Alberta Cancer Foundation

The New Tobacco

In 1952, the year he starred in The Quiet Man with Maureen O’Hara, actor John Wayne took on another role: himself. Wayne appeared in ads for Camel, languidly cradling a cigarette between his fingers. The images accompanied the actor saying things like, “I tried many different cigarettes. I chose Camel for their flavour and the way they agree with my throat.”

Illustration by Raymond Reid

Those smokes, however, did not agree with his lungs. Wayne was diagnosed with lung cancer 12 years later. He went on to film a public service announcement for the American Cancer Society that urged people to seek regular medical check-ups. He was never able to give up tobacco, and died from stomach cancer in 1979.

That John Wayne shilled for Camel is hardly surprising. Hollywood stars of that era who puffed on screen were not so much promoting an ideal as portraying a social norm. What is surprising is how much that social norm has changed since 1952. Tobacco continues to be a leading cause of preventable death, but sustained anti-smoking campaigns and policy changes have led to significant decreases in the numbers of smokers in Canada, the U.S. and elsewhere. Kenneth E. Warner, a professor of public health at the University of Michigan, estimated that in the United States alone, legislation for the marketing, licensing, taxing and education of tobacco has prevented an estimated 100 million people from lighting up. A similar approach in Canada has led to equally impressive reductions. In the 1960s, roughly half of Canadians over the age of 15 smoked; today it is 18 per cent.

The success of tobacco control has provided some lessons for other areas of public health, but especially in one area now considered an epidemic: obesity. Roughly a quarter of Canadians are now overweight and obese – double the 1985 figure. Last year, federal, provincial and territorial health ministers said Canada “is in the midst of a childhood obesity epidemic.” Excess weight contributes to diabetes, other chronic illnesses and some cancers. Morbidity rates linked to obesity are also rising, according to a recent study by the Canadian Institute for Health Information and the Public Health Agency of Canada. It found that obesity and excess weight contributed to nine per cent of deaths in 2000.

Health-care costs are rising with weight-related illnesses – in Alberta these costs are not much lower than those of tobacco – and these figures have made obesity the new tobacco. As Ken Kyle, who was also a contributor to the World Health Organization’s International Framework Convention on Tobacco Control, notes, approximately one-third of cancer deaths are caused by poor nutrition and inactivity, the same percentage as caused by tobacco products. “Tobacco control is not ‘done,’” says Kyle, who has spent a career in policy and cancer prevention. “But efforts now need also to be made in obesity control.”

Law-makers and public health researchers believe that tobacco control provides lessons for obesity and are applying similar strategies to regulate healthy weights. It’s not the first time anti-smoking strategies have been applied to other public health issues. In the U.S., for instance, Congress pointed to tobacco labelling when putting forward legislation about alcohol. But obesity has drawn more parallels and broader action. A buffet of laws – from “soda taxes” on sugary beverages to bans on junk food in schools  – inspired by tobacco policy are on the books. In Canada, the Standing Committee on Health recommended legislating labels on pre-packaged foods, setting regulations about levels of trans fats and establishing food and physical activity programs in schools. Provinces, meanwhile, have their own initiatives, such as a physical activity tax credit in Alberta and a ban on trans fats in schools
in Ontario.

The first step to reduce the waistlines of a nation and help prevent cancers linked to obesity (such as breast, endometrium, colon and kidney cancers) is to determine which strategies are most effective. As public health researchers are discovering, changing a social norm isn’t as simple as nutritional labelling at fast-food restaurants or banning pop from schools – it involves changing our attitudes.

“Eat food. Not too much. Mostly plants.” It’s the message that resonates with readers of Michael Pollan’s book In Defense of Food. In it, he urges people to adopt a diet of healthful, unprocessed food in moderate proportions.

Pollan’s modern dictum is wise, if prosaic.

But it’s easier said than done. The feast-and-famine cycle ancient humans experienced is built into the bodies of modern humans. It doesn’t make sense in an age of automobiles and desk jobs and prepackaged food. Yet there remains a biological urge to stuff ourselves, and it’s aided by convenient access to food. (When was the last time you foraged for your supper? And rooting around in the freezer doesn’t count.)

Historically, educating the public about a health risk has not single-handedly reversed outcomes. After epidemiological research on the links between smoking and cancer were released, health advisors believed that “smokers would see the error of their ways and quit,” as Kenneth E. Warner, a professor of public health at the University of Michigan wrote in an essay in the book Policy Challenges in Modern Health. And indeed, the consumption of tobacco dropped – for a while. But rates picked up and more comprehensive, aggressive campaigns were needed. “Likely, the most important message from the anti-smoking campaign,” Warner wrote, “is that tackling the obesity problem requires a sustained, thoughtful, well-resourced, multi-dimensional effort.”

