Monday, January 28, 2013

Punishing Smokers and the Obese--what?

Heidi Klum: Role model for the obese?
I just read an Associated Press story in my local paper with the headline, "Do penalties for smokers and the obese make sense?" It proposes either punishing folks whose conditions are likely to require greater health care expenditures or letting "these health sinners die prematurely."
In other words, there are only two options for smokers, whose annual health-care costs are "about $96 billion," and the obese, ($147 billion): Death before they otherwise would go--perhaps saving the system old-age-related health care costs--or taxes and restrictions designed to curb smoking or eating, to offset the extra services they'll likely need while alive the usual length of time.

Does this sound crazy to you?

The most glaring and offensive assumption is that smoking is a choice that is equivalent to a choice to be obese.

The big argument in the article is whether penalties are unfair to the poor, who tend to be both smokers and obese. A secondary argument is about whether it's fair that other people sharing a health carrier should be forced to absorb the expenses of your smoking or obesity. Sorry, those are not the relevant questions, and certainly shouldn't be posed as if these two divergent health problems are comparable.

Daniel Callahan: shame fatties
Quoted is bioethicist Daniel Callahan, senior research scholar at The Hastings Center, New York. He got in trouble last week for a paper in which he suggests that the obese, already "lost," aren't going to be helped, but overweight folk don't really realize how badly-off they are, and need "nudging" by policy and practice toward eating less and having some self-control. His paper got press under the term "fat-shaming," though that isn't exactly what he advocates. He describes how social pressure got him to quit smoking, and thinks that when the brains of the bulging understand how they're harming their bods with excess weight, they'll gain motivation to slim.

Does he have any evidence that fat people are unaware they're chunking up? Does he think our society, that confronts everyone purchasing food in a check-out line with magazine covers of impossibly thin movie stars, offers little pressure to be healthy, fit and slender?

Here we have an individual who truly has little understanding of the complexities of the obesity issue, yet suggests we ask the portly, "Fair or not, do you know that many people look down upon those excessively overweight or obese, often in fact discriminating against them and making fun of them or calling them lazy and lacking in self-control?"

The central mistake in both Dr. Callahan's paper and the Associated Press piece is the belief that the smoking and obesity problems are parallel, subject to the same causes and cures. The causes of both, implicitly, are exactly the taunts Dr. Callahan points out to those of size: laziness, lack of will-power and self-control.

That such a paper could be called scholarly and get published is astonishing; that newspapers would carry such assertions and suggestions is appalling.

You can teach a smoker to completely stop smoking--but never an eater to completely stop eating. Smokers have a range of physical and emotional reasons for smoking; science is constantly revealing new causes for overweight and obesity, many of them out of individuals' control.

A few days ago, Nicholas D. Kristof wrote in the New York Times about the impact of en-utero and at-birth influences on offsprings' obesity. He described research in which genetically identical mice fed and exercised the same were of greatly differing sizes--depending on whether they were exposed to an endocrine-disrupting chemical at birth. A single exposure determined whether they spent life obese or normal-sized. Kristof used the information to argue against endocrine-disruptors, such as the plastic additive BPA, in the environment.

'Flabby' and normal mouse differ only by at-birth endocrine disruptors
I wonder how he feels about dieting, then. If the "flabby" mouse ate and exercised the same as his thin brother, yet was programmed to be obese in a way he could never change, why ever argue for eating less and exercising more? For these mice, is a calorie a calorie, or does the calorie do something different depending on warped or healthy chromosomes?

Could you shame an endocrine-disruptor-exposed obese person into losing weight? How about someone with obesity as a souvenir of the Adeno 36 virus, also shown to change both people and animals from svelte to swollen after exposure? Can you "nudge" into skinniness someone whose hormones have gone wacky? Or those experiencing obesity as a side-effect of needed medication for another condition?

The Associated Press story talks about the success of rules limiting smoking in public places, and cites NY Mayor Bloomberg's ban of sugary drinks in 16-ounce or larger cups as another policy to address a health problem. I've never seen anyone harmed by second-hand soda, and there's scant evidence that selling16 versus 20-ounce fountain drinks makes for smaller bodies. New York government is meddling in restaurant commerce with a kindly intent but with the erroneous assumption that like smoking, obesity can be extinguished through laws better able to help people than they, themselves, can.

