(UAB Cancer Epidemiology and Control Seminar Series, September 16, 1998)
I'd like to start by talking a bit about Brad's work with smokeless tobacco. Some of you may already be familiar with his research and his book, but I think the response to them nicely illustrates my theme.
Brad's position, which he sets forth in his 1995 book For Smokers Only, is straightforward. He thinks smokers ought to give up tobacco completely. But if they choose not to, he says, they are much better off using smokeless tobacco than smoking cigarettes.
In his book, Brad notes that oral cancer is the only life-threatening risk associated with the use of smokeless tobacco, and even that disease is twice as common among smokers. He estimates that "if all 46 million smokers used smokeless tobacco instead, the United States would see, at worst, 6,000 deaths from oral cancer [a year], versus the current 419,000 deaths from smoking-related cancers, heart problems, and lung disease."
By this measure, Brad says, smokeless tobacco is 98 percent safer than smoking. He and Philip Cole estimate that life expectancy for a 35-year-old smokeless tobacco user is 80.9, virtually the same as for nonusers.
Brad's pitch to smokers goes like this: You can enjoy tobacco flavor and nicotine at a fraction of the risk, without the pesky smoke. But he emphasizes that "smokeless tobacco should only provide a viable and comparatively safe damage control measure for the current and last generation of nicotine addicts. Forty years or so from now I hope there are no tobacco users left on the planet."
Brad has been condemned by other opponents of tobacco not because what he says is inaccurate but because they consider it detrimental to the cause. "To say that one form of tobacco is safer than the other at this point in the debate is just irresponsible," said Gregory Connolly, director of the Massachusetts Tobacco Control Program. "Tobacco is tobacco.…It's like telling someone to jump from the fifth floor instead of the 10th floor."
The American Association of Oral and Maxillofacial Surgeons preferred a different analogy: "Suggesting this switch is like telling someone to use a rifle instead of an Uzi." The president of the American Dental Association called Brad's proposal "naive at best and irresponsible at worst." The National Cancer Institute said recommending a switch to smokeless tobacco "sends the wrong message."
Harm Reduction vs. Prohibitionism
This criticism reflects a shift in the anti-smoking movement from harm reduction toward prohibitionism. The shift can be seen by comparing two reports from Consumers Union that were published two decades apart. The 1972 report Licit and Illicit Drugs said "efforts should be made to popularize ways of delivering frequent doses of nicotine to addicts without filling their lungs with smoke." Accordingly, one of its suggestions was to "popularize chewing tobacco and snuff."
That recommendation was conspicuously absent from The Facts About Drug Use, a 1991 Consumers Union report. Instead, the authors expressed concern about the rising popularity of smokeless tobacco, especially among adolescents. "The evidence is compelling that smokeless tobacco produces nicotine levels in the body comparable to those produced by smoking and carries additional risk of cancer of the mouth," they said, giving no indication that snuff and chewing tobacco might pose less of a health hazard than cigarettes.
Public health officials give the topic the same one-sided treatment. In 1986 Surgeon General C. Everett Koop issued a report that condemned smokeless tobacco as carcinogenic and addictive. He warned against "the tragic mistake of replacing the ashtray with the spittoon." That same year, Congress banned broadcast ads for smokeless tobacco and required warning labels.
One of those labels sums up the prevailing view, echoed by public health officials, anti-smoking activists, self-help books, and newspaper columnists: Smokeless tobacco "is not a safe alternative to cigarettes." That message is true enough, but it's hardly helpful to anyone interested in assessing the relative risks of different tobacco products. In particular, it's of no use to cigarette smokers considering a switch.
This insistence on abstinence, coupled with a refusal to acknowledge that different forms of a drug pose different levels of risk, should be familiar to anyone who's been following the drug policy debate in this country. It's the sort of attitude I've come to expect from supporters of the war on drugs. It's also the sort of attitude I've come to expect from tobacco's opponents, including those who say they are motivated by a desire to promote "the public health." This has to be a disturbing phenomenon for anyone who believes that the public health model offers a more rational and compassionate alternative to the war on drugs.
