John Cawley is a professor at Cornell University in Ithaca, New York and co-Director of Cornell's Institute on Health Economics, Health Behaviors and Disparities. His research focusses on the economics of risky health behaviours, in particular those that relate to obesity. For the next four years, Cawley will be working part-time at Erasmus University Rotterdam, as Erasmus Initiative Professor of Health Economics with the team Smarter Choices for Better Health, one of Erasmus’ initiatives to make a difference and have a real impact on society.
On Friday October 12 he was one of the keynote speakers at the kick-off conference for Smarter Choices for Better Health, held at Erasmus University.
Can you explain what you do?
‘I’m an economist who studies the economics of risky health behaviours such as poor diet, obesity, physical inactivity, and smoking. My main focus is obesity, but I’m interested generally in risky health behaviours and how people make decisions about them. For example, what causes people to engage in risky behaviors? What are the consequences for their health and for society as a whole? What are the effects of government policies to prevent and reduce risky health behaviours?'
Why do people engage in risky health behaviours?
‘Because they all give pleasure! Smoking gives you a nicotine fix, taking drugs makes you high, drinking makes you tipsy. So, the question is rather: why don’t we do more of them?
One characteristic common to all of these behaviors is that the pleasure is experienced immediately, but the health consequences occur much more long-term. As a result, people who are not very forward-looking or who are impulsive may engage in them too much.’
You are affiliated with Erasmus University Rotterdam for the coming four years, as part of the Smarter Choices for Better Health initiative. What do you think of this multidisciplinary initiative in tackling this subject?
‘I think it’s great. If you want to seriously study health behaviour, your approach has to be multidisciplinary because there is no one discipline that has all of the answers. The decisions are to some extent economic, like taxes on cigarettes may make people buy fewer cigarettes. But there are also sociological components, genetic influences, and epidemiologic aspects. It is really necessary to have a multidisciplinary team studying these issues.’
Do you believe it is possible to make smarter choices for better health?
‘Yes, absolutely. One useful thing about economics is that it provides guidance on when and how the government should intervene. The test is: in what way is the free market failing? If there are such failures, policies should seek to fix them. For example, people might lack information about the risks of smoking, or of unprotected sex. As a result, they might engage in too much of those activities. The logical response is to provide that missing information. Another market failure might be external costs; does your risky behaviour harm anyone else? If the behaviour is victimless, it is none of my business what you do. But in case of obesity, there are high costs of obesity-related illness like diabetes to the healthcare system, and as a result everybody pays higher taxes and premiums. To reduce those external costs, governments could subsidize exercise or tax foods that especially promote obesity, like sugar-sweetened beverages.’
'If you want to seriously study health behaviour, your approach has to be multidisciplinary because there is no one discipline that has all of the answers.'
John Cawley, part-time Professor of Health Economics at Erasmus University Rotterdam
Is there a difference between prevention in the United States and in the Netherlands?
‘There are some big differences in the prevalence of risky health behaviors. For example: even though the prevalence of obesity has increased in both countries, it is more than twice as high in the U.S. as the Netherlands. The U.S. is also struggling with an epidemic of fatal drug overdoses that thankfully the Netherlands is not experiencing.
There are also a lot of interesting differences in the ways risky health behaviours are regulated. Historically the Netherlands had more liberal laws regarding marijuana but now some U.S. states (like California, Oregon, and Colorado) are legalizing it for recreational purposes, making it even more available than it is in the Netherlands, while other states continue to outlaw it even for medicinal purposes. Policy varies a lot across states.’
What will be your role at EUR?
‘It is wonderful that this initiative is bringing together a lot of different researchers. Erasmus University Rotterdam has a large and outstanding group of health economists, it is one of the best universities in the world for health economics. I’m excited to work with them, as well as the fantastic set of team members from other disciplines.’
Will you be able to bring the outcome of this collaboration back to the U.S.?
‘Absolutely. One nice thing about risky behaviours is that they are universal. Everyone to some extent struggles with the temptation to overeat, use drugs, smoke, abuse alcohol and have risky sex. Because the same basic problems around risky behaviour exist everywhere, we can all learn from each other. It’s exciting to study the different approaches of different countries, and to determine what is working in one country and bring those lessons to other places.’
If it is so intrinsically human to have an urge for risky behaviour, how can we ever solve these problems?
‘Great question. None of these behaviors are genetically determined. We know from economics that people do respond to incentives. There have been success stories. For example: we’ve seen dramatic decreases in smoking worldwide due to policies, information and taxes. So it is possible to change.
On the other hand: in the US the obesity rate has tripled since 1960, and it’s not because our genes have dramatically changed since 1960. That change in weight is the result of changing circumstances, policies, and environment. High-calorie food is more easily available, and sedentary entertainment has become much more abundant. Paid work has also become more sedentary. Even my job – being a professor – has become more sedentary. When I was in graduate school, if I needed an article, I had to walk several blocks to the library, go downstairs into the stacks, search for the bound volume, and photocopy it. Now I just stay at my desk and click the mouse to download the PDF. These changes accumulate and can affect people’s weights.
However, just as changing circumstances led to the rise in obesity, I believe we can also reduce obesity. We want to keep the benefits of technological progress but minimize the negative consequences that can sometimes arise. That’s the challenge that all countries are facing.’