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Volume 1:
No. 1, January 2004
TOOLS AND TECHNIQUES
Law as a Tool for
Preventing Chronic Diseases: Expanding the Spectrum of Effective Public
Health Strategies
George A. Mensah, MD, Richard A. Goodman, MD, JD, MPH,
Stephanie Zaza, MD, MPH, Anthony D. Moulton, PhD,
Paula L. Kocher, JD, William H. Dietz, MD, PhD,
Terry F. Pechacek, PhD, James S. Marks, MD, MPH
Suggested citation for this article: Mensah GA,
Goodman RA, Zaza S, Moulton AD, Kocher PL, Dietz WH, et al. Law as a tool for preventing chronic diseases:
expanding the spectrum of effective public health strategies. Prev
Chronic Dis [serial online] 2004 Jan [date cited]. Available
from: URL: http://www.cdc.gov/pcd/issues/2004/
jan/03_0033.htm
Part 1 of 2
Abstract
Law, which is a fundamental element of effective public health policy and
practice, played a crucial role in many of public health's greatest
achievements of the 20th century. Still, conceptual legal frameworks for the
systematic application of law to chronic disease prevention and control have
not been fully recognized and used to address public health needs. Development and
implementation of legal frameworks could broaden the range of effective
public health strategies and provide valuable
tools for the public health workforce, especially for state and
local health department program managers and state and national
policy makers. In an effort to
expand the range of effective public health interventions, the Centers for
Disease Control and Prevention will work with its partners to
explore the development of systematic legal frameworks as a tool for
preventing chronic diseases and addressing the growing epidemic of obesity,
heart disease, stroke, and other chronic diseases and their risk factors.
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Introduction
This paper examines the potential need for and role of systematic legal
frameworks in preventing and mitigating chronic diseases. In part
1 of this 2-part series, we describe the role and use of laws, as well as
the demonstrated effectiveness of laws, in supporting selected public health
interventions. In part 2, we will provide an overview of U.S. jurisprudence
and legal methods relevant to public health problems and outline potential contours of legal frameworks adaptable to chronic
disease prevention by offering examples from different public health
domains.
The terrorist attacks of fall 2001 and events since then, including the epidemic of severe acute respiratory syndrome (SARS),
have focused immense attention on public health legal preparedness and on
the role of law in assuring the public's health (1,2). One prominent example
is a renewed interest in quarantine, including the adequacy of relevant
legal authorities and due process protections. In addition to the highly
visible legal aspects of such recent problems involving acute diseases,
seminal work is underway to provide options for strengthening laws essential
to public health infrastructure and public health practice (3). Other
commentators have examined the roles of specific legal processes, such as
litigation, and of legal frameworks as tools for addressing public health
problems (4,5).
Efforts of the Centers for Disease Control and Prevention (CDC) in
relation to the heightened interest in the role of law in public health
practice are centered in its own Public Health Law Program and in several
other CDC programs, including the National Center for Chronic Disease
Prevention and Health Promotion (NCCDPHP). These efforts broadly encompass
approaches to assist public health practitioners at all levels to improve
their understanding of the legal foundations of public health and to develop
their ability to use systematic legal frameworks and laws for
achieving program goals and objectives. Achieving comprehensive public
health legal preparedness to address public health emergencies is an
important goal of this endeavor. Public health legal preparedness can be
defined as a public health system's attainment of specified legal benchmarks
or standards essential to the preparedness of the public health system. The
core elements of public health legal preparedness (Table
1) are relevant and
applicable to legal preparedness in other, non-acute domains of public
health, including chronic disease prevention (1).
In addition to the prominent role laws have played in response to recent
public health emergencies, laws have contributed
significantly to many notable public health achievements (6-8). Examples of
such critical contributions include the landmark 1905 U.S. Supreme
Court decision, Jacobson v Massachusetts, which upheld the constitutionality
of compulsory immunization; federal requirements for fortification of foods;
the Safe Drinking Water Act of 1974; warning notices on cigarette packs; and
seat belt laws (6,9). Despite the historically important role for law in
public health and the rapidly growing number of publications on the subject,
conceptual frameworks for the application of law to public health have not
yet been fully explicated, and their benefits remain only partly realized.
