Public Health has a Tobacco Problem

Image taken from page 855 of '[A series of original Portraits and Caricature Etchings by ... J. Kay; ... with biographical sketches and illustrative anecdotes. [Edited by H. P.]]'The widely circulating media reports that compare bacon to tobacco in terms of its capacity to cause cancer reveals the “tobacco problem” with public health communication.

By “tobacco problem” I don’t mean that researchers or communicators are on the take from “Big Tobacco” or that they have got the facts wrong about its association with cancer. The tobacco problem is that the success of tobacco control has produced a conceptual and political myopia. Or what I call a “tobacco control style of thought”.

Ian Hacking describes a “style of thought” as a particular way of seeing the world or problem that allows some ideas to be thinkable and actionable, while rendering other ideas as unthinkable. The success in linking smoking with cancer and the implementation of controls to regulate its use have contributed to a tobacco control style of thought.

The effect is that all public health issues are shoe-horned to fit the tobacco control model.

Eating bacon and red meat, drinking soda or frequenting fast-food restaurants, or sitting in a chair for too long are all equated with smoking. Why? Because saying bacon is like tobacco means that the problem and corresponding solution is well understood by the public and policy-makers.

Except it isn’t. All of these activities are extremely different from smoking. Eating bacon is not the same as smoking cigarettes. Everyone outside the tobacco control style of thought can see this.

The Australian Agriculture Minister Barnaby Joyce said it is a “farce to compare sausages with cigarettes“. Does Barnaby have financial and political interests in saying that? Yes. Is he wrong in saying that? No.

Sure, saying “bacon causes cancer” generates headlines, but it also distracts from focusing on the actual research on the health effects of processed meats. Public health Image taken from page 277 of 'Lilliput Lyrics ... Edited by R. Brimley Johnson. Illustrated by Chas. Robinson'communicators and researchers need to break out of the tobacco control style of thought that makes bacon or soda look like tobacco.

Public health is currently in a battle with libertarians who cry “Nanny” every time they are told that an activity or behaviour should be regulated. However, in equating activities like eating processed meat or sitting at a desk with smoking, public health communicators give the appearance of legitimacy to the “Nanny State” cry. This does real damage to the credibility of public health research and erodes public understanding of risk factors and epidemiology.

Like the boy who cried wolf, if public health communicators continue to compare everything to smoking, soon people will stop listening.

Lifestyle Intervention and the Aesthetics of Obesity and Smoking

The sustained concern over obesity as a threat to population and economic security has led to a proliferation of medical and non-medical experts intervening in the daily lives and practices of individuals. These interventions commonly fall under the rubric of lifestyle. Seen as both the cause and solution, the modern lifestyle is the target of modification strategies and techniques.

Of course, interventions into lifestyle are not entirely new or exclusive to obesity. Smoking, homosexuality, extreme sports or drug-use have all been described as lifestyles with associated health risks that justify outside intervention. Yet, I contend that obesity is unique in its characterization as a political, economic, aesthetic and public health problem that emanates from individual choices and practices.

The uniqueness of obesity is partly evidenced in comparison to smoking. While smokers have attracted a significant share of vitriol and harassment, much of the blame for smoking and the associated health impacts is reserved for “Big Tobacco”. If repentant, smokers can be characterized as the victims of industry deception and chemical addiction. Although there is anger directed toward “Big Food”, obesity is primarily framed as the result of individual choice and lack of control.

Furthermore, there is an aesthetic difference that distinguishes obesity from smoking. While there are active efforts to counter the “coolness”of smoking, the iconic images of Humphrey Bogart or Audrey Hepburn with cigarettes in hand continue to influence Western aesthetics. And the more recent fictional characters, Don Draper and Joan Halloway stubbornly resist the cliché that “kissing a smoker is like kissing an ashtray”. In contrast, the aesthetics and celebrity of obesity are comical, grotesque or both. Cartoon characters like Homer Simpson or Peter Griffin who eat anything within reach, from a week old sandwich to the legs of a paralytic friend, serve to confirm the message that obesity is grotesque in form and the result of lack of control.

This aesthetic also carries with it a judgement on the ability of an individual to self-govern and also to govern others. Kim Beazley, the former leader of the opposition in Australia was once told by Prime Minister Bob Hawke that the Australian people wouldn’t elect a fat prime minister. A contemporary example in the US is Chris Christie. Since at least the 2012 Republican primaries Christie’s weight has been a continual talking-point. These discussions are set to increase as speculation grows over his intentions to run for President in 2016.

Contemporary concerns about obesity and its relation to aesthetics, self-governance and the governance of others resembles regulations over sexual conduct in Ancient Greece. In examining the problematization of sexual practice in Ancient Greece, Michel Foucault outlines the link between a husband’s sexual conduct, household management and governance of the city. According to Foucault, the Greek husband’s authority and control over his home (of which his wife was a part) reflected his ability to have authority and control over himself and the life of the city.  While the husband was free to engage in sexual practice outside of the conjugal relation, “having sexual relations only with his wife was the most elegant way of exercising his control” (HSII, 151). Further, when Aristotle condemns extra-marital sexual relations as dishonourable it is not that the activity deviates from a moral law or order, rather such action demonstrates the husband’s inability to conduct himself in relation to the ethical substance of pleasure with the appropriate degree of self-control and mastery.

The example of Nicoles the ruler of Cyprus illustrates this point. According to Isocrates, Nicocles explains his conjugal fidelity in saying, “I am the king, and because as somebody who commands others, who rules others, I have to show that I am able to rule myself.” Therefore if Nicocles wishes to rule others and the city with glory and authority then he must rule himself first. Foucault argues that for the Greeks the mode of subjection was politico-aesthetic in which “political power, glory, immortality and beauty are all linked together at a certain moment.” Thus the Greek free man is at liberty to engage in sexual activity with someone other than his wife, however if he has accepted the politico-aesthetic mode of subjection, if he wishes his existence to be characterized by self-mastery and beauty, then he will recognize the particular rules of conduct that are constitutive of that subjectivity.

In a somewhat similar fashion, the American (or Australian, or any citizen of a Western liberal democracy) is free to indulge in whatever culinary and dietary activity he or she wishes, however, in return the society will discount beauty and the capacity for self-governance and the governance of others and thereby justify interventions into their daily choices, activities and practices.

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