Part of the problem is simply inconsistency. After all, if public health specialists can endorse oral methadone as a safer alternative to injected street heroin, why can't they endorse oral tobacco on similar grounds? If they recognize that drinking coca tea is not tantamount to smoking crack, why can't they concede that sticking a Skoal Bandit between your lip and gum is not the same as smoking cigarettes?
But there is a sense in which it may be a good thing that public health specialists are inconsistent. If, as they seem to assume, the government has the authority to minimize morbidity and mortality by discouraging risky behavior, there is no end to the interventions that could be justified in the name of "public health"–and no safe harbor for individual freedom. Although the public health approach to illegal drug use may look good compared to the status quo, public health prescriptions for legal activities tend to increase government interference with personal decisions.
I'll return to that point later. First let's compare the public health model with the prohibitionist approach that has long dominated U.S. drug policy.
We can start with slogans. It's hard to beat "a drug-free America" for sheer hubris, but "a smoke-free society" comes close. And while "Just Say No" and "zero tolerance" are admirably mindless, "Health for All"–the official goal of the World Health Organization–is breathtakingly so. Both "a smoke-free society" and "Health for All," by the way, were supposed to be achieved "by the year 2000." They've still got time.
Slogans, of course, can be misleading as well as revealing. Let's dig a little deeper. The stated aim of the prohibitionists is to eliminate drug use–by which they generally mean the use of certain drugs, set apart from accepted intoxicants by custom, superstition, and historical accident. The stated aim of the public health specialists is to minimize morbidity and mortality–including the harm associated with the use of all drugs, whatever their legal status.
Thus, the public health specialists are in some ways more realistic than the drug warriors: They acknowledge that any drug, licit or illicit, can be harmful in certain circumstances. And they stress harm rather than drug use per se. This implies that the consumption of psychoactive substances is not necessarily problematic. It also suggests a willingness to consider the undesirable effects of attempts to discourage drug use.
Public health specialists recognize that the costs of a given anti-drug policy may outweigh its benefits, even if it succeeds in reducing drug use. In practical terms, this willingness to consider all costs, which also implies an openness to evidence, is the most important way in which public health specialists differ from prohibitionists.
This open-mindedness leads public health specialists to oppose restrictions on access to clean injection equipment, because dirty needles spread disease. It leads them to criticize state and federal regulations that discourage the proper treatment of pain. It leads them to question the Schedule I classification of marijuana, which prevents doctors from prescribing a potentially useful medicine. It leads them to reject punishments for drug offenses that seem disproportionate to the harm caused by use of the substance. It leads some public health specialists to go further, calling for decriminalization of drug use.
Punishment or Treatment?
Even the most moderate prohibitionist is not likely to go that far. The prohibitionist orientation is basically punitive: Using certain drugs is a crime; people who do it deserve to be arrested, humiliated, imprisoned, and divested of their property. The public health orientation, by contrast, is therapeutic: Drug use is a disease; people afflicted by it need to be treated. There is a wide range of opinion about what kind of drug use constitutes a disease and whether treatment should be voluntary. But the disease model, to which I'll return, is central to the claim that drug use is a public health issue.
In terms of policy, both prohibitionists and public health specialists talk a lot about "education." Prohibitionists seem more willing to bend the truth if they think it will help scare people away from drugs, while public health specialists are more likely to insist that drug "education" have a sound scientific basis. They note that scare tactics tend to backfire in the long run, as people recognize that they've been misled and learn to distrust the source. Still, public health messages about drugs, like public health messages in general, are aimed at changing behavior, not simply disseminating facts.
And public health officials are not above misleading the public if they think it will help discourage smoking. Consider the recent campaign against cigars. For decades we've known that cigar smoking, though risky, is not nearly as dangerous as cigarette smoking, mainly because cigar smokers typically do not inhale. That point was confirmed by a recent NCI monograph.
Overall, the NCI reported, daily cigar smokers get oral and esophageal cancers almost as often as cigarette smokers. But they face much lower risks of lung cancer, coronary heart disease, and chronic obstructive pulmonary disease–the three main smoking-related causes of death. In a 1985 American Cancer Society study cited by the NCI, men who smoked a cigar or two a day were only 2 percent more likely to die than nonsmokers, a statistically insignificant difference. By contrast, the mortality rate was 69 percent higher for men who smoked a pack of cigarettes a day and 88 percent higher for those who smoked more than that.