With few exceptions, systematic legal frameworks have not been developed for
preventing chronic diseases and their major risk factors.
Although the term "legal framework" is given further definition later in
this 2-part article, we use this term to broadly connote a conceptual
approach for addressing public health problems through logical and rational
combinations of legal dimensions — including but not limited to U.S.
jurisprudence, basic sources of U.S. law, legal theories, and legal
mechanisms and tools — which are appropriately tailored to a specific public
health problem. The term law as used here may take the form of
constitutional provisions, statutory enactments, regulations, ordinances,
government-initiated litigation, court rulings, or policies adopted by
public-sector bodies such as school and zoning boards. Law also includes
policies or treaties adopted by international bodies.
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Discussion
The Role of Law in Addressing Selected Public Health Interventions
Two overarching goals of our national public health agenda are to
increase the quality and number of years of healthy life and to eliminate
health disparities (10). For chronic diseases, these goals necessitate a
comprehensive strategy that includes interventions for prevention and
control of categorical diseases and their risk factors, individual
behavioral change, environmental change, improvements in clinical and
preventive services, and organizational change (11). Promoting patient
compliance and health providers' adherence to established best practices in
all persons — regardless of patients' racial/ethnic background, sex,
geographic determinants, or socioeconomic status — is also important. These
interventions can be accomplished through a variety of mechanisms, including
health education, development and use of information systems, and
development and implementation of policies and guidelines. Policies, in
turn, can be implemented as regulations, ordinances, other laws, or as
organizational practices.
Achievement of these overarching national goals requires a strengthening of
the public health infrastructure and development of adequate capacity to
undertake the core public health functions of assessment, policy
development, and assurance (12). In all of these areas, the role of law can be crucial. For
example, identifying and strengthening key components of the public health
infrastructure — such as the development of a diverse and competent public
health workforce, information and communication systems, and health
department surveillance and laboratory capacities — can be important purposes
of appropriate legislation (13,14). Similarly, legislation can
help provide state or local governments with the power to encourage or induce
health care providers, allied health professionals, and businesses to
promote and protect the public's health in order to increase the quality and
number of years of healthy life (15). Laws can play pivotal roles in the
elimination of disparities in access to and delivery of quality health care
(16-18). In addition, appropriate laws undergird the broader mission of
state and local public health agencies in assessing the burden of chronic
diseases, setting priorities, allocating resources, and delivering health
services (14).
Laws work to achieve their desired results in a variety of ways. Some laws
directly require a behavioral change on the part of individuals in the
target population — such as seat belt laws — whereas others directly change the
environment — such as community water fluoridation or food fortification laws —
and require no new action on the part of the target population to be
effective. Other laws are more complex in their mechanism of inducing a
change. For example, some laws, such as smoking bans, require a behavioral
change that ultimately results in an environmental change with
beneficial effects on the target population. Other laws require an
organizational policy change that ultimately leads to a behavioral change,
such as required insurance-industry coverage of smoking cessation services, a
requirement that leads to an increased demand for and delivery of the
services, which eventually yields greater cessation rates. These examples and
still other laws have been used to address chronic diseases and injuries (Table
2). As discussed in the following sections, 3 of these laws — smoking bans, blood alcohol concentration (BAC)
laws, and food fortification regulations —
demonstrate the impact and effectiveness of legislation on specific public
health problems. A fourth example, a legal framework for tobacco control,
illustrates the potential role of international law to
address chronic diseases and their major risk factors.
1. Smoking bans and restrictions
Tobacco use is the single largest cause of preventable premature death in
the United States (11,21,22), and exposure to environmental tobacco smoke (ETS)
is an important preventable cause of illness and death (23-25). Reducing
smoking indoors is one means to reduce exposure to ETS, and this outcome can
be brought about by policies, regulations, or laws. Smoking bans, which
prohibit smoking entirely, and restrictions, which limit smoking to
designated areas, were thus developed to limit smoking in workplaces and
other public areas.
