For the first time since the Civil War, American life expectancy is projected to decrease, owing to the diseases associated with obesity such as diabetes, ultimately causing cardiovascular death (1). In the past 30 years, the prevalence of obesity among U.S. adults has doubled, as has the incidence of type 2 diabetes (2). Enough data. We need to attack obesity.

The U.S. was faced with a similar problem 40 years ago: the dangers of smoking were graphically demonstrated in over 7,000 articles (3). Surgeon General Luther Terry convened an Advisory Committee that stated: “Cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action” (3). In 1965, the U.S. Congress adopted the Federal Cigarette Labeling and Advertising Act, and in 1969 the Public Health Cigarette Smoking Act. These laws required a health warning on cigarette packages, banned cigarette advertising in the broadcast media, and called for annual reports on the health consequences of smoking. Since then, we have seen massive public information campaigns, bans on smoking in public places, exclusion of smokers from the workforce in certain corporations, nicotine patches, and cigarette taxes. For example, between 1970 and 2001, the federal tax on cigarettes increased from 8 cents to 34 cents/pack, and state cigarette taxes increased from 11 to 43 cents. Over the same period, the consumption decreased from 32 billion to 22 billion packs/year in the U.S. For every 10% increase in price, cigarette consumption decreases 4% (4). We can count this as partial success: nearly one-half of all living adults who ever smoked have now quit. However, 46 million Americans still smoke.

What lessons can we learn from smoking? The combination of warning labels, taxation, a public campaign, business participation, and legislation have been effective.

At the University of Virginia, we have initiated a program that could become a model for the U.S. In May 2004, we began to create “warning labels” on the 120 vending machines in the UVa Health System. Each snack and beverage was color-coded: red, yellow, or green. In consultation with our dieticians, we labeled red those items 201 calories or more (or 10.1% or more saturated fats), yellow were items 141 to 200 calories (or 5.1% to 10% saturated fat), and green items 140 calories or less (and <5% saturated fat). We also added a 5-cent “tax” (approximately 8%) to the cost of the red items and donated the proceeds to the UVa Children’s Fitness Program. Large signs explaining the program were placed next to each vending machine.

After one year, the red item sales decreased 5.3%, yellow increased 30.7%, and green increased 16.5%. We collected $6,700 in the nickel tax. Interestingly, total sales increased 8.3%. Although this was not a randomized trial, the results seemed worthy of further study. We are now planning to color-code each of the items in one of our two hospital cafeterias and compare sales between the two. After the initial data collection, a tax is planned. We have begun discussions with state officials to reproduce both the vending machine and cafeteria programs in schools throughout Virginia.

The surgeon general must attack obesity in much the same way that Luther Terry attacked smoking. In 2001 and in 2006, the surgeon general has issued statements and even a “Call to Action” (5). But these were not specific enough to result in action.

To give credit where credit is due, when the Master of Business Administration students at Rice University in Houston, Texas were investigating ways to pay for America’s uninsured, they proposed a “fast food tax.” Most definitely, the “unhealthy food tax” builds on that idea. Recent studies have estimated that to cover the uninsured would require an additional $83 billion/year (8); the “unhealthy food tax” would get us one-third of the way there. If we went “all the way” and had an unhealthy food tax equal to the 42% cigarette tax, we could pay for all of the uninsured. Of course, the point is to reduce consumption of fatty food, but there might be collateral benefits.

What can cardiology do? We can advocate for the health of America and hopefully decrease the number of people who will die from cardiovascular disease. We can support the surgeon general if those initiatives are begun, advocate for their enactment, and work to operationalize the plans. We can be sure that we and every one of our patients know his or her body mass index (BMI). We don’t do very well right now: in 1 study of patients after myocardial infarction, the BMI was documented in only 14% of patients (9). We can work with our own local cafeterias and state school systems to put systems in place similar to the one at the University of Virginia. We can advocate for better exercise programs in schools and in the workplace. Finally, cardiologists can perform research not on the problems of obesity—we have enough data—but on solutions.

It is abundantly clear that, in short order, obesity will kill more people than smoking. The time has come for the country to get serious about obesity and take lessons from smoking. Cardiologists should appropriately take the lead.