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3
Law and the Public’s Health: Law as a
Tool for Improving Population Health
This chapter focuses on the category of laws, regulations, and other
public policies primarily designed to protect the public’s health or safety,
especially by targeting individual or private sector behaviors that present
health or safety hazards to the population. Examples include driving with-
out a seatbelt, smoking in bars, creating exposures to toxic substances, and
advertising tobacco products to minors. Chapter 4 continues the discussion
by focusing on intersectoral policies that—without being designed primar-
ily to protect health—affect health outcomes, and calls for incorporating
consideration of health effects (both positive and negative) in policymaking
in other sectors of government and in the private sector.
Below, the committee discusses the major ways in which laws enacted by
federal, state, and local legislatures, regulations promulgated by the Execu-
tive Branch and its agencies, and to a lesser extent, litigation through the
judicial system may be used as public health interventions. The committee
provides examples of some prominent areas for policymaking, and explores
the roles of public health agencies (and associated boards of health or other
government executives) in making or shaping health policies. Government
policy interventions work at a level far above the individual to transform the
conditions for health and can achieve efficiencies and economies of scale that
are not possible with one-on-one health education or clinical encounters.
MODELS OF LEGAL INTERVENTION
Government has at its disposal a toolbox of law and public policy tools
to improve population health (Gostin, 2010a; Gostin et al., 2008). Some
57
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58 FOR THE PUBLIC’S HEALTH: REVITALIZING LAW AND POLICY
are in areas where the public health agency plays a critical or lead role and
policies are designed explicitly to affect health. These are the focus of this
chapter. Legal and public policy tools for the public’s health include
• t
axation, incentives, and spending (e.g., cigarette and other “sin”
taxes and allocation of the tax to combat the problem, may include
pricing policies and financial incentives);
• a
ltering the informational environment (e.g., food or drug labeling,
and disclosure of health information);
• a
ltering the built/physical environment (e.g., zoning, toxic waste);
• a
ltering the natural environment (e.g., clean water, air, environmen-
tal justice);
• d
irect regulation (e.g., seat belts, helmets, drinking water fluori-
dation, folate fortification of grain-based products, iodized salt;
licensure of medical care providers and facilities);
• i
ndirect regulation (e.g., tort litigation in tobacco); and
• d
eregulation (e.g., distribution of sterile injection equipment or
criminalization of HIV risk behaviors).
Most of the tools above refer largely to interventions aimed specifically at
improving or protecting health, and some involve public health agencies
directly. However, the distinctions between health-oriented and non-health
policy are blurred in some areas, especially the built/physical environment,
where zoning and land use have become increasingly focused on health.
Box 3-1 provides examples of public policies in each of the categories above
as applied to food and nutrition.
Using the Law to Achieve Population Health Objectives
The principles that form the basis for legal interventions by public
health agencies and others in government to protect and improve the pub-
lic’s health include discharging the statutory duty to protect from harm and
promote health and safety. In many cases, this is done by intervening to
attenuate externalities—negative side effects of individual actions such as
speeding, addressed by imposing speed limits, and of business sector actions
such as emitting air pollution, addressed by setting and enforcing air qual-
ity standards. Some legal interventions are more controversial than others
and starkly illustrate the challenge of balancing public goods and individual
freedoms due to varying norms/attitudes, expectations, and values that may
inform both public opinion and decision-making by legislators in different
jurisdictions.