Obesity is a more complex social issue than tobacco in some basic, but important, ways. Preventing tobacco-related illness requires people stop using tobacco, even if the methods to achieve cessation are broad. “There is a clear causal link between the particular behaviour of smoking and bad health outcome,” says Nola Ries, an associate researcher with the Health Law Institute at the University of Alberta. “It’s easier to show that if you have fewer people smoking that you will reduce overall a population’s incidences of cancer related to smoking.”

Preventing obesity-related illness is not as clear-cut. Cessation is not an option and the correlation between a particular intervention can be more difficult to track. “It’s easier to show that interventions like cycling lanes lead to more physical activity,” Ries notes. “That itself is a healthy thing, but whether it translates to lower obesity rates is a longer-term measure.”

The matter is further complicated by the issue of blame. This is not, experts say, solely the fault of an individual. We live in what health researchers call an “obesogenic” world. “Our whole environment is set up in a way to promote obesity,” Ries says. “Even when tobacco use was more prevalent, you couldn’t say the environment was ‘tobaccogenic.’ ” Though some public health professionals might disagree on this point, noting how an entire cultural norm had to change before smoking rates dropped, most agree that modern society is, as the American author Kelly D. Brownell dubbed it in Food Fight: The Inside Story of the Food Industry, a “toxic food environment.”

Only public policy, proponents believe, will help change that environment.

Food is necessary for life and, though some foods are better than others, no single meal or single food has the same impact as a puff on a cigarette. Breakfast at a greasy spoon, a candy bar, a venti mocha frappuccino will not alone cause a chronic illness. Should governments apply “snack taxes” to your bag of chips, even if you’re not overweight? Should the 75 per cent of the population that maintains a healthy body mass index subsidize the health care costs of the 25 per cent who do not? Can you legislate good health? These are questions being batted back and forward on the editorial pages of newspapers. The common refrain of naysayers is that there is no place for the state in the kitchens of a nation.

The nanny state complaint has been a minor voice in the debate on policy. “I think what we can draw from tobacco control is the importance of multi-sectoral, multi-jurisdictional, multi-level sustained intervention,” says Dr. Mark Tremblay, director of Healthy Active Living and Obesity Research at the Children’s Hospital of Eastern Ontario Research Institute. “That’s why efforts at smoking cessation succeeded. That’s a huge lesson. That’s the only way you can transform a social norm.”

Canadian researchers like Tremblay have called for greater national leadership, increased funding and more partnerships between federal, provincial and municipal governments – each of which regulates different arenas such as taxation, marketing and schools. The question for most is not whether government intervention is necessary, but what it will look like. Anti-obesity and physical activity advocates face, according to Nola Ries and her University of Saskatchewan research colleague Barbara von Tigerstrom, a tangled web of “ideological opposition and jurisdictional wrangling.” Provinces regulate schools and therefore have control over school nutrition and physical activity programs for children. The federal government has implemented a children’s fitness tax credit and has said it will expand the program to include adults. Meanwhile, a federal private members’ bill amending the Competition Act and the Food and Drugs Act is aimed at protecting children from food advertising.

Multiple levels of government and numerous ideas – from proposed snack taxes to fruit subsidies – have been introduced. However, little has happened on the legislative front. Ries and von Tigerstrom wrote about roadblocks to laws on physical activity and healthy eating in a 2010 article for the Canadian Medical Association Journal: “legal measures are spare,” they note, “with little consistency across the country.”

This is where the history of tobacco control comes in. For decades, lobbyists struggled to change the social norm; to make a cool-looking John Wayne, posing with a Camel cigarette, look uncool. It was only through sustained, aggressive and sweeping changes that a social shift came about. “Forty years ago, Canada had the highest tobacco use rate in the world,” says Kyle. “We are now among the lowest in the OECA [Organization for the Economic Co-operation and Development].” The timeline also mirrors tobacco. Tobacco consumption was at its peak in the early 1960s. Today, many health researchers and policy analysts say that the obesity issue is at the point tobacco was when John Wayne was doing those public service announcements. “Advocacy for obesity control,” Kyle says, “is where tobacco was 30 years ago.”

The message is patience, persistence, funding and leadership. Tremblay, for one, has spent his career calling for action and leadership; he’s thought about what leadership should look like. “It starts with a plan. We don’t even have a national physical activity act.” Canada was once a leader in exercise science and physiology, he says, exasperated, but has fallen behind. “The U.S. has dedicated funding and a national plan with comprehensive, large sector themes devoted to individual action items.” Transforming an obesogenic environment into a healthy one, Tremblay says, will not be cheap: “The cost will be in the billions, not in the tens of thousands.”

Whether any of these initiatives will work is another matter. Anti-smoking activists only managed to make smoking socially unappealing after experimenting with different policies. “You can only find out how populations will respond to changes in policy or legislation that encourage or discourage certain behaviours,” Ries says, “by trying certain initiatives and measuring outcomes.” Preventing obesity will not, everyone agrees, be a piece of cake.