NBER WORKING PAPER SERIES

THE CONTRIBUTION OF BEHAVIOR CHANGE AND PUBLIC HEALTH TO IMPROVED
U.S. POPULATION HEALTH
Susan T. Stewart
David M. Cutler
Working Paper 20631 http://www.nber.org/papers/w20631 NATIONAL BUREAU OF ECONOMIC RESEARCH
1050 Massachusetts Avenue
Cambridge, MA 02138
October 2014

This paper was prepared for the National Institute of Health Office of Behavioral and Social Sciences
Research (NIH OBSSR), for inclusion in a publication entitled Review of Behavioral and Social Sciences
Research Opportunities: Innovations in Population Health Metrics. This work was supported by National
Institute on Aging (NIA) research grant P01 AG31098. We are grateful to Kaushik Ghosh and Jean
Roth for advice and assistance with data analysis. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.
At least one co-author has disclosed a financial relationship of potential relevance for this research.
Further information is available online at http://www.nber.org/papers/w20631.ack
NBER working papers are circulated for discussion and comment purposes. They have not been peerreviewed or been subject to the review by the NBER Board of Directors that accompanies official
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© 2014 by Susan T. Stewart and David M. Cutler. All rights reserved. Short sections of text, not to exceed two paragraphs, may be quoted without explicit permission provided that full credit, including
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The Contribution of Behavior Change and Public Health to Improved U.S. Population Health
Susan T. Stewart and David M. Cutler
NBER Working Paper No. 20631
October 2014
JEL No. I1,I10,I12,I18
ABSTRACT
Adverse behavioral risk factors contribute to a large share of deaths. We examine the effects on life expectancy (LE) and quality-adjusted life expectancy (QALE) of changes in six major behavioral risk factors over the 1960-2010 period: smoking, obesity, heavy alcohol use, and unsafe use of motor vehicles, firearms, and poisonous substances. These risk factors have moved in opposite directions. Reduced smoking, safer driving and cars, and reduced heavy alcohol use have led to health improvements, which we estimate at 1.82 years of quality-adjusted life. However, these were roughly offset by increased obesity, greater firearm deaths, and increased deaths from poisonous substances, which together reduced quality-adjusted life expectancy by 1.77 years. We model the hypothetical effects of a 50% decline in morbid obesity and in poisoning deaths, and a 10% decline in firearm fatalities, roughly matching favorable trends in smoking and increased seat belt use. These changes would lead to a 0.92 year improvement in LE and a 1.09 year improvement in QALE. Thus, substantial improvements in health by way of behavioral improvements and public health are possible.

Susan T. Stewart
NBER
1050 Massachusetts Ave
Cambridge, MA 02138 sstewart@nber.org David M. Cutler
Department of Economics
Harvard University
1875 Cambridge Street
Cambridge, MA 02138 and NBER dcutler@harvard.edu While health is often thought of in terms of diagnosed medical conditions, it is modifiable behavioral risk factors such as obesity and smoking that account for the largest portion of deaths each year.1,2 For example, Mokdad et al.1 report that in 2000, 43% of total deaths were accounted for by six behavioral risk factors: smoking (18%), obesity (17%), alcohol consumption (4%), motor vehicle accidents (2%), firearms (1%), and illicit drug use (1%).

In addition to affecting mortality, these modifiable behavioral factors have significant effects on health-related quality of life (HRQOL).3,4,5,6 Smoking, heavy alcohol use, and obesity have been causally linked to a myriad of diseases and symptoms,6,7,8 and injuries from motor vehicle accidents and firearms can be severe. When feasible, considering this nonfatal impact can provide a more comprehensive picture of the health