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Comment by jncfhnb | Hacker News Reader

Seems dubious to me that smoking explains any of these things. I would guess just a cultural cofounder.

Obesity and fentanyl would be my guess.

Smoking is a major health risk, so it makes sense to me that it's a major factor. Not sure why you'd want to remove it as a confounder.

I think parent comment was pointing to lack of establishing a causation link. The finding in their abstract is extrapolated by statistical inference. For example smokers tend to drink more etc. The paper does take such factors into account. Personally I wouldn't jump to such a strong conclusion from statistical inference because it closes the door on other factors that might be even stronger when combined together. The paper reflects motivated reasoning more than a discovery outcome. That said, smoking is of course a major health risk, I am just pointing at the research approach.

Smoking is a major health issue, but it's barely a driver of midlife mortality. Smoking tends to kill you later.

Smoking is bad for you, but it's unlikely to kill you in midlife.

In the paper they claim it matters for midlife mortality too:

> People who start smoking at age 18 begin to exhibit higher mortality several decades later, with particularly large effects beginning at ages 45–64 (Lawton et al. 2025). A health-capital model allows the mortality rates of older persons to be determined not only by their current smoking behavior but also by smoking in earlier years. In the United States, smoking rates started falling for college graduates earlier than they did for the non-college population.

...

> [...] with rapidly improving treatments and screening for lung cancer (Howladeret al. 2020), the major impact of smoking over the longer-term—particularly for people aged 55–64 arises from other more-common tobacco-related diseases such as chronic obstructive pulmonary disease (COPD); cardiovascular diseases such as strokes, aneurysms, and heart attacks; diabetes; and other types of cancers (Carter et al. 2015). Perhaps more surprising is that past county-level smoking rates are highly predictive of deaths of despair. This finding, however, is consistent with an emerging literature in biology that points to a causal influence of smoking on drug addiction [...]

It is associated with other adverse behaviors like a sedentary lifestyle. Smokers aren't generally athletically motivated.

When my city banned public smoking, there was an immediate and statistically significant decrease in heart attacks and strokes.

But probably not for the reason you think.

What was the reason?

Actually, later in their paper they say: "Although we have argued for a causal role for smoking in generating these patterns, the growing mortality gaps still seem too large and the causes of death too varied to blame the patterns on the adverse health effects of tobacco use alone. As noted above, smoking is likely to play a role in amplifying the impact of other factors adversely affecting midlife mortality, such as the marketing efforts by opioid manufacturers targeted to areas with high rates of smoking-related illness, coupled with epigenetic changes making smokers more susceptible to opioid use disorders. Still, the strength of our findings that smoking is predictive of spatial trends in midlife mortality points towards different mechanisms needed to explain the troubling trends that have unfolded since 1990."

> manufacturers targeted to areas with high rates of smoking-related illness

Oof

> epigenetic changes making smokers more susceptible to opioid use disorders

This one seems… a bit mystic to me. I would have been much quicker to suggest that a psychological propensity to start smoking mirrors a propensity to start using other drugs vs. arguing for emergent effects of cellular behavior.

Yeah it seems silly.

Why is college the primary group factor…? Is there some sort of health effect of sitting college classrooms for 5 years? Seems unlikely.

College education is highly associated and predicted by income/access to wealth.

Wealth inequality seems like a more likely explanation. Not seeing how they controlled for that across college vs non-college groups.

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