Complex mechanisms underlie the relationship between smoking bans or
restrictions and chronic disease prevention. To start, the laws require a
change of behavior on the part of smokers who must delay or avoid smoking in
indoor settings. This behavioral change, in turn, results in an improved
environment and thus does not require individuals in the target
population to take any action. For smoking bans and restrictions to be
effective, they must bring about a measurable improvement in
the environment — specifically, reductions in exposure to the components of ETS,
such as nicotine vapor.
To investigate whether there was measurable improvement in the environment,
Hopkins and colleagues conducted a systematic literature review as part
of the Guide to Community Preventive Services (26). They identified 10 studies
that evaluated the effect of smoking bans in workplaces. The studies showed
an average 72% reduction in exposure to components of ETS. Smoking bans were
more effective in reducing ETS exposures than were smoking restrictions, and
bans were effective in a wide variety of public and private workplaces and
health care settings. These findings suggest that the effectiveness of
smoking bans should extend to most indoor workplaces in the United States.
2. Laws on blood alcohol concentration
In 2000, alcohol-related motor-vehicle crashes resulted in 17,380 deaths and
more than 300,000 injuries in the United States (27). The BAC at which the majority of drivers are impaired can be
established as the legal per se limit for motor vehicle operation (illegal
per se means that a BAC above the set limit is a violation in and of itself
and that actual impairment need not be demonstrated). Until recently, most
states set this level at 0.1%. As early as 1983, however, some states
lowered the BAC limit to 0.08%.
BAC laws are hypothesized to exert their effect primarily through powerful
psychological deterrence of alcohol consumption (28). Most drivers are never
stopped and tested for suspected alcohol-impaired driving (28). By virtue of
their threatened penalties (e.g., loss of driver's license, jail time,
fines, public humiliation), these laws deter drivers from consuming alcohol
or cause them to limit their consumption before driving.
Because of the hypothesized mechanism of action of these laws, and because
such a small proportion of drivers is ever stopped and tested for suspected
alcohol-impaired driving, establishing the effectiveness of 0.08% BAC laws
requires measurable reductions in alcohol-related motor-vehicle crashes. In
particular, fatal alcohol-related crashes provide a sensitive measure of the
effectiveness of 0.08% BAC laws. A systematic literature review conducted as
part of the Guide to Community Preventive Services identified 9 studies
that evaluated the effectiveness of 0.08% BAC per se laws (29). Each study
evaluated 0.08% BAC laws in one or more of the 16 states that implemented
the laws before January 1, 1998. After implementation of the laws, the
median decrease in fatal alcohol-related motor-vehicle crashes was 7%. On
the basis of these studies, the estimated number of lives that could be
saved annually if all states were to enact 0.08% BAC laws ranges from 400 to
600.
3. Food fortification for the prevention of nutritional deficiency diseases
Regulation has played a substantial role in reducing and eliminating
nutritional deficiency diseases in the United States. At the outset of World
War II, the high percentage of recruits who were ineligible for military
service because of nutritional deficiency diseases prompted the Council on
National Defense to request that the National Academy of Sciences establish
a Food and Nutrition Board (FNB)(30). At the time, niacin deficiency
accounted for approximately 100,000 cases of pellagra annually, and
pellagra was the eighth or ninth leading cause of death in many southern
states (31). The cause of pellagra was unknown before 1937 (32). One of the first
activities of the FNB was to establish recommended intake levels of
approximately a dozen nutrients, including niacin. Enrichment of bread was
effected by the Food Distribution Order No. 1 issued on
December 29, 1942, which became effective January 18, 1943. Several states
instituted mandatory enrichment laws for bread and flour at the same time
(31). Enrichment laws were followed in a short time by a decrease in
pellagra-related morbidity and mortality. More recently, in 1998, the Food
and Drug Administration mandated the addition of 140 mcg of folic acid per
100 gm of cereal-grain products (33) to reduce the prevalence of neural tube
defects (NTDs) (20). This strategy appears to have produced a 19% reduction
in the frequency of NTDs (20).
4. International legal framework for tobacco control
Policy interventions offer a great opportunity to influence decisions on
tobacco use at the societal level. Experience in the United States and in
other developed countries indicates that policy interventions have a
substantially greater impact than do interventions that target individuals.
