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 but drinking, using illegal drugs, overeating, failing to exercise, owning a gun, speeding, riding a motorcycle 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 (nearly 1,500 pages in two volumes), 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." Similarly, Introduction to Public Health notes that the field, which once "had much narrower interests," now "includes the social and behavioral aspects of life- -endangered by contemporary stresses, addictive diseases, and emotional instability." 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." Issues published in 1995 offered articles like "Menthol vs. Nonmenthol Cigarettes: Effects on Smoking Behavior," "Compliance with the 1992 California Motorcycle Helmet Use Law," "Correlates of College Student Binge Drinking, " and "The Association Between Leisure-Time Physical Activity and Dietary Fat in American Adults." In a sense, the change in focus is understandable. After all, Americans are not dying the way they once did. The chapter on infant mortality in A Treatise on Hygiene and Public Health reports that during the late 1860s and early 1870s two-fifths to one-half of children in major American cities died before reaching the age of five. The major killers included measles, scarlet fever, smallpox, diphtheria, whooping cough, bronchitis, pneumonia, tuberculosis, and "diarrheal diseases." Beginning in the 1870s, the discovery that infectious diseases were caused by specific microorganisms made it possible to control them through vaccination, antibiotics, better sanitation, water purification, and elimination of carriers such as rats and mosquitoes. At the same time, improvements in nutrition and living conditions increased resistance to infection. 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, the public health establishment is focusing on those causes and the factors underlying them. Having vanquished most true epidemics, it has turned its attention to metaphorical epidemics of unhealthy behavior. In 1979 Surgeon General Julius Richmond released Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention, which broke new ground by setting specific goals for reductions in mortality. "We are killing ourselves by our own careless habits," Secretary of Health, Education, and Welfare Joseph Califano wrote in the introduction, calling for "a second public health revolution" (the first being the triumph over infectious diseases). Healthy People, which estimated that "perhaps as much as half of U.S. mortality in 1976 was due to unhealthy behavior or lifestyle," advised Americans to quit smoking, drink less, exercise more, fasten their seat belts, stop driving so fast, and cut down on fat, salt, and sugar. It also recommended motorcycle helmet laws and gun control to improve public health. 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. Treating risky behavior like a contagious disease 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 finding 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 obese increased from a quarter to a third between 1980 and 1991. " The government is not doing enough," complained Philip R. Lee, an assistant secretary in the Department of Health and Human Services. "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, JoAnn E. Manson, said, "It won't be long before obesity surpasses cigarette smoking as a cause of death in this country." In his book The Fat of the Land, journalist Michael Fumento argues that obesity, defined as being 20% or more above one's appropriate weight, is only part of the problem. (See also "Busting the Low-Fat Dieting Myth," CR, October 1997.) According to a 1996 survey, 74% of Americans exceed the weight range recommended for optimal health. "So instead of talking about a third of Americans being at risk because of being overweight," he writes, "we really should be talking about somewhere around three fourths." If, as Philip R. 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. Lest you think this proposal merely facetious, it has been offered, apparently in all seriousness, by at least one economist, who wrote in The Orlando Sentinel: "It is somewhat ironic that the government discourages smoking and drinking through taxation, yet when it comes to the major cause of death--heart disease--and its spiraling health- care costs, politicians let us eat with impunity .... It is time to rethink the extent to which we allow people to impose their negative behavior on those of us who watch our weight, exercise and try to be as healthy as possible." Kelly Brownell, a professor of psychology at Yale University who directs the school's Center for Eating and Weight Disorders, has also suggested a "junk food" tax, along with subsidies for healthy foods. "A militant attitude is warranted here," he told the New Haven Register last year. "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?" Of course, a tax on certain foods would be paid by the lean as well as the chunky. 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 your life, most Americans would (I hope) agree, that's your business, not the government's. Yet many of the same Americans believe not only that the state should take an interest in whether people smoke but that it should apply pressure to make them stop, including fines (a.k.a. tobacco taxes), tax-supported nagging, and bans on smoking in the workplace. In a 1997 talk show appearance, New York City lung surgeon William Cahan, a prominent critic of the tobacco industry, explained the rationale for such policies: "People who are making decisions for themselves don't always come up with the right answer." Since they believe that smoking is inherently irrational, tobacco's opponents tend to assume that smokers are stupid, ignorant, crazy, or helpless--though they rarely say so in such blunt terms. They understandably prefer to focus on the evil tobacco companies, portraying smokers as their victims. Yet there is a palpable undercurrent of hostility toward smokers who refuse to get with the program. On two occasions in recent years, I was sitting at a (smoke-flee) table with a group that included both a smoker and a busybody who took it upon himself to berate the smoker for his unhealthy habit. In both cases, the smoker, constrained by politeness, offered only the mildest of objections, and no one intervened on his behalf. Imagine what the reaction would have been if, instead of a smoker, the meddler had zeroed in on a chubby diner, warning him about the perils of overeating and lack of exercise. I suspect that the other diners would have been appalled, and the target, in turn, would have been more likely to offer the appropriate response: Mind your own damned business. It seems we have special license to pick on smokers as a way of demonstrating our moral superiority. The same sort of arrogance can be observed among public health specialists, but they are more consistent. 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 S. Billings put it this way: " All 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, speed, 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. One such expert, writing in The New England Journal of Medicine two decades ago, declared "The real malpractice problem in this country today is not the one described on the front pages of daily newspapers but rather the malpractice that people are performing on themselves and each other....It is a crime to commit suicide quickly. However, to kill oneself slowly by means of an unhealthy life style is readily condoned and even encouraged." The article prompted a response from Robert F. Meenan, a professor at the University of California School of Medicine in San Francisco, who observed: "Health professionals are trained to supply the individual with medical facts and opinions. However, they have no personal attributes, knowledge, or training that qualifies them to dictate the preferences of others. Nevertheless, doctors generally assume that the high priority that they place on health should be shared by others. They find it hard to accept that some people may opt for a brief, intense existence full of unhealthy practices. Such individuals are pejoratively labeled `noncompliant' and pressures are applied on them to re-order their priorities." The dangers of basing government policy on this attitude are clear, especially given the broad concerns of the public health movement. According to John J. Hanlon's 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." The textbook Principles of Community Health tells us: "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 Meenan noted in The New England Journal of Medicine: "Virtually all aspects of life-style could be said to have an effect on the health or well-being of society, and the decision [could then be] reached that personal health choices should be closely regulated." Writing 18 years later in the same journal, Faith T. Fitzgerald, a professor at the University of California, 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 .... In effect, we have said that people owe it to society to stop misbehaving, and we use illness as evidence of misbehavior." 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." Former Surgeon General C. Everett Koop, for his part, seems completely 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. This is paternalistic tyranny in its purest form, arrogating to government the authority to judge "the welfare of the individual" and elevating "the community as a whole" above mere people. Ignoring the distinction between self-regarding behavior and behavior that threatens others, Koop compares efforts to discourage smoking and other risky behavior to mandatory vaccination of schoolchildren and laws against assault. While Koop may simply be confused, some defenders of the public health movement explicitly recognize 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." Of all the risk factors for disease and injury, it seems, freedom is the most pernicious. And you thought it was smoking. Mr. Sullum is a syndicated columnist and a senior editor at Reason magazine. This article is adapted from For Your Own Good: The Anti- Smoking Crusade and the Tyranny of Public Health, published this year by The Free Press. Sullum, Jacob, Smoking and the tyranny of public health.(Cover Story). Vol. 81, Consumers' Research Magazine, 07-01-1998, pp 10(5).