The NCI emphasized that the risk from cigars increases with the frequency of smoking and the degree of inhalation. Cigar smokers who inhale deeply face measurably higher risks of heart disease and emphysema (though still not as high as those faced by cigarette smokers), and the risk of lung cancer for a five-cigar-a-day smoker who inhales approaches the risk for a pack-a-day cigarette smoker.
That sort of cigar smoker is unusual, however. "As many as three-quarters of cigar smokers smoke only occasionally," the NCI noted, and "the majority of cigar smokers do not inhale." Since the available data apply only to people who smoke at least one cigar a day, it said, "the health risks of occasional cigar smokers…are not known." In other words, there is no evidence that smoking cigars in moderation–with moderation defined by the way most cigar smokers actually behave–poses a measurable health risk.
Yet the NCI monograph was portrayed by the press as debunking the "myth" that cigars are safer than cigarettes. How come?
Well, the monograph itself implicitly criticized cigar enthusiasts for suggesting that an occasional cigar is no big deal, even though the data it presented tended to support that view. The NCI called the recent increase in cigar smoking "disturbing" and "alarming," and it downplayed the differences between cigars and cigarettes. "Cigars are not safe alternatives to cigarettes," said NCI Director Richard Klausner, neatly skirting the issue.
That kind of obfuscation–similar to the line on smokeless tobacco–has been repeated again and again by public health officials. An article on cigars that appeared in The New York Times last year quoted Michael Eriksen, director of the CDC's Office on Smoking and Health. This is what he had to say about the hazards of cigars: "Tobacco is tobacco is tobacco." The Times itself went further, incorrectly asserting that cigars pose "higher risks than…cigarettes." Last February, the NCI's Donald Shopland told USA Today, "You're smoking a whole pack of cigarettes when you smoke a cigar."
Shopland's estimate is two and a half packs shy of the figure preferred by California officials. A TV ad sponsored by the California Department of Health Services shows a cigar in a man's mouth morphing into 70 cigarettes, the number that, according to the narrator, "you'd need to equal the nicotine in that big fat stogie."
The comparison is misleading even in terms of nicotine delivery. According to the NCI monograph, a typical premium cigar yields about as much nicotine as a dozen cigarettes, not 70. The 70-to-1 ratio is also bound to encourage erroneous conclusions about the relative health risks of cigars. According to The Sacramento Bee, the ad "points out that smoking cigars poses the same health risks as smoking cigarettes." The Los Angeles Times described the ad as "comparing the effects of one cigar to smoking the equivalent of 70 cigarettes."
As with propaganda about illegal drugs, such scare tactics have the potential to backfire. After seeing the California ad, someone who smokes a couple of cigars a week might conclude that he would be no worse off smoking a pack of cigarettes a day. Alternatively, someone who realized how deceptive the ad was might be inclined to dismiss future warnings from public health agencies.
Aside from education, the policy prescriptions offered by public health specialists sound quite different from those offered by drug warriors. Prohibitionists emphasize interdiction, crop eradication, and other attempts to reduce the supply of drugs, along with arrests, fines, property forfeiture, and imprisonment for producers, sellers, and buyers. Public health specialists emphasize treatment, taxes, and regulations.
Both sets of policies are aimed, in part, at deterring certain kinds of drug use by making them more expensive and less convenient. While the public health prescriptions certainly seem milder, their effects can be similar. Voluntary treatment, for example, is clearly preferable to incarceration, but many advocates of drug treatment would send uncooperative "patients" to jail. In her recent history of drug use in America, the journalist Jill Jonnes explains the rationale for coercive drug treatment: "It is well known in the drug world that most addicts will not seek treatment except under some sort of duress," she writes. "Nor, for the most part, will they stick with it unless forced."
This attitude is encouraged by the disease metaphor that is central to the public health model. A disease is something inherently undesirable that happens to people against their will. No one in his right mind wants to be sick. Furthermore, this is a disease that is said to impair the patient's judgment; one of its symptoms is "denial." Where's the harm, then, in forcing an addict to be well? Under the circumstances, this would seem the compassionate thing to do.