Another striking and shockingly erroneous parallel appearing in news media, by the way, is between smoking and gun ownership, seen as similarly dangerous. If we can legislate limitation of smoking, and thereby save lives, we can legislate limitation of gun ownership, again saving lives. The comparison fails, however, in that the vast majority of gun owners are responsible, law-abiding citizens whose weapons could stop a crazy person's rampage, thus saving, rather than taking, lives. Current campaigning to eliminate gun ownership (gift cards for guns turned in; creating hurdles to gun ownership; limiting size of ammunition clips), especially as portrayed by the New York Times' "expose" this weekend on what the paper considers the gun industry's efforts to capture children as future customers, contains the same misguided underpinning: Big businesses want profit despite causing harm, and government needs to step in to protect people from their own deleterious decisions in patronizing them.

The Associated Press story does acknowledge a difference between second-hand smoke and first-hand-to-mouth imbibing: "When you eat yourself to death, you're pretty much just harming yourself," University of Illinois professor Jay Olshansky concedes. The Affordable Care Act allows a surcharge for smokers, but none for the overweight or obese, however. New studies showing that overweight and mild obesity correlate with greatest longevity don't do much for the argument that smoking and obesity are equal evils.

And that's my point: The thickening of America is a unique issue, and, if these longevity studies are correct, doesn't have to be, in all cases, a problem. I think our culture has thoroughly shamed people whose bodies are wider than ideal, and the number of diet books and slimming industries, feeding $20 billion annually into our economy, testifies to the extent Americans care about their weight, health and appearance. Don't tell me our nation needs "nudging" or penalties or restrictions to motivate us toward healthy size. Don't even suggest that people are unaware of their shapes or even the healthfulness of their diets. They know, and a plethora of forces acts on their food decisions and ultimately, whether they are fat or thin.


  1. Penalties are surely unfair for the poor people, it is true that smoking is a dangerous thing which seriously damages our health and takes hundreds of lives globally but punishing smokers is not the only solution.

  2. I don't think it is unfair, this will help to bring down the ratio of smoking as people will try to quit to stay away from the penalties.

  3. It sure must be interesting at the dinner table when a liberal, you, sits down with your husband, a conservative.
    There may be some of the correlations you raise between smoking & obesity, but in both cases I believe that it boils down to choices the individual makes.
    Growing up I was very thin and generally in my years from 24 on I put on weight which I attribute to being married.
    When I went through a divorce I lost weight, back to my earlier years, due to the many emotional aspects of a divorce, but I also ran and that helped to take the weight off.
    Now that I’m in my 60’s it is harder to lose weight and much easier to put it back on thanks to times like Thanksgiving & Christmas and the meals that occur. Previous to this past year I was up to 260#, I am 6’1”, and was able to drop to 220# watching what I eat and limiting portions, that was until Thanksgiving & Christmas where I jumped back up to 235. I’m losing the weight slowly, now I’m back on track. I can’t run at this point due to bad knees but I can make choices as to what I eat and how much.
    I would ask, why can’t the people who I see in the store who are obese not buy soda and carbs which seems to be a staple of an obese person’s diet?
    I would ask why an obese person can’t seek medical assistance to lose weight. It’s available.
    In the 60+ years I’ve been alive I’ve never smoked a cigarette.
    I’ve had a lot of exposure to 2nd hand smoke since my parents, grandparents, aunts & uncles all smoked. It was a choice they made, I’m sure, reinforced by the glamor of Hollywood and the lack of knowledge of health issues with smoking.
    My best friend when he started smoking, asked, while hacking and coughing, if I wanted a cigarette, stating it was cool. I remember that I said, I was cool enough already. Throughout my years there has always been an opportunity to start, but I haven’t. With the cost of cigarettes, I don’t see how some can afford it but they seem to be able to afford cigarettes, soda and carbohydrates in mass quantities.
    Again, choices made.
    I am glad that at least one aspect of my personal belief is supported with OBAMA’s CARE.
    For years I have said that if someone wants to take up smoking, especially in today’s world, that they should, upon their first doctors visit, usually for bronchitis, be made to sign a release that when the ravages of their choice to smoke really takes place, that they will be responsible for the choices they made and be solely responsible for the costs associated. There would be plenty who would gladly sign.
    Now if you could get a note from a doctor, maybe 2 so you can’t buy a note like that, saying that you need to smoke or that you had a DNA marker for a propensity to smoke then that would be a different story.
    Ultimately, it boils down to choices and I hope I have made my position clear.
    BTW, my mother died of lung cancer, my father of Emphysema and my sister, who was a smoker, breast cancer.

  4. There is no such thing as a “bioethicist."