By Spencer B. King, III, MD

The recently published book, Scarcity: Why Having Too Little Means So Much, by Sendhil Mullainathan and Eldar Shafir (published by Times Books), presents ideas about how thinking is changed in the face of inadequacy. Based partly on studies in behavioral science and economics, the authors show that scarcity of money causes behavior that is counterproductive to solving the problem, and scarcity of time leads to procrastination that also compounds the time shortage. There are numerous examples of investigations demonstrating how farmers lacking adequate resources make short-term decisions that negatively impact long-term goals, and how business people with inadequate time put things off that waste more time in the long term. There are economic implications for addressing poverty, as well as efficacies in business and life.

In addition to the scarcity of time and money in our lives, I wonder if a scarcity of political courage might be responsible for changes in our brain function that lead to decisions or indecisions that are adverse. It doesn’t require much imagination to see this happening across the political spectrum.

There are, however, examples of scarcity of political courage that clearly affect our success in dealing with cardiovascular health. I serve on the regional American Heart Association (AHA) board with a number of medical and business leaders. The AHA has a strong commitment to prevention of cardiovascular disease, and a recent discussion focused on the efforts to reduce the long-term impact of cardiovascular disease with specific programs at the local level. An attack on childhood obesity was chosen as one that could garner broad support. I pointed out that, as laudable as trying to impact health through dietary changes and exercise programs is, there is a much more impactful intervention that has very strong evidence for reducing future cardiovascular morbidity and mortality: reduction in the incidence of smoking.

Although my comments were met with agreement, my suggestion of a campaign to raise the cigarette tax in Georgia (one of the lowest in the country) was met with “we can’t go down that road again.” I was quickly reminded of the last attempt to pass an increase in cigarette tax in the Georgia legislature. After aggressive lobbying, the plan was voted down and replaced with a surtax on hospitals to replace the revenue which would have been gained with the cigarette tax. In other words, don’t rattle the cigarette lobby and don’t get charged by your opponent with taxing their voting constituency. Just raise the taxes on the hospitals already operating at a loss to care for the complications of smoking.

There’s overwhelming evidence that significant increases in the costs of cigarettes will reduce consumption. A recent review published in the New England Journal of Medicine suggested that doubling the price of cigarettes in the next decade through increased taxes would reduce worldwide consumption by one-third, while increasing annual revenues by $300-400 billion. After a move to raise cigarette tax substantially, France saw their national cigarette consumption halve from 1990–2005.

I recently heard of a study in Florida that calculated that each pack of cigarettes cost $15.00 in future medical costs. A program there called “Good Behavior Games” aimed at rewarding children for not smoking was considered so potentially beneficial to the future health care costs that it was supported to the tune of $1 million by a health insurance company.

Perhaps profit-driven industries (insurance companies) can do battle with the cigarette industry, but this public health problem also needs the collective public (government) to weigh in as well by raising the cost of smoking. The short-term desire to avoid a political backlash should not forever impede clear thinking about long-term solutions. Cigarette smoking is our number one environmental public health hazard.

We have sufficient time and money; where we’re experiencing scarcity is in the political courage to avoid further procrastination. Perhaps the impact on brain function from scarcity of political will needs to be studied, as has been the scarcity of money and time. Treating the complications of cardiovascular disease is one of American health care’s strength; preventing cardiovascular disease is not. All we are lacking is political will.

Spencer B. King, III, MD, is president of the Saint Joseph’s Heart and Vascular Institute and Professor of Medicine Emeritus at Emory University School of Medicine in Atlanta. He is also editor-in-chief of JACC Cardiovascular Interventions. He has been a pioneer in interventional cardiology, directing the first trial of angioplasty versus surgery.