The history of motorcycle helmet laws—using the tool of direct
regulation—illustrates the arguments on both sides of a piece of legislation,
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BOX 3-1
Actual and Hypothetical Examples of the Legal Models
of Intervention Applied to Food and Nutrition
a. Tax and spend: Subsidies for healthy school lunches
b. Informational environment: Laws requiring disclosure of calories on restau-
rant menus
c. Built/physical environment: Laws on fast-food or liquor store density
d. Natural environment: Food safety laws that order changes to the disposal of
animal waste contamination of water sources
e. Direct regulation (of persons, professionals, businesses): Requiring forti-
fication of cereal grains with folate to prevent birth defects
f. Indirect regulation: Tort liability lawsuit brought by overweight adults or chil-
dren against fast-food chaina
g. Deregulation: End subsidies of agricultural products that contribute to un-
healthy eating, including corn used to produce inexpensive sweeteners, and
corn and soy used for feed, meat, and dairy
a See Mello et al., (2003). The case Pelman v. McDonald’s was initially dismissed “without
prejudice” and with detailed guidance on how to refile. It was later refiled, [I.4] amended to
reflect two more narrowly constructed claims of negligence, that is, failure to warn consumers
about the “danger and hazard” created by the ingredients and additives in the food, and fraud
(fraudulent and deceptive business practices). The refiled claim was dismissed because the
plaintiffs failed to prove they had viewed the advertising they claimed was misleading and
deceptive about the ingredients in the restaurant chain’s products (e.g., the claim that fries
were cooked in zero-cholesterol oil, but failure to inform that they were cooked in even more
unhealthy trans fats).
and the fact that empirical evidence is sometimes outweighed in the legis-
lative arena by ideological or moral arguments. The Highway Safety Act
of 1966 required that states enact and enforce motorcycle helmet laws to
receive highway funding. By 1975, 47 states and the District of Columbia
had done so. However, organized opposition by national- and state-based
anti-helmet advocacy groups succeeded in overturning the federal sanctions,
and a later effort to provide a financial incentive for such laws failed. In
2007, three decades after nearly universal enactment of state helmet laws,
only 20 states and the District of Columbia required all riders to wear hel-
mets (Moulton et al., 2007). Three states have no helmet laws, and in 27 of
the remaining states, only young people under age 18 or 21, depending on
the state, were required to wear helmets, and new riders were required to
wear helmets for a year. Six of these states required that adult riders obtain
$10,000 of medical insurance coverage, or that novice riders wear a helmet
for the first year (Jones and Bayer, 2007).
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60 FOR THE PUBLIC’S HEALTH: REVITALIZING LAW AND POLICY
The evidence base demonstrating the efficacy of helmet laws in reducing
rates of death and serious head trauma is robust, and includes a Cochrane
Collaboration review (Liu et al., 2009). Additional research indicates that
the economic burden of hospital treatment for unhelmeted compared to hel-
meted motorcyclists is a considerable $250,231,734 (Eastridge et al., 2006).
Rich natural experiments of the effects of the repeal of helmet laws showed
dramatic increases in injuries and deaths. However, because the evidence
of harm reduced or prevented by helmets has not persuaded antihelmet
advocacy groups, a discussion of the ethical and conceptual dimensions
of the debate is clearly needed (Cherry, 2010; Gostin and Gostin, 2009;
Jones et al., 2006). Antihelmet activists argued that helmet laws infringed
on their individual liberties and violated the due process clause under the
14th Amendment to the United States Constitution. They argued that their
choice to ride without a helmet affected their personal well-being alone and
had no effects on others. Proponents of helmet laws made three types of
arguments: (1) an economic/utilitarian argument on the basis of direct and
indirect costs incurred by society from motorcycle deaths and injuries; (2)
an evidence-based argument about the proven effectiveness of helmets in
preventing severe injuries and fatalities; and (3) a moral/paternalistic argu-
ment that civilized governments protect their citizens from inflicting great,
but preventable, damage to themselves and burdening their families with
wrenching grief and cost. Gostin and Gostin (2009) have shown that the
debate about individual freedoms, especially in this particular context, may
be one-sided, emphasizing the rights of individuals to freedom of actions
that do not harm others—physically, at least. However, this argument shows
little regard for the attendant freedom that accrues to the same individuals
from avoiding disability, and the averted burden to society, by preventing
crash-related permanent injuries and death.