Just as treatment can resemble prison, taxation can resemble prohibition. Prohibition itself can be viewed as a tax, raising the prices of certain goods by making them riskier to produce and sell. Conversely, a high enough tax produces some of the dramatic side effects associated with prohibition.
When the Canadian government sharply increased cigarette taxes in 1989 and 1991, the consequences precipitated a crisis and a dramatic policy reversal. In response to smuggling, violence, and widespread disobedience, the Canadian government announced big tax cuts in February 1994. The solicitor general cited "a frightening growth in criminal activity" and "a breakdown in respect for Canadian law." The prime minister said "smuggling is threatening the safety of our communities and the livelihood of law-abiding merchants. It is a threat to the very fabric of Canadian society." If the price of cigarettes goes up dramatically in this country, whether through legislation or as a result of liability settlements, we can expect to see an increase in black market activity, though the magnitude of the problem is a matter of dispute.
Regulations, too, can simulate the effects of prohibition by restricting information, discouraging innovation, and banning the sale of products that people want to buy. The FDA, for example, has seriously considered requiring the tobacco companies to gradually eliminate nicotine from cigarettes. Such a policy would not only invite a black market in full-strength cigarettes, it would actually increase the hazards faced by current smokers, who would tend to smoke more to compensate for the reduction in nicotine. Remarkably, this proposal has been suggested by some of the same people who note that nicotine compensation undermines the health advantages of low-yield cigarettes.
Which raises the issue of safer cigarettes. Cigarette manufacturers have dramatically reduced tar yields during the last four decades or so. Although there is considerable dispute about the extent of the benefit–since the official yields are not a very good measure of what smokers actually absorb–the evidence suggests that cigarettes today are significantly less hazardous than they were in 1950, even allowing for compensatory behavior. If the government had stopped the tobacco companies from introducing low-yield brands, or if it had forbidden them to advertise tar yields, we would not have seen this trend.
The next wave of safer cigarettes, represented by the R.J. Reynolds brand Eclipse, promises more-substantial improvements. But an advertising ban or FDA regulation–both of which would make it much more difficult, if not impossible, to introduce new brands–would discourage the development of such products.
The reaction of tobacco's opponents to Eclipse and an earlier RJR attempt at a safer cigarette, Premier, illustrated the tension within the anti-smoking movement between harm reduction and prohibitionism. Representative Henry Waxman, a California Democrat who is one of the tobacco industry's most outspoken critics in Congress, said Eclipse was a positive development. John Pauly, a smoking expert at Roswell Park Cancer Center, said: "We have come to realize that despite numerous warnings since 1964, there exists a very large segment of the smoking population who are either unwilling or unable to give up smoking. It's worthwhile to come in with a safer cigarette."
Other opponents of smoking viewed the new brands with alarm. "We think it's just a desperate attempt on their part to reverse the growing social taboo against smoking," an American Lung Association spokeswoman said of Premier. "It would be too bad to see the current momentum–which has encouraged a lot of people to quit smoking–defused or confused," said Jan Hitchcock, associate director of Harvard's Institute for the Study of Smoking Behavior and Policy. As Matthew Meyers, then staff director of the Coalition on Smoking or Health, explained, "The fact that a product is safer doesn't mean that there is a net health gain if it ends up leading more people to smoke."
Similarly, the physician and addiction specialist John Slade has argued that innovation in cigarette design threatens public health because it encourages people to keep smoking. "If the new products were not available," he wrote in 1990, "more people would be able to respond directly to concerns about illness and death from smoking and become completely abstinent from nicotine." Slade argued that the government should "prohibit any new products unless they first had demonstrated their safety. Had such a policy been in effect in 1950, the only cigarettes on the market today would be unfiltered 70 mm smokes, and far fewer people would be smoking."
Now, it's possible to make a public health case for keeping cigarettes as dangerous as possible. It hinges on the notion, suggested by Myers and Slade, that the health benefits enjoyed by smokers who switch to safer cigarettes are swamped by the health costs associated with people who start or continue smoking because safer cigarettes are available. I'm not sure how you would test this hypothesis, but I find it rather implausible.
