobacco and the State: Part 3–How Cancer Became Good News

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Erik Devereux
June 28, 2024

This is the third column in a series on the responses of democratic governments to the public health disaster caused by nicotine addiction (first column, second column). The key point of this series is that certainly by 1965 the federal government and the state governments should have aggressively ended access to nicotine products in the United States. That the public sector slow walked policies to do that is a component of why the public gradually lost trust in our democratic institutions. Often it is hard to do the right thing; equally often the consequences of not are far worse.

Several years ago, I had a conversation with an oncology nurse at a coffee shop in Northern Virginia. The nurse told me a fact about cancer treatment that I had not seen widely discussed in news coverage of nicotine addiction: Of the patients in the local cancer treatment clinic, nearly all either were current or former cigarette smokers. These patients had every variety of cancer—lung, larynx, esophagus, breast, stomach, liver, pancreas kidney, colon. You name it, using tobacco clearly caused it.

When you ask nicotine addicts about the risks, often they will come back with the expectation that “only” one in ten develop lung cancer. This sounds like a low risk until you transform it into another realm such as asking, “Would you board a commercial airline flight knowing it had a 1 in 10 chance of crashing?” Most people would not get on that plane. But speaking under the influence of their nicotine addiction, smokers and vapers are prone to extreme confirmation bias vastly underestimates the risks associated with consuming tobacco products.

If you add in the near certainty of developing COPD, emphysema and heart disease, nearly 100 percent of all long-term nicotine addicts will experience lethal health effects which shorten lifespan and make the end-of-life experience one of nonstop suffering. A common refrain among the opponents of the tobacco industry is to ask, “What other legal product is this lethal when used as intended?”

A problem for public policy is that to the industries that develop and sell treatments for those effects—including pharmaceutical companies, medical technology companies, hospitals, clinics and doctors—this all is good news. One reputable estimate is that the cancer care industry is worth at least $200 billion annually. That number does not include the contribution of nicotine addiction to the pulmonary and cardiac care industries. It is a reasoned estimate to peg the value of all healthcare associated with nicotine addiction at closer to $500 billion annually.

Consequently, the health care sector’s perspective on tobacco and nicotine inevitably has been compromised by its financial stake in treating nicotine addicts. This is a canonical example of the “wicked problem” of putting prevention ahead of treatment in public policy. Regardless of domain, prevention denies service providers huge profits while saving individual taxpayers small amounts of taxes. As James Q. Wilson informed public administration long ago, those facing concentrated benefits or concentrated costs are likely to prevail in the public arena over those facing diffuse benefits or costs.

News accounts recently reported the heartrending account of a small businessman from Ohio who was “self-insured” (meaning not really insured) and found he had non-Hodgkins lymphoma. He traveled immediately to one of the most famous cancer treatment centers in the United States and was told that to get the first dose of chemotherapy without insurance he needed to pay something in the range of $50,000 right on the spot. That dose of chemotherapy did not cost anything near to that price to manufacture. The marginal cost might have been under $100 (maybe even under $10). This is but a small indication of the incredible profits lurking in cancer treatment when lives literally are on the line.

What tobacco and nicotine have yielded are a set of incentives that bind two immensely powerful industries against public health. Ironically, the stated mission of one of the two is to enhance health. The United States could entirely avoid a huge share of cancer cases in the future by ending nicotine consumption now. As I pointed out in my previous column, almost all nicotine addicts take up the habit as children so government efforts to end nicotine use could be directed specifically at the well-being of children under the obligation to protect children from predation and exploitation.

Apparently, our democratic institutions have been significantly powerless in the face of the preferences of these industries regarding the regulation of nicotine.

There are two more “players” in this drama to which this series will now turn. The first comprises state and local governments who derive operating revenue from taxes on nicotine products. Eliminating those products would eliminate those revenues. The second comprises a broad swath of the entertainment industry that is noteworthy for high rates of nicotine addiction, constant depiction of nicotine use as “cool” in front of the children who will become the next generation of addicts and a general unwillingness to be held accountable for the consequences.

Author: Erik Devereux will be Associate Teaching Professor in the Department of Public Policy, Management, and Analytics at the University of Illinois-Chicago beginning this August. He has a B.S. from the Massachusetts Institute of Technology (Political Science, 1985) and a Ph.D. from the University of Texas at Austin (Government, 1993). He is the author of Methods of Policy Analysis: Creating, Deploying, and Assessing Theories of Change (available for free here).

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