As is the case with use of tobacco products (see Box 3-2), the consump-
tion of unhealthy foods has serious implications not only for the individual,
but for the common good. Smoking presents a threat to the health of others
through environmental tobacco smoke, and an economic threat to busi-
nesses, which face higher medical care costs and losses in productivity, and
to society in general (CDC, 2005; Musich et al., 200).1 Similarly, the con-
sumption of unhealthy foods—whether containing trans fatty acids (shown
to increase the risk factors for heart disease [Mensink et al., 2003], the
leading cause of death in the United States), high in salt (known to increase
blood pressure, a known risk factor for cardiovascular disease), or high in
sugars (contributing to weight gain, which is related to a variety of chronic
1 The economic impact of smoking is complex. Data indicate that the societal costs of caring
for ill smokers are in some ways offset by the savings incurred when smokers die, generally at
younger ages than nonsmokers.
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LAW AND THE PUBLIC’S HEALTH
illnesses)—presents high costs to employers and society as a whole. The an-
nual economic cost of obesity-related health conditions is an estimated $117
billion (Mello et al., 2003). Although some critics of policy interventions
in the area of nutrition in general and trans fats in particular charge that
such interventions interfere with consumer freedom to enjoy doughnuts,
fried chicken, and other products prepared using partially hydrogenated
vegetable oils, the reality is that consumer autonomy is overestimated for a
number of reasons (Resnik, 2010; Wilson and Dawson, 2010). The belief in
consumer autonomy is based on an assumption that people are entirely free
agents in the marketplace. However, this overlooks what is known about
human behavior (such as underestimating risk, optimism bias) and the fact
that companies marketing products known to have deleterious health ef-
fects use highly sophisticated advertising and product labeling developed to
exploit known consumer vulnerabilities (IOM, 2007; Wilson and Dawson,
2010). As is the case with smoking, people who are poor and less educated
have higher levels of exposure to unhealthful foods, in part because they
often live in neighborhoods where choosing less healthy options is facilitated
by a high ratio of fast-food purveyors to fresh fruit and vegetable retailers.
OTHER EXAMPLES OF LEGAL AND POLICY TOOLS
Policy Interventions on the Informational Environment
Unhealthy foods and beverages may be targeted from different angles,
including compelling or requiring manufacturers and retailers to take or
avoid certain actions and modifying the informational environment. Indus-
try packaging, labeling, and multimedia advertising of such products are
based on market research, and the results are highly attractive products
often accompanied by confusing or misleading information (Gostin, 2010b;
Mello et al., 2006; Pomeranz, 2011). Several federal agencies have the
authority to regulate businesses that produce some types of health-related
information. For example, the Food and Drug Administration (FDA) has
oversight of food labeling; the US Department of Agriculture has oversight
of food safety; and the Federal Trade Commission (FTC) has oversight of
food advertising. An industry policy to adopt a third-party certified “Smart
Choices” labeling convention to identify certain foods as healthier garnered
a warning letter from the FDA due to concerns about the potential of
misleading consumers with labeling that suggested healthfulness (Layton,
2009; Taylor and Mande, 2009). Similarly, a food company’s claims about
the benefits (i.e., increased child attentiveness) of its sugary breakfast cereal
were challenged by and settled with the FTC for false advertising (FTC,
2009, 2010). The FTC’s authority allows it to intervene in the marketplace
when a company makes deceptive claims. Although this authority is nar-
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BOX 3-2
Lessons from the History of Tobacco Policy
The case of tobacco illustrates why a multi-faceted approach is needed to address
some health threats (although, given the incomplete success of anti-tobacco campaigns,
it also illustrates the enormous challenge of addressing complex health problems). The
tobacco story also provides a rich example of a suite of public health interventions (in-
cluding the power to tax and spend, indirect regulation through litigation, and intervening
on the information environment), several of them public policies, to improve population
health, specifically by reducing mortality and morbidity due to its use.
It is important to note that the anti-tobacco campaign illustrates that the laws enacted
at the federal, state, and local levels include a variety of taxes on tobacco products, bans
on indoor smoking (first in workplaces, and later in restaurants and bars), restrictions
and enforcement on sales to minors, and a range of advertising regulations. The 58.2
percent decrease in the prevalence of smoking among adults since 1964 ranks among
the 10 great public health achievements of the 20th century (CDC, 1999; IOM, 2007).