In any case, something other than public health seems to be at work here. The opposition to safer cigarettes, like the opposition to smokeless tobacco as an alternative to cigarettes, is reminiscent of the opposition to methadone maintenance and needle exchange programs. In all these cases, critics argue that making drug use safer "sends the wrong message." Prohibitionists want drug use to be dangerous, the better to deter the uninitiated and encourage users to quit. Public health specialists, on the other hand, should welcome the opportunity to reduce the harm associated with drug use.
Demon Rum and the Devil's Weed
As I suggested earlier, the anti-smoking movement has been strongly influenced by prohibitionist thinking. Historically, the people who railed against the Devil's weed–people like Benjamin Rush, the Rev. George Trask, and Lucy Page Gaston–were the same people who railed against demon rum. During the 19th and early 20th centuries, the anti-tobacco movement was closely tied to the temperance movement. After the 18th Amendment was enacted, many people thought national tobacco prohibition should be next. That never happened, but 19 states did ban the sale of cigarettes early in this century.
The anti-tobacco crusaders of that time, like their predecessors in earlier centuries, worried about the impact of smoking on the soul as well as the body. In addition to the long list of physical maladies they attributed to smoking, they warned that cigarettes impaired intelligence, suppressed ambition, and corrupted one's moral character. Nowadays you rarely hear that sort of talk. Tobacco's contemporary opponents prefer the ostensibly neutral language of public health. But one can still hear echos of the old moralism.
"What difference is there between a smoker and a suicide," asked a Jesuit priest in 1658, "except that the one takes longer to kill himself than the other? Because of this perpetual smoking, the pure oil of the lamp of life dries up and disappears, and the fair flame of life itself flickers out and goes out, all because of this barbarous habit." He thus anticipated by three centuries Joe Califano's statement as secretary of health, education, and welfare that "people who smoke are committing slow-motion suicide."
In 1726 Cotton Mather warned: "If once you get into the way of Smoking, there will be extreme hazard, of your becoming a Slave to the Pipe; and ever Insatiably craving for it. People may think what they will; But such a Slavery, is much below the Dignity of a Rational Creature; and much more of a Gracious Christian." In 1904, the educator Charles B. Hubbell said "the cigaret habit is more devastating to the health and morals of boys and young men than any habit or vice that can be named.…Once the cigaret habit becomes established its servitude is almost certain and unending."
Compare those statements with the rhetoric of former FDA Commissioner David Kessler. "Once they have started smoking regularly," he says, "most smokers are in effect deprived of the choice to stop smoking….Nicotine addiction 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 notion that smoking is "a pediatric disease" puts a scientific veneer on some very old concerns about drug dependence. Kessler seems to side with those who view addiction as a form of slavery from which there is no escape. For him, smoking is something that happens to people, not something that people choose to do.
In addition to reinforcing misconceptions about addiction, tobacco's opponents play to popular prejudices about drugs. Jack Henningfield says "a cigarette is essentially the crack cocaine form of nicotine delivery." Strictly speaking, this is just another way of saying that people smoke cigarettes–not exactly a startling revelation. The purpose of such rhetoric is not to inform but to demonize tobacco in the same way that crack cocaine has been demonized. Gregory Connolly, the Massachusetts public health official, says "tobacco extract" is "a drug called nicotine. It's a euphemism. It's like calling heroin 'poppy seed soil.' It's a drug, it's a drug, it's a drug."
The Moralism of Public Health
We could view such comments as lapses from the calm, scientific approach that public health specialists usually advocate. But the real problem with the public health model is more fundamental than that.
In contrast with early anti-smokers, public health specialists claim to be neutral and scientific. Yet they are engaged in a moral crusade no less than George Trask and Lucy Page Gaston were. With the government's help, they are trying to enforce a commandment: Thou shalt not compromise thy health. The drive to minimize morbidity and mortality condemns anyone who chooses to sacrifice health for other values.
Public health conceals its moral agenda by pathologizing the behavior it targets. From a public health perspective, smoking is not an activity or even a habit. It is "Public Health Enemy Number One," "the greatest community health hazard," "the single most important preventable cause of death," "a pediatric disease," "the manmade plague," "the global tobacco epidemic." It is something to be stamped out, like smallpox or yellow fever. This view of smoking is part of a public health vision that encompasses all sorts of risky behavior, including not just smoking and illegal drug use but drinking, overeating, owning a gun, riding a bicycle without a helmet–in short, anything that can be said to increase the incidence of disease or injury.
