Public health hotline: using policy to influence health behaviors.

Human health behaviors are major contributors to premature death and disability in the United States and throughout the world. In the United States, more than 75% of premature deaths are caused by tobacco use, physical inactivity, poor nutrition and heavy alcohol use.1 Over the past 50 years, public health professionals have used health education as a tool to try to change these behaviors. Health education includes informing people about the risks of the behavior and working with them to develop positive attitudes towards changing their behavior, problem solving for their behavior, and developing new skills to change their behavior. Despite the widespread efforts of health education, the effect on the population's health behaviors has been modest. Consequently, over the past 20 years, there has been a shift in emphasis to try to discover what really works to change behavior. The social ecological model postulates that human behavior occurs within a broader sphere of influence which includes not only the individual's psychology but also their social setting.2 This model also examines the effect of institutions such as work and school; community design; and, at the broadest level, public policy. There has been a renewed interest in the effects of public policy on health behaviors. While public health policy has existed in the United States for quite a long time, most of the emphasis was on infectious disease (eg, quarantine policy), food safety (eg, restaurant inspections), and consumer safety (eg, requiring seatbelts in cars). More recently, policy has been used as a powerful influencer on health behaviors. This article will examine the different types of policies that have been used to reduce the adverse health effects of tobacco use, heavy alcohol consumption, physical inactivity, and poor nutrition in the United States. The prevalence of tobacco use in the United States has declined from 42% of adults in 1965 to just over 20% today.3 While some of this reduction can be attributed to health education and increasing awareness of the effects of smoking on health, much of it is due to changes in public policy. The main policy areas that have been addressed include taxes on tobacco, clean indoor air laws, and reducing minor's access to tobacco products. The price of cigarettes has been shown to be strongly related to consumption. For instance, a 10% increase in price is estimated to have a 4% drop in smoking prevalence.4 In 2009, the US Federal Government increased the tax on a pack of cigarettes from $0.39 to $1.01. States vary widely in the amount they tax cigarettes from New York ($4.35 per pack) to Missouri ($0.17 per pack). Clean indoor air laws ban smoking in businesses including restaurants, bars, and other public places. States and localities that have implemented clean indoor air laws have seen drops in hospitalization from heart attacks between 8% and 17%.5 Currently half of the states have clean indoor air laws. In 1992, the federal Government enacted the Synar amendment which requires States to enact and enforce laws prohibiting selling or distributing tobacco products to individuals under the age of 18. States are required to keep their illegal sales rates to minors (under 18 years old) to less than 20%. This law has been very successful. For example in Hawai‘i, the illegal sales rates to minors dropped from 44% in 1996 to less than 5% today.6 Alcohol control policy has also been highly effective. Here the main policy strategy has been a harm reduction approach especially in reducing drunken driving accidents. Overall the strategy has been very successful reducing the number of alcohol related traffic fatalities from 26,173 in 1982 to 13,846 in 2008.7 Alcohol related fatalities now account for only 37% of the total traffic fatalities compared to 60% in 1982.7 Several policy initiatives contributed to this reduction. These include: reducing the blood alcohol level (BAL) for drunken driving arrests, enforcement of underage drinking laws, and server liability laws. As of 2002, all states had reduced their BAL cutoff for drunk driving from 0.10 to 0.08. A BAL of 0.08 percent means that a person has eight parts alcohol per 10,000 parts blood in the body.7 It is illegal to serve anyone under the age of 21 alcohol in the United States. Over the last 15 years most states have implemented undercover police operations to determine if establishments are selling alcohol to minors. In Hawai‘i, if an establishment sells alcohol to minors, they are issued a fine of at least $1,000. If they are caught three times, they risk losing their license to sell alcohol. Server liability known as Dram Shop laws exist in 35 states for service to adults and 42 states for service to minors. These laws make the server liable if they serve an already intoxicated person or a minor who subsequently causes death or injuries to third-parties. While the United States has had great success in reducing the health effects of regulated substances such as tobacco and alcohol, policy around health promoting behaviors has proven to be more difficult. Since 1995, obesity has increased from 15.9% of the adult population to 27.6%.8 This rapid rise in obesity has led many public health officials and lawmakers to consider what policies might help reverse this trend. The main behaviors underlying obesity—physical inactivity and poor nutrition—have been targeted for change. Regulating food sale and consumption is difficult and the government has often relied on voluntary change by the food industry. However, two policies, mandatory menu labeling and taxing sugar sweetened beverages have been gaining political support throughout the country. Mandatory menu labeling requires restaurants to include calorie information on all the dishes served. To date, two states, California and Vermont have implemented these laws and another four states have passed laws but not yet implemented them.9 The idea behind menu labeling is simple: informed customers are better able to make good decisions on what to order. A recent study shows that almost 2/3 of customers are aware of calorie information at fast food restaurants with labeling.10 There is also evidence that menu labeling leads to a small reduction in the amount of calories ordered.11 National legislation requiring menu labeling for chain restaurants and vending machines has passed and will be enacted in 2012. Sugar sweetened beverage taxes are also being proposed around the country. These bills would raise the tax on any beverages with added caloric sweeteners. Sugar sweetened beverages are a leading source of added sugar in the American diet and have been linked to obesity, diabetes, and heart disease.12 Research estimates that a 10% increase in price could lead to an 8%–10% decrease in consumption.13 As of May 2011, 15 states including Hawai‘i have introduced legislation to increase taxes on sugar sweetened beverages. However, none have been adopted yet. For physical activity, the potential policies are not as clear. Since the 1950s, there has been a steady engineering of physical activity out of everyday life. The movement of people to the suburbs along with modern conveniences has reduced the amount of non-exercise caloric expenditure throughout the day. Non-leisure time physical activity, such as cycling and walking for transport, has declined steadily. Zoning policies which favor single-use areas have proliferated increasing the distance between residential and retail areas. There have been several initiatives at the local level to improve zoning codes and increase non-motorized transportation infrastructures. Nationwide, two policies have been gaining support to improve the safety of pedestrians and cyclists for active transportation: Safe Routes to School (SRTS) and Complete Streets. SRTS is a comprehensive approach to increase walking and biking to school through engineering, education, enforcement, encouragement, and evaluation.14 Complete Streets focuses on safely accommodating all modes of transportation, prioritizing pedestrians and cyclists, through a variety of policies and practices.15 By 2010, there were 48 municipalities including Hawai‘i with Complete Streets ordinances and another 99 with resolutions.16 Despite the enthusiasm for enacting these policies to address the growing obesity problem, the effects are expected to be modest. Policies such as Complete Streets could take over a decade before their effects are seen and menu labeling appears to make less than 100 calorie differences in the items ordered. However, once a comprehensive set of policies are developed, research tested and enacted, there should be a substantial influence on obesity rates in the United States. In conclusion, policy has played an important role in the United States in addressing health behaviors especially in the area of tobacco and alcohol use. Future policy development around physical activity and nutrition should help in addressing rising obesity rates.