Although the public health effort to lower tobacco use continues, many important les-
sons have been learned, some of which may be relevant to other areas where policy
action is needed to change the conditions for health. Despite considerable gains, 2007
data show that approximately a fifth of U.S. adults smoke, resulting in 443,000 prema-
ture deaths yearly and annual costs of $193 billion in direct health-care expenditures
and productivity losses each year (CDC, 2009). Only two states, California and Utah,
reached the Healthy People 2010 objective of a 12 percent smoking rate. Although
Utah’s rate is linked with the religious beliefs of a majority of state residents, California’s
low rate has been shown to be associated with that state’s aggressive and multifaceted
strategies against tobacco use (Graff and Ackerman, 2009).
Cigarette smoking is an individual behavior that affects both the health of the smoker
and the health of others who are exposed to the secondhand smoke. For decades, a
debate has occurred in multiple settings over the individual liberty of smokers, and the
appropriateness of government interference with personal choices regarding tobacco
rowly drawn, the increase of evidence about nutrition-related television
advertising and the proportion that is misleading or inaccurate may allow
the Commission to take action in a wider range of cases. The primary chal-
lenge to public policy on the informational environment in which the public
makes health-promoting or health-damaging choices lies in the protections
afforded by the First Amendment to “commercial speech” to further both
a business’s economic interests and the audience’s need for information
(Mello et al., 2008).
Although FDA and other agencies—either explicitly mandated to pro-
tect population health or like FTC, indirectly responsible for overseeing
and controlling certain market phenomena that may have some health
consequences—have authority to take certain regulatory actions against
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use. The 2007 Institute of Medicine report, Ending the Tobacco Problem: A Blueprint
for the Nation, eloquently summarizes the key elements of the debate, including those
that began to shift social norms:
For many years, a policy paradigm emphasizing consumer freedom of choice and decry-
ing unwarranted “paternalism” dominated public opinion and policymaking on tobacco.
In retrospect, however, the committee believes that predominant emphasis on consumer
choice in public opinion during this period was largely shaped by the tobacco industry’s
successful efforts to deny and obscure the addictiveness and health consequences of
tobacco use, and on an array of resulting market failures, including information asym-
metry between producers and users, distorted consumer choice due to information
deficits, and product pricing that did not reflect the full social costs (especially the effects
on nonsmokers). As the scientific evidence about addiction and the health effects of
tobacco use has grown, and the industry’s deceptive strategies have been exposed in
the course of state lawsuits and other tobacco-related litigation, public understanding of
tobacco addiction has quickly deepened and the ethical and political context of tobacco
policymaking has been transformed. (IOM, 2007, p. 33)
As public health practitioners have turned to the tobacco example for lessons that may
be used to address other health threats that may be effectively targeted through legal or
policy means, especially nutritional factors associated with the increasing prevalence of
adult and child obesity, several things have become clear (Kline et al., 2006). Although
food products, unlike tobacco, are generally not carcinogenic products, there are some
parallels between the ethical and civil liberties arguments used in both cases, and in
the “ecologic” aspects of unhealthy foods and those of tobacco. In the case of smok-
ing, data indicate that most addicted adults began smoking in adolescence and before
developing mature judgment, and that earlier life preferences tend to ignore long-term
risks and are generally replaced by health-oriented preferences later in life (IOM, 2007).
These factors indicate that smoking often begins at a vulnerable time of life, before au-
tonomy or true independence can be said to emerge. Smoking behavior is associated
with education level, parental occupation, and household poverty status, illustrating
that factors beyond individual choice are highly influential in shaping smoking behavior.
industry, there are some statutory or resource-related gaps in their ability
to enforce. For example, the Government Accountability Office recently
concluded that unlike the FTC, which can require companies to provide
evidence in support of their advertising claims, “FDA bears the burden of
proving that a structure/function claim is false or misleading without having
the authority to compel companies at the investigation stage to produce the
evidence that the companies assert as support for their advertising claims”
(GAO, 2011, p. 25). The FDA does possess this authority for drug and
device regulation. Also, federal agencies sometimes lack the resources to
enforce the law. Fines thus become simply the cost of doing business, and
lack of agency authority to require removal of misleading information rather
than requiring highly-publicized corrections of that information leave a con-
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64 FOR THE PUBLIC’S HEALTH: REVITALIZING LAW AND POLICY
siderable gap in the application of agency authority. This is an area where
the collaboration with state and local governments discussed in Chapter 2
may prove helpful, as they often have the capabilities to enforce federal law
that federal agencies themselves may lack.