Although this sweeping approach is a relatively recent development, we can find intimations of it in the public health rhetoric of the 19th century. In the introduction to the first major American book on public health, U.S. Army surgeon John S. Billings explained the field's concerns: "Whatever can cause, or help to cause, discomfort, pain, sickness, death, vice, or crime–and whatever has a tendency to avert, destroy, or diminish such causes–are matters of interest to the sanitarian."
Despite this ambitious mandate, and despite the book's impressive length, A Treatise on Hygiene and Public Health had little to say about the issues that occupy today's public health professionals. There were no sections on smoking, alcoholism, drug abuse, obesity, vehicular accidents, mental illness, suicide, homicide, domestic violence, or unwanted pregnancy. Published in 1879, the book was instead concerned with things like compiling vital statistics, preventing the spread of disease, abating public nuisances, and assuring wholesome food, clean drinking water, and sanitary living conditions.
A century later, public health textbooks discuss the control of communicable diseases mainly as history. The field's present and future lie elsewhere. "The entire spectrum of 'social ailments,' such as drug abuse, venereal disease, mental illness, suicide, and accidents, includes problems appropriate to public health activity," explains Principles of Community Health. "The greatest potential for improving the health of the American people is to be found in what they do and don't do to and for themselves. Individual decisions about diet, exercise, stress, and smoking are of critical importance."
The extent of the shift can be sensed by perusing a few issues of the American Public Health Association's journal. In 1911, when the journal was first published, typical articles included "Modern Methods of Controlling the Spread of Asiatic Cholera," "Sanitation of Bakeries and Restaurant Kitchens," "Water Purification Plant Notes," and "The Need of Exact Accounting for Still-Births." This year the journal has offered articles on topics such as "Weight Loss Methods," "Trends in Safety Belt Use," "Household Exposure to Firearms," and the "Prevalence of Cigar Use in 22 North American Communities."
In a sense, the change in focus is understandable. Americans no longer live in terror of smallpox or cholera. Despite occasional outbreaks of infectious diseases such as rabies and tuberculosis, the fear of epidemics that was once an accepted part of life is virtually unknown. The one exception is AIDS, which is not readily transmitted and remains largely confined to a few high-risk groups. For the most part, Americans are dying of things you can't catch: cancer, heart disease, trauma. Accordingly, public health specialists are focusing on those causes and the factors underlying them. Having vanquished most true epidemics, they have turned their attention to metaphorical "epidemics" of unhealthy behavior.
Treating risky behavior like a contagious disease obscures some important distinctions. Behavior cannot be transmitted to other people against their will. People do not choose to be sick, but they do choose to engage in risky behavior. The choice implies that the behavior, unlike a viral or bacterial infection, has value. It also implies that attempts to control the behavior will be resisted.
Public health used to mean keeping statistics, imposing quarantines, requiring vaccination of children, providing purified water, building sewer systems, inspecting restaurants, regulating emissions from factories, and reviewing drugs for safety. Nowadays it means, among other things, banning cigarette ads, raising alcohol taxes, restricting gun ownership, forcing people to buckle their seat belts, and making illegal drug users choose between prison and "treatment." In the past, public health officials could argue that they were protecting people from external threats: carriers of contagious diseases, fumes from the local glue factory, contaminated water, food poisoning, dangerous quack remedies. By contrast, the new enemies of public health come from within; the aim is to protect people from themselves rather than each other.
This approach 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 which found 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." It quoted the panel's chairman, Jules Hirsch: "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 overweight increased from a quarter to a third between 1980 and 1991. "The government is not doing enough," complained Assistant HAS Secretary Philip R. Lee. "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, Joan E. Manson, said "it won't be long before obesity surpasses cigarette smoking as a cause of death in this country."
If, as Assistant Secretary Lee recommended, the government decides to do more about obesity–the second most important preventable cause of death in this country, soon to be the first–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 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."
Of course, a tax on junk food would be paid by the lean as well as the plump. It might be more fair and efficient to tax people for every pound over their ideal weight. Such a market-based system would make the obese realize the costs they impose on society and give them an incentive to slim down.
