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Healthy People noted that "formidable obstacles" stand in the way of improved public health. "Prominent among them," it said, "are individual attitudes toward the changes necessary for better health. Though opinion polls note greater interest in healthier lifestyles, many people remain apathetic and unmotivated.…Some consider activities to promote health moralistic rather than scientific; still others are wary of measures which they feel may infringe on personal liberties. However, the scientific basis for suggested measures has grown so compelling, it is likely that such biases will begin to shift." In other words, people engage in risky behavior because they don’t know any better. Once they realize the risks they are taking, they will change their ways.
But what if they don’t? In the case of smoking, self-styled defenders of public health seem genuinely puzzled by the fact that so many people persist in this plainly irrational habit. They insist that people smoke not because they like it but because they were tricked by advertising and enslaved by nicotine before they were old enough to know better. Scott Ballin, former chairman of the Coalition on Smoking or Health, once told me, "There is no positive aspect to [smoking]. The product has no potential benefits....It’s addictive, so people don’t have the choice to smoke or not to smoke."
Hence smokers who acknowledge the risks of their habit but cite countervailing rewards are dishonest or deluded, displaying the classic defense mechanisms of rationalization and denial. The sociologist Anne Wortham, herself a smoker, says tobacco’s opponents believe that if you smoke, "you are in a state of false consciousness, because you are not aware of what is in your interests. It’s the refusal to acknowledge people’s capacity to make choices. You just define them out of the discourse. ‘Addiction’ says they can’t even talk about their own likes and dislikes. We can decide for them."
Public health specialists are used to dictating from on high, because their field developed in response to deadly threats that spread from person to person and place to place. Writing in 1879, John Billings put it this way: "All admit that the State should extend special protection to those who are incapable of judging their own best interests, or of taking care of themselves, such as the insane, persons of feeble intellect, or children; and we have seen that in sanitary matters the public at large are thus incompetent."
Billings was defending traditional public health measures aimed at preventing the spread of infectious diseases and controlling hazards such as toxic fumes. It’s reasonable to expect that such measures will be welcomed by the intended beneficiaries, once they understand the aim. The same cannot be said of public health’s new targets. Even after the public is informed about the relevant hazards (and assuming the information is accurate), many people will continue to smoke, drink, take illegal drugs, eat fatty foods, buy guns, eschew seat belts and motorcycle helmets, and otherwise behave in ways frowned upon by the public health establishment. This is not because they misunderstood; it’s because, for the sake of pleasure, utility, or convenience, they are prepared to accept the risks. When public health experts assume these decisions are wrong, they are indeed treating adults like children.
That tendency is apparent in the rhetoric of the anti-smoking movement. Although more than 90 percent of smokers are adults, the best-funded anti-smoking group in Washington these days is called the Campaign for Tobacco-Free Kids. During this year’s debate over tobacco legislation, it ran ads warning that "Every Day, Without Action on Tobacco, 1,000 Kids Will Die Early." The claim conjured up images of fifth-graders dying from lung cancer, 12-year-olds keeling over with heart attacks in the cafeteria, and high school sophomores with emphysema wheezing as they climb the stairs on the way to their next class.
As commissioner of the Food and Drug Administration, David Kessler also tried to infantilize smokers. "Nicotine addiction," he said, "is a pediatric disease that often begins at 12, 13, and 14, only to manifest itself at 16 and 17, when these children find they cannot quit. By then our children have lost their freedom and face the prospect of lives shortened by terrible disease."
The "pediatric disease" label also reflects the public health tendency to pathologize risky behavior, thereby obscuring the role of individual choice. From a public heath perspective, smoking is not an activity or even a habit. It is "the greatest community health hazard," "the single most important preventable cause of death," "the manmade plague," "the global tobacco epidemic." It is something to be stamped out, like polio or scarlet fever.
Treating risky behavior like a contagious disease invites endless meddling. The same arguments that are commonly used to justify the government’s efforts to discourage smoking can easily be applied to overeating, for example. If smoking is a compulsive disease, so is obesity. It carries substantial health risks, and people who are fat generally don’t want to be. They find it difficult to lose weight, and when they do succeed they often relapse. When deprived of food, they suffer cravings, depression, anxiety, and other withdrawal symptoms.
Sure enough, the headline of a March 1985 article in Science announced, "Obesity Declared a Disease." The article summarized a report by a National Institutes of Health panel finding that "the obese are prone to a wide variety of diseases, including hypertension, adult onset diabetes, hypercholesterolemia, hypertriglyceridemia, heart disease, cancer, gall stones, arthritis, and gout." The panel’s chairman said: "We found that there are multiple health hazards at what to me are surprisingly low levels of obesity. Obesity, therefore, is a disease."
More recently, the "epidemic of obesity" has been trumpeted repeatedly on the front page of The New York Times. The first story, which appeared in July 1994, was prompted by a study from the National Center for Health Statistics that found the share of American adults who are obese increased from a quarter to a third between 1980 and 1991. "The government is not doing enough," complained Philip Lee, assistant secretary of health and human services. "We don’t have a coherent, across-the-board policy."
The second story, published in September 1995, reported on a New England Journal of Medicine study that found gaining as little as 11 to 18 pounds was associated with a higher risk of heart disease–or, as the headline on the jump page put it, "Even moderate weight gains can be deadly." The study attributed 300,000 deaths a year to obesity, including one-third of cancer deaths and most deaths from cardiovascular disease. The lead researcher, JoAnn Manson, said, "It won’t be long before obesity surpasses cigarette smoking as a cause of death in this country."
The odds are that you are part of this epidemic, since most of us are fatter than the experts say we should be. According to a 1996 survey, 74 percent of Americans exceed the weight range recommended for optimal health.
If, as Philip Lee recommended, the government decides to do more about our national weight problem, what would "a coherent, across-the-board policy" look like? As early as June 1975, in its Forward Plan for Health, the U.S. Public Health Service was suggesting "strong regulations to control the advertisement of food products, especially those of high sugar content or little nutritional value." But surely we can do better than that. A tax on fatty foods would help cover the cost of obesity-related illness and disability, while deterring overconsumption of ice cream and steak.
What was once a joke is now a serious policy proposal. Kelly Brownell, a professor of psychology at Yale University who directs the school’s Center for Eating and Weight Disorders, has repeatedly suggested taxing foods based on their nutritional content. "A militant attitude is warranted here," he told the New Haven Register. "We’re infuriated at tobacco companies for enticing kids to smoke, so we don’t want Joe Camel on billboards. Is it any different to have Ronald McDonald asking kids to eat foods that are bad for them?" In its first issue of the year, U.S. News & World Report included the idea of a junk food tax on its list of "16 Silver Bullets: Smart Ideas to Fix the World."