Direct and Indirect Regulation: Deregulation
In recent years, the model of direct regulation that has been used suc-
cessfully in the context of smoking and other health challenges has been
explored for its potential in addressing food-based threats to population
health. Sugar-sweetened beverages represent one of many products that
contribute to Americans’ intake of excess calories. However, efforts to
legislate relative to this and other unhealthy food products will become po-
litically feasible only when the proponents of regulation are able to “show
that the industry is not behaving responsibly on its own—neither market
forces nor the industry’s own professional codes of ethics lead it to conform
to public expectations” (Mello et al., 2008, p. 4). Industry’s attempts at
self-regulation have been limited primarily to collaborating with schools,
communities, and local governments—a decision that allows companies to
maintain greater flexibility—and avoiding more stringent attention from
state governments. Relationships with schools and communities also meet
the industry preference for statements of principles rather than binding
commitments (Mello et al., 2008).
Other forms of regulation involve actions that build safety into a prod-
uct or environment rather than attempting to modify human behavior. For
example, setting standards (this may also be done through legislation, tool
[c] in Box 2-1) to improve the safety of motor vehicles by changing certain
features to reduce different types of risks has been more effective and effi-
cient than teaching people to be better drivers (Vernick, 2011). That is also
true of building safer roads and enforcing existing safety laws.
Indirect regulation through litigation has been successfully employed by
tobacco control programs. The Master Settlement Agreement with 46 state
attorneys general who had brought litigation against tobacco companies
was the major event in the tobacco battles. The agreement required seven to-
bacco companies to change their strategies for marketing tobacco products,
pay the states an estimated $206 billion, finance a $1.5 billion anti-smoking
campaign, open previously secret industry documents, and disband industry
trade groups believed to be concealing damaging research from the public
(Office of the Attorney General, 2011).
Litigation has been contemplated or attempted in a range of areas, in-
cluding firearm and motor vehicle safety. However, Congress can preempt
litigation by enacting legislation that provides special protection for some
types of products, rather than allowing the courts to make determinations
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about a case’s worthiness (Vernick, 2011). This is the case with firearms liti-
gation. Congress enacted the Protection of Lawful Commerce in Arms Act
in 2005, which gives firearms manufacturers and retailers broad immunity
from litigation (Vernick et al., 2007).
Capewell and Lloyd-Jones (2010) offer several powerful, recent ex-
amples of public policies that can facilitate the prevention of cardiovascular
disease at the most upstream or distal level possible.2 These include deregu-
lation, such as the public policies enacted in Poland, Finland, and the Eu-
ropean Union, that have shifted government agricultural subsidies in ways
that are designed to change national nutritional patterns or norms, such as
away from an emphasis on meat and dairy and toward fruits and vegetables.
Incentives: A Step Down from Regulation, or
in Combination with Regulation
Although there are numerous examples where industry is mandated by
the government to bear the cost of harms created by its products (i.e., when
harms cross a certain threshold, often based on evidence about dose-effect
relationships [e.g., for toxic waste and cleanup, and chemical contamination
of groundwater]), the notion of a less antagonistic way to engage industry
bears greater consideration than it has received (EPA, 2004). Examples of
incentives include labeling, such as obtaining an “organic” label, subsidies,
government purchasing, and food policies, such as sale of food in govern-
ment cafeterias, public parks, and beaches.