If this idea strikes most people as ridiculous, it's not because the plan is impractical. In several states, people have to bring their cars to an approved garage for periodic emissions testing; there's no logistical reason why they could not also be required to weigh in at an approved doctor's office, say, once a year, reporting the results to the Internal Revenue Service for tax assessment.
Though feasible, the fat tax is ridiculous because it's an odious intrusion by the state into matters that should remain private. Even if obesity is apt to shorten a person's life, most Americans would (I hope) agree, that's his business, not the government's. Yet many of the same people believe not only that the government should take an interest in whether a person smokes but that it should apply pressure to make him stop, including fines (a.k.a. tobacco taxes), tax-supported nagging, and bans on smoking outside the home.
Accustomed to Power
Because the public health field developed in response to deadly threats that spread from person to person and place to place, its practitioners are used to dictating from on high. Writing in 1879, John Billings put it this way: "[A]ll admit that the State should extend special protection to those who are incapable of judging of 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 incompetent children.
The dangers of basing government policy on this attitude are clear, especially given the broad concerns of the public health movement. According to textbook Public Health Administration and Practice, "public health is dedicated to the common attainment of the highest levels of physical, mental, and social well-being and longevity consistent with available knowledge and resources at a given time and place." Principles of Community Health tells us that "the most widely accepted definition of individual health is that of the World Health Organization: 'Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.' " A government empowered to maximize health is a totalitarian government.
In response to such fears, the public health establishment argues that government intervention is justified because individual decisions about risk affect other people. "Motorcyclists often contend that helmet laws infringe on personal liberties," noted Surgeon General Julius Richmond's 1979 report Healthy People, "and opponents of mandatory [helmet] laws argue that since other people usually are not endangered, the individual motorcyclist should be allowed personal responsibility for risk. But the high cost of disabling and fatal injuries, the burden on families, and the demands on medical care resources are borne by society as a whole." This line of reasoning, which is also used to justify taxes on tobacco and alcohol, implies that all resources–including not just taxpayer-funded welfare and health care but private savings, insurance coverage, and charity–are part of a common pool owned by "society as a whole" and guarded by the government.
As Robert F. Meenan, a professor at the University of California School of Medicine in San Francisco, noted in The New England Journal of Medicine two decades ago, "virtually all aspects of life style could be said to have an effect on the health or well-being of society, and the decision reached that personal health choices should be closely regulated." Writing 18 years later in the same journal, Faith Fitzgerald, a professor at the University of California at Davis Medical Center, observed: "Both health care providers and the commonweal now have a vested interest in certain forms of behavior, previously considered a person's private business, if the behavior impairs a person's 'health.' Certain failures of self-care have become, in a sense, crimes against society, because society has to pay for their consequences."
Public Health vs. Freedom
Most public health practitioners would presumably recoil at the full implications of the argument that government should override individual decisions affecting health because such decisions have an impact on "society as a whole." C. Everett Koop, for his part, seems untroubled. "I think that the government has a perfect right to influence personal behavior to the best of its ability if it is for the welfare of the individual and the community as a whole," he writes. Koop thus implies that the government is authorized to judge "the welfare of the individual," and he elevates "the community as a whole" above mere people.
Some defenders of the public health movement have explicitly recognized that its aims are fundamentally collectivist and cannot be reconciled with the American tradition of limited government. In 1975 Dan E. Beauchamp, then an assistant professor of public health at the University of North Carolina, presented a paper at the annual meeting of the American Public Health Association in which he argued that "the radical individualism inherent in the market model" is the biggest obstacle to improving public health.
"The historic dream of public health that preventable death and disability ought to be minimized is a dream of social justice," Beauchamp said. "We are far from recognizing the principle that death and disability are collective problems and that all persons are entitled to health protection." He rejected "the ultimately arbitrary distinction between voluntary and involuntary hazards" and complained that "the primary duty to avert disease and injury still rests with the individual." Beauchamp called upon public health practitioners to challenge "the powerful sway market-justice holds over our imagination, granting fundamental freedom to all individuals to be left alone."
Public health, in other words, is inconsistent with the right to be left alone. Of all the risk factors for disease or injury, it seems, freedom is the most pernicious.