When Health Policy and Empirical Evidence Collide: The Case of Cigarette Package Warning Labels and Economic Consumer Surplus

摘要

In its graphic warning label regulations on cigarette packages, the Food and Drug Administration severely discounts the benefits of reduced smoking because of the lost “pleasure” smokers experience when they stop smoking; this is quantified as lost “consumer surplus.” Consumer surplus is grounded in rational choice theory. However, empirical evidence from psychological cognitive science and behavioral economics demonstrates that the assumptions of rational choice are inconsistent with complex multidimensional decisions, particularly smoking. Rational choice does not account for the roles of emotions, misperceptions, optimistic bias, regret, and cognitive inefficiency that are germane to smoking, particularly because most smokers begin smoking in their youth. Continued application of a consumer surplus discount will undermine sensible policies to reduce tobacco use and other policies to promote public health. The 2009 Family Smoking Prevention and Tobacco Control Act (HR 1256, 2009) required the United States Food and Drug Administration (FDA) to issue a regulation requiring cigarette companies to place large graphic warnings on all cigarette packages. As part of the process of issuing this regulation, the FDA conducted a cost–benefit analysis of the graphic warning label regulation. 1 In its analysis, the FDA estimated the benefits of graphic warning labels, including reduced tobacco-induced illness and premature death, then cut the estimated benefits of these warning labels in half to account for the cost of lost “pleasure” smokers incurred as a result of quitting (and lost pleasure would-be smokers would never experience) because of the new warning labels. The FDA quantified the cost of this lost pleasure using the economic concept of “consumer surplus,” which is the difference between what a utility maximizing individual would be willing to pay and the actual price. 2–6 Because of the extent that smokers are willing to pay more for cigarettes than their monetary cost, this willingness to pay more is an indication that smokers obtain a surplus benefit of smoking beyond the cost of the cigarettes. The FDA justified applying a large discount to the estimated health benefits of the warning labels, stating, The concept of consumer surplus is a basic tool of welfare economics… . In an analysis of benefits based on willingness-to-pay, we cannot reject this tool and still fulfill our obligation to conduct a full and an objective economic analysis. 1 (p36714) Consumer surplus based on willingness to pay is a well-established concept in classical economics and is grounded in rational choice theory, a normative model of human decision-making. 7 Rational choice theory represents human decision-making at its most logical, when decisions are the result of careful cost–benefit analysis, with people choosing the option that maximizes the utility of the choice after subtracting perceived costs. 8–10 When applied to smoking, this theory posits that smokers (and potential smokers) smoke because they computed that the current and future benefits of the pleasures of smoking outweigh the present value of future financial, social, and medical costs of smoking. 11–13 These benefits may include both the physiologic responses and emotional or social advantages (either real or imagined) that smoking provides. By contrast, a large body of empirical evidence from cognitive behavioral sciences demonstrates that smokers (and would-be smokers) smoke because they are addicted and overestimate their ability to quit in the future. 14 Rational choice theory (and the adjustments that have been proposed to deal with addictive behaviors) assumes stable preferences, foresight, knowledge, and adequate cognitive abilities to make the decision to start or continue smoking. Conversely, empirical evidence demonstrates that these assumptions are seriously violated by smoking behavior that almost always begins during adolescence 15 (p179) and continues in adulthood through addictive consumption. In addition, there is no empirical literature that suggests adults who start smoking engage in deliberate decision-making processes in which they evaluate risks against benefits. The empirical literature suggests the opposite; even adults, who presumably are better equipped to consider the risks and benefits of smoking, do not anticipate regret or understand addiction. 16–18 Applying a significant loss in (real or potential) consumer surplus when measuring the value of antismoking initiatives has important implications for policy, including reducing the benefits of proposed health regulations. This reduction in the estimated benefits of the policy results in weakened regulations that are harder to defend when challenged in court. 19,20 In using consumer surplus, a measure grounded in rational choice theory, to estimate a theoretical “cost” of not smoking, 1 (p36772), 4 the FDA is ignoring the strong empirical evidence against