In addition to using the tool of direct and indirect regulation described
above, requiring industry to make certain changes to their products or
requiring consumers to operate within certain limits, the government may
use the influence of its “bully pulpit” to motivate shifts in how private-
sector entities operate with regard to products that are known to have the
potential to harm health. One example comes from the United Kingdom,
where the government has used a policy of collaboration and the incentive
of public reporting to engage the food industry in taking voluntary steps to
meet or exceed government-set guidelines for sodium levels in food. British
and American analyses have shown that even small reductions in popula-
tion risks, such as sodium intake, can lead to considerable improvements in
population health and corresponding economic savings realized by govern-
ments and employers (see Box 3-3). Another example of setting voluntary
guidelines and working with industry to adopt them comes from the FDA,
2 The term primordial prevention, used by Capewell and Lloyd-Jones (2010), has been
defined as “intervention at the most distal point in the chain of causality” (Starfield, 2001, p.
454) and preventing the emergence of predisposing social and environmental conditions that
can lead to causation of disease (Starfield et al., 2008).
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BOX 3-3
Reducing Salt Intake: Examples of the Potential
of Laws to Affect Health Outcomes
Beginning in 2003, UK health authorities began a dialogue with the food indus-
try about the levels of salt in food products and a collaborative effort to lower the
salt intake in the population. In 2005, the UK’s Food Standards Agency Strategic
Plan 2005–2010 established a target to reduce the average salt intake to 6g
(approximately a teaspoon) per day by 2010. Voluntary salt reduction targets for
the salt content of key food categories (e.g., breads, breakfast cereal, prepared
cheeses and meat products, different types of snacks) were published in 2006,
and revised in 2009. In 2008, the agency found that the nation’s average daily salt
consumption fell from 9.5 g in its 2000–2001 national nutrition and diet survey to
8.6 g. The agency regularly reports on the progress of major food companies in
meeting the voluntary targets. As examples, an update in March 2010 noted that
a major brand of chips contained 55 percent less sodium, with several companies
already meeting the 2012 targets for specific categories of foods. The agency
estimates that meeting the target of 6 g daily intake of sodium will result in the
prevention of 20,200 premature deaths per year (Food Standards Agency, 2008,
2009a,b, 2010).
The National Institute for Health and Clinical Excellence commissioned an
economic model to measure the potential effects on cardiovascular disease risk
factors of enacting legislation to eliminate trans fats or reduce dietary salt con-
sumption by 3 grams per day. Modelers estimated that each of these proposed
interventions could lead to discounted savings of more than $1 billion per year.
In 2008, the U.S. Congress asked the Institute of Medicine to make recom-
mendations for reducing sodium intake of Americans. U.S. dietary guidelines call
for no more than 2,300 mg per day for persons ages 2 or older. This is equivalent
to approximately 6 g of salt per day. The average American consumes more than
3,400 mg of sodium per day. Decreasing salt intake could have dramatic effects
on population health outcomes and medical expenditures.
In a modeling study, Palar and Sturm (2009, p. 49) found that reducing Ameri-
cans’ sodium intake to the recommended level (2,300 mg) would “reduce cases of
hypertension by 11 million, save $18 billion health care dollars, and gain 312,000
QALYs [quality-adjusted life years] that are worth $32 billion annually.” Danaei and
colleagues (2009) estimated that high dietary sodium is responsible for more than
100,000 US deaths. This is clearly an area ripe for policy interventions.
which is developing a uniform system for front-of-package food labeling and
will attempt to implement it through voluntary guidelines and then move
on to a mandated approach if necessary (Pomeranz, 2011).
One legal scholar has proposed policy strategies for holding industry
financially responsible for negative health effects related to the use of its
products. Sugarman (2009) has described this approach as “performance-
based regulation” that would offer an alternative to litigation or to mandat-
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LAW AND THE PUBLIC’S HEALTH
ing a certain way to operate. It would compel industries to act to lessen the
externalities, or collateral damage, caused by different types of consumer
products that are linked with a great proportion of morbidity and mortal-
ity and cause harm both to the individuals consuming or using them and
to others (in some cases the harm is economic). This type of regulatory
approach would seek to “harness private initiative in pursuit of the public
good” by setting regulatory targets for the industry to reach (Sugarman,
2009, p. 1035). Companies would be allowed to employ existing methods
or create new ones to decrease the harm of their products (or, in the case of
tobacco, to lower the rates of consumers using their products). Companies
reaching prescribed targets would receive public recognition (similar to the
UK publishing the sodium-lowering efforts of specific food companies), and
those failing to reach targets would be required to pay a fine.
