Obesity Management: Lessons and
Cautions from the Tobacco Experience
Edward P. Richards
Director, Program in Law, Science, and Public Health
Harvey A. Peltier Professor of Law
Louisiana State University Law Center
richards@lsu.edu
http://biotech.law.lsu.edu/cphl/slides/naccho-2005.htm
Learning Objectives
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Understand how obesity and smoking differ
Understand why stigmatization, the core of antismoking strategy, is inappropriate for obesity
Understand how obesity control differs from
tobacco control
Key Differences Between Tobacco and
Food
History of Tobacco
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Smoking is a very old problem, with roots in the
US colonial experience
 Tobacco was the major trade good
Demographics
 Tobacco was always bad for you
 If you died from yellow fever, it did not matter
Tobacco was not a public health issue until life
expectancy reached the 60s
History of Obesity
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Like tobacco, its sequella are chronic diseases
and were not a significant issue when life
expectancy was short
Unlike tobacco, obesity was not a widespread
problem until relatively recently
 It is the rate of increase, especially in children,
that makes obesity a high priority
Obesity is a new cultural phenomenon
Stigmatization of Smokers
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The main strategy for tobacco control is
stigmatizing smoking
 Smoking is bad for your health
 Second hand smoke injures others
It is OK to treat smokers as bad people
Behaviors v. Conditions
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Smoking is a behavior
 When you aren’t smoking, no one knows you
are a smoker
 Quit smoking, you are instantly a non-smoker
Obesity is a condition
 You are obese all the time
 While you try to lose weight, you are still fat
Love the Sinner, Hate the Sin
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Smokers are only stigmatized when smoking
 You can be a secret smoker
Fat people are fat all the time
 Stigmatize being fat and you stigmatize fat
people
 There are no secret fat people
Does Obesity need More Stigma?
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Smoking was cool
 Smoking is still cool for kids
Fat has not been cool in the US for a 100 years
 No kid wants to be fat to be cool
 Being fat has been a stigma for a long time
Differential treatment always causes stigma
Who is Obesity Bad For?
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Smoking is bad for everyone
Gross obesity
 Bad for everyone
Moderate obesity
 Risks depend on the predisposition to diabetes
Ignoring this differential risk is bad policy
Recognizing differential risk complicates policy
Race and Class and Gender
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Obesity is strongly correlated with race and class
and gender
 Poor black women have the highest rates
 Rich white women have the lowest
 Fat is beautiful is predominately a minority
cultural value
Using stigma and differential treatment as public
health strategies has significant racial impact
Good Food is a Luxury Good
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Fresh fruit and vegetables are expensive
 They are available at limited locations and
times in many stores
 Can everyone shop at Whole Foods?
Agriculture policy focuses on grains and meat
 Lends itself to American strengths
 Fresh produce requires people, not machines
Cheap Calories are Important to the Poor
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For some people, super-sizing is a good deal
A fast, cheap meal may be the only meal option
Not everyone who eats fast food is fat
Not everyone who eats health food is thin
Not everyone has time to prepare cheap,
nutritious foods
Relative Costs
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Stopping smoking saves a lot of money
Eating healthy costs a lot of money or time
This cannot be addressed just through education
Physical Activity is a Luxury for Many
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Exercise policy tends to be made by people who
have time to go to the gym
Advice about incorporating exercise in daily life is
not realistic for many poor people
Poverty and Obesity
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Obesity is related to education, poverty, and
difficult working situations
Without addressing the underlying issues, it is
impossible to address obesity
Without addressing this, we risk shifting obesity
to another source of discrimination against the
poor
Tobacco v. Food Companies
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Tobacco companies are the enemy
 Their products are bad
 Their cooperation is a sham
Food companies are essential
 There are no bad foods, just bad diets
 McDonalds sells health foods in India
Food companies must be partners, not enemies
National v. Local Problems
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Tobacco is a national product with local sales
Local restaurants are more important than
national chains
 National policy ignores them
 Local health departments already have
relationships with them
Their cooperation is essential and only local
public health can make that work
The Effect on Others
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Smoking in public is a nuisance to non-smokers
Banning smoking in public benefits non-smokers
 Mostly pretty speculative – the big benefit is to
the smokers who cannot get as many puffs
 Gets rid of the choice issue, however
Being fat has no direct effect on others
Addiction
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Tobacco is addictive
 Addiction means tobacco is the main problem
 Culture grows from addiction
Food is not addictive
 Culture drives obesity
 Psychiatric problems drive obesity
 Genetics drive obesity
Treatment
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Smoking treatments are cheap and safe
 Once you have been off for a while, you can
stop the treatment
Obesity treatments are expensive, dangerous, and
mostly failures
 They have to be life long, because the problem
is with the person and not with the food
Protection against Snake Oil
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Physicians are rushing to offer dangerous
medical and surgical treatments
 Remember Phen-Fen?
 Obesity surgery is the last resort, not the first
The federal government does not regulate medical
practice, just initial drug approval
The states must act aggressively to stop quackery
Special Issues for Local Public Health
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National policy is set at 30,000 feet
 Focuses on national concerns and cannot
address local issues
Food and food culture are local and regional
Food is essential to local culture and food policy
must be tailored to individual cultural and regional
needs
Footnote for another day:
Litigation is not the
answer