smoking, second-hand smoke inhalation, and societal norms about smoking are influenced by the price of cigarettes, bans on indoor smoking, and advertising regulations (Brownson et al., 2006; Garrett et al., 2011). The obesogenic environment reflects decisions by the food industry and restaurants about the content and sizes of their offerings; business strategies about where to locate supermarket chains and fast food outlets; ballot decisions on parks, playgrounds, and pedestrian walkways; school board policies on high-calorie cafeteria menus and vending machine contracts; and the marketing of electronic devices to children (Brownell and Warner, 2009; Institute of Medicine, 2006, 2009b, 2009c, 2011c; Nestle, 2002).

Public- and private-sector policies affect drinking and driving, binge drinking, prescription and illicit drug abuse, and the use of contaminated needles by injection drug users. Policies can also influence access to contraceptives and firearms. Both the incidence and lethality of injuries are affected not only by personal choices, but also by decisions made by manufacturers, builders, lawmakers, and regulatory agencies that control product safety, road design, building codes, traffic congestion, law enforcement of safety regulations (e.g., use of seatbelts, blood alcohol testing), fire hazards, and the availability of firearms.

Policies also affect the social and economic conditions in which people live, and the quality of education—from preschool through college and professional schools (Bambra et al., 2010). Political and economic institutions, which help drive the economic success of nations, are subject to a range of public policies (Acemoglu and Robinson, 2012). Tax policy and decisions by employers, business leaders, government, and voters affect job growth, household income, social mobility, savings, and income inequality. They determine the strength of safety net and assistance programs and the quality of the environment, from its physical characteristics (e.g., pollution, housing quality) to social surroundings (e.g., crime, stress, social cohesion). The relevance of macroeconomic government policies on health was exhibited in a natural experiment when East and West Germany unified in 1989-1990: after unification, the mortality rates for the elderly in the eastern part of the country declined to those of the western part (Scholz and Maier, 2003; Vaupel et al., 2003).5


5The German experience also provides a useful reminder that interventions to improve health outcomes (and address the U.S. health disadvantage) can be effective among older adults. Notwithstanding the importance of addressing the causes of the U.S. health disadvantage among young people (e.g., violence, transportation-related accidents) and the influence of early life conditions on future health trajectories (see Chapter 3), policies to improve the health of middle-aged and older adults are also vitally important.

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