An Example of the Cost-Effectiveness of Policy Approaches
The discussions leading up to and subsequent to the passage of the Af-
fordable Care Act, and the political dialogue on other topics, made clear
that getting value for major national investments is important to Americans
and to their elected representatives. The committee believes that policy in-
terventions can be effective and of high value in addressing major causes of
death, disease, and disability at the population level. The committee’s belief
is based on evidence reviews of the effectiveness of public policies aimed at
injury prevention, tobacco control and prevention of environmental tobacco
smoke, prevention of excessive alcohol consumption, and requirement of
immunization for school entry (Elder et al., 2010; Hopkins et al., 2001;
Task Force on Community Preventive Services, 2009; Task Force on Com-
munity Preventive Services et al., 2005). CDC has examined the effectiveness
of state school-entry immunization requirements and found that they can
be effective at achieving the high immunization rates needed to protect the
population, but their effectiveness depends on the quality of enforcement
(CDC, 2007).
The California Tobacco Control Program illustrates the powerful impact
of that state’s tobacco taxation policy on adult and youth smoking rates and
on medical care costs (Graff and Ackerman, 2009). In California, between
1989 and 2004, $1.8 billion was spent on the tobacco control program, and
$86 billion was saved in personal health care expenditures alone (and 3.6
billion fewer packs of cigarettes were bought) (Lightwood et al., 2008). An
additional example of the cost-effectiveness of legal interventions is found
in alcohol taxation. Elder et al. (2010) conducted a systematic review of
the literature on alcohol tax policy for the Guide to Community Preventive
Services. The researchers found robust evidence (across countries, study
designs and analyses, and time periods) that alcohol pricing and taxation
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68 FOR THE PUBLIC’S HEALTH: REVITALIZING LAW AND POLICY
are inversely associated with excessive alcohol consumption and related
harms. Two studies included in the review estimated the cost-effectiveness
of alcohol tax interventions based on modeling. One study examined “costs
and outcomes of 84 injury prevention interventions for the United States
and found that an alcohol tax of 20 percent of the pretax retail price of-
fered net cost savings (i.e., the savings outweigh the costs) even after taking
into account the adverse economic impact of reduced alcohol sales,” and
the other study examined the cost-effectiveness of alternative policies to ad-
dress excessive alcohol use and “found that taxation was the most effective
and cost-effective intervention in populations with a 5 percent or greater
prevalence of heavy drinkers” (Elder et al., 2010, p. 223).
Evidence to Inform Policymaking
The committee’s discussion about the role of evidence in policymaking
cuts across two distinct, but increasingly overlapping, categories of public
policy: health policies and intersectoral policies with health effects. Chapter
4, which describes intersectoral or “health in all policies” approaches, also
provides more extensive discussion of the process of assessing the evidence
for and health impact of all policies that affect or could affect health.
CONCLUSION
Based on its review of the literature and information obtained at its
information-gathering meetings with pertinent experts,
The committee concludes that an array of legal and policy tools is
available to help local, state, and federal governments promote and
protect the public’s health, and urges legislatures and government
agencies to familiarize themselves with and to deploy such tools in
addressing the leading causes of disease, injury, and early death in
every community.
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CDC. 2007. Vaccination coverage among children in kindergarten—United States, 2006–07
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CDC. 2009. State-specific prevalence and trends in adult cigarette smoking—United States,
1998–2007. Morbidity and Mortality Weekly Report 58(09):221-226.
Cherry, R. 2010. Repeal of the Pennsylvania motorcycle helmet law: Reflections on the ethical
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