Comparing Smoking with Being Higher Weight

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I’ve received several reader questions about a situation where those who are pushing the medicalization of higher-weight bodies often try to make some kind of comparison to smoking. Today, we’re looking at three examples:

Example 1
When we talk about the extremely high failure rate of intentional weight loss interventions, one reply (often from healthcare providers) is something like "5% success rate is great! I tell patients to stop smoking and that has a 95% failure rate too!”

This is not an apt comparison for several reasons.

The primary difference is pretty simple. Smoking is a single behavior – every smoker smokes. They share a specific, identifiable behavior that is different than non-smokers. Being fat is a body size (being classified as “overw*ight” or “ob*se” in current medical science is about a certain ratio of weight and height and it’s been changed over time, including at the request of companies that sell dieting.)  Fat people don’t share a single behavior, or even a group of behaviors, that are different than thin people’s behaviors (in fact, there are fat and thin people with the exact same behaviors.) Fat people are as varied in their behaviors as any other group of people.

Now let’s talk about what a successful intervention looks like. Smokers become non-smokers when they quit smoking – when they stop doing a single, specific behavior. In order for fat people to become not fat, they must change their body size.  Where “smoke less” is a behavioral change, “weigh less” is not.

Some people suggest that the behavioral intervention is “eat less and exercise more.” This is a problem on several levels. For the sake of our comparison to quitting smoking, it’s still absolutely not apt. Smoking is, again, a simple, single behavior. Even if we bought into the “eat less and exercise more” idea, deciding how much to eat and how much exercise is to do is objectively more complicated than simply not lighting a cigarette. And it’s even more complicated than that. You see, there are fat people who eat less and exercise more than thin people already. There are fat people dealing with things like eating disorders and food insecurity who don’t eat enough and who over-exercise. There are fat people who run ultramarathons. Again, suggesting that “eat less and exercise more” is the same thing as “don’t smoke” is stereotyping, not healthcare. And just so we’re clear, “eat less and exercise more”  has been studied extensively and has never been shown to lead to significant long-term weight loss for more than a tiny fraction of people. In fact, there is no behavioral intervention that has been shown to produce significant, long-term weight loss in more than a very small number of people.

Then there are issues with attempts and failures.  Even if we assume that smoking and weight loss have a similar failure rate (ie: the vast majority of people who try fail long term) the difference here is that a smoker is statistically healthier for every day they don’t smoke – even if they start smoking again. Intentional weight loss attempts do not work that way.  When we lose weight and gain it back, we subject our bodies and minds to the negative impacts of weight cycling. People who attempt weight loss are not healthier for the attempt and, in fact, it’s likely the opposite.

Finally, smoking is causally related to health problems, being fat is only correlationally related. There is good research showing that quitting smoking improves health. In addition to a lack of evidence that significant long-term weight loss is even possible for most people, there is also no research showing that the few fat people who are able to suppress their weight have health improvements because of the weight loss.  There is, in fact, research that suggests that they don’t.

 Example 2
“Well, just because non-smokers get lung cancer doesn’t mean that smoking doesn’t cause lung cancer, just like the fact that not all fat people get health issues doesn’t mean that being fat doesn’t cause health issues.”

Again, body size is not a behavior, and the things that fat people have in common are typically more the weight stigma, weight cycling, and healthcare and other access inequalities that they experience, rather than behaviors in common that differ from those of thin people. When you add those confounding variables to the fact smoking has been found to literally cause cancer, we can see that, again, this is not an apt comparison.

If fat people get some type of cancer more often than thin people, we first have to account for the confounding variables (weight cycling, weight stigma, healthcare inequalities – like doctors who don’t give appropriate preventative screenings to fat people, screening tools that were built for thin bodies, fat people avoiding these screenings because of their experiences of fatphboia, etc.) as well as eliminating the possibility that something that causes the body to be larger is also causing the cancer. Until those things are fully understood, guesses and assumptions about body size causing cancer just amount to harmful weight stigma (and can create a situation where all of those issues aren’t explored or rectified because of the tendency of healthcare to look for a way to blame fat bodies and then, regardless of how shaky the justification is, they just stop looking at anything else.)

Moreover, even if someone proved that higher weight and cancer were causally related, that would not be the same as proving that weight loss will reduce the cancer risk. (Similarly,  people with cis-“male” pattern baldness are more likely to have heart attacks, but getting them to grow hair, or put on wigs, will not change their risk.) Not to mention that, again, weight loss has a failure rate that hovers near 100%.

Example 3
Shaming people gets them to quit smoking, so shaming fat people will get them to be thin

Even if someone believes that being fat requires some sort of health intervention (and I don’t think the evidence supports that) and even if someone believes that shaming smokers has been/is a good public health intervention (and I’m not agreeing that it is) they cannot logically draw the conclusion that shaming is an appropriate intervention for fat people. Shaming smokers shames people for something that they do, shaming fat people shames them for how they look. Beyond the issues we’ve already discussed, there’s the fact that if smokers wish to avoid the shame and stigma, they have the option to hide their behavior.  Fat people have no such option except to avoid ever going out in public.  It’s simply not the same thing.

As a reminder, health is an amorphous concept, it is not an obligation, barometer of worthiness, or entirely within our control. And regardless of what you believe about smoking, being fat, and health, they are simply not comparable from a public health perspective and continuing to treat them as if they are does serious harm.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.