Michael Bloomberg, the billionaire mayor of New York City, is a fanatical opponent of smoking, and if you had his life, you'd want to live as long as possible, too. Things might look different to, say, a waitress at a roadside chain restaurant, like the ones Barbara Ehrenreich described in "Nickel and Dimed" (2001), who smoke out of "defiant self-nurturance," because "work is what you do for others; smoking is what you do for yourself." Don't they know that cigarettes are bad for them? Yes. That message has reached "well over 90 percent" of the population, according to Harvard economist David Cutler. Although smoking has declined steeply in the United States from its peak in the early 1950s, when nearly half of all adults smoked (compared with about 21 percent today), it is proving remarkably intransigent at the bottom of the socioeconomic ladder. As of 2006, 35 percent of Americans with a ninth- to 11th-grade education—like the ones Ehrenreich wrote about—smoked. The figure for Americans with a graduate degree—like Bloomberg, a Harvard M.B.A.—was 7 percent.
Those figures, in turn, help explain the discouraging statistic that Cutler and two coauthors reported in a recent issue of the journal Health Affairs: that increases in life expectancy in recent decades have been concentrated almost entirely among better-educated Americans. To put it concretely, says Ellen Meara, an assistant professor of health-care policy at Harvard Medical School, if you were 25 in 1990 with a high-school diploma or less, your life expectancy was 49.6 years more, to 74.6. If you had attended college at all, even without graduating, you could expect to live more than five years longer, to 80. In 2000, a 25-year-old with any college experience had a life expectancy of 81.6, an improvement of a year and a half. The other group was stuck exactly where it had been 10 years before, a finding that Cutler described as "harsh."
Life is unfair in many ways, and the better educated and better paid have some obvious advantages, including better access to health care. But why should a voluntary decision not to smoke be among them? Is it willpower? Actually, the defining characteristic of the people Ehrenreich wrote about was how hard they worked, every bit as hard as, say, a college-educated journalist.
No one knows for sure. Some public-health experts blame tobacco companies for "targeting" low-income and minority neighborhoods with billboards and store promotions—but surely that's a case of going where their remaining customers are. No doubt they'd be happy to sell cigarettes to people who shop at health-food stores if they could. So researchers look for psychological explanations. They suggest that blue-collar workers who smoke choose present gratification over future benefits. But there's also evidence that attending college by itself encourages healthy behavior; when community colleges open in rural areas, enrolling local youths who otherwise would have gone into the work force, smoking goes down.
Perhaps there's a clue in a bit of unpublished research by Cutler on a related question: why does seat-belt use go up with education? Anyone can understand the danger of flying through the windshield in a collision. But some data suggest that the less education you have, the likelier you are to agree with the statement "It doesn't matter if I wear a seat belt, because if it's my time to die, I'll die."
So for anyone reading this who never got beyond high school, here's a bit of free advice: it does matter. Life is uncertain, but that's no reason to surrender to fate. You don't need a Harvard M.B.A. to understand that.