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