International law now represents a tool for such policy interventions.
International law can be defined as the rules that regulate the relations
among sovereign states and other actors (e.g., international organizations
and individuals) in the international system (34). Treaties — written
agreements among sovereign states, the obligations of which are legally
binding — are one of the classic sources of international law (34).
In 1999, the World Health Organization (WHO) initiated the Framework
Convention on Tobacco Control (FCTC) as an international treaty focusing on
a health issue (34). In May 2003, the treaty text of the FCTC was
unanimously adopted by the World Health Assembly (35). This landmark health
treaty will be put into force when 40 member states have signed and ratified
it. The FCTC is both an international legal framework for tobacco control
(e.g., addressing international cigarette smuggling issues) and a framework
for a broad range of legal, regulatory, and policy approaches (e.g., excise
taxes, clean indoor air policies, restrictions or bans on advertising and
promotion, package warnings and labeling, product regulations, and
ingredient disclosures) that all WHO member states are encouraged to
implement.
Rationale for Legal Frameworks
The examples discussed above demonstrate the value of laws and regulations
in preventing and controlling diseases and injuries, as well as the
effectiveness of laws in helping to achieve program goals and objectives. In
addition, they highlight the rationale and need for more comprehensive, systematic
frameworks of legal theories and authorities to
support the prevention and control of a broader array of chronic diseases
(36).
The basic elements of a conceptual legal framework include definitions of
key terms, delineation of scope, and articulation of a logic model or chain
of causation. A logic model for the role of law in chronic disease prevention
could trace
the flow of causality involving laws, agents of intervention (i.e., the
entities to which laws apply), the behavior of those agents (some behaviors
affect the sources of chronic disease while others affect those susceptible
to chronic disease), and health outcomes or status. Successful identification and implementation of legal
frameworks based on this logic model depend, in part, on a fuller
understanding of the spectrum of legal theories and methods relevant to
public health practice.
Caveat lector
It is important to emphasize that the use of legal frameworks in public
health practice has limitations. Nor can law alone prevent chronic diseases. The process by which laws are passed
sometimes can be arduous and fraught with controversy. Even when appropriate
legislation is eventually enacted, the levels of application and enforcement
can vary a law's
effectiveness in achieving the intended public health goals.
Legal frameworks and laws should therefore not be used in isolation but should be
viewed as only one of several tools to be employed in the public health
practice armamentarium.
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Conclusion
Laws have played a decisive and fundamental role in advancing the
public's health. Their contribution is particularly evident in the
prevention and control of communicable diseases, which were the leading
causes of death at the turn of the 20th century, and in the realm of
injury prevention. Today, the leading causes of death and disability are
chronic diseases, especially diseases of the heart, cancer, and stroke. For
most of these chronic diseases, however, there are no systematically
developed frameworks for the application of law to preventive efforts. In
the relatively few instances where the role of law has been fully applied to
the prevention and control of chronic diseases and their risk factors (e.g.,
tobacco control and prevention), the
observed impact and effectiveness demonstrate the public health benefits
they offered.
The time has come for a full exploration of comprehensive
legal frameworks for preventing and controlling the growing epidemics of
obesity, heart disease, stroke, and other chronic diseases and their
related major risk factors. These frameworks will be a crucial addition to
the tools available to the public health workforce, especially state and
local health department program managers as well as state and national
policy makers. They also can assist program
managers' interaction with city mayors, legislators,
governors, and other policy makers. Their successful development,
implementation, and continuing evaluation for effectiveness will require a
broadly collaborative, multidisciplinary effort guided by both scientific
and legal expertise. In an effort to expand the spectrum
of effective public health interventions, the CDC will work with its partners to explore the development of these systematic legal
frameworks as a tool for preventing chronic diseases and protecting and
promoting the public's health.
In the second part of this paper, we provide an overview of pertinent U.S.
jurisprudence, including current legal theories and methods, examine
examples of legal frameworks in public health, and conclude by suggesting
specific options for exploring the development of systematic legal
frameworks for preventing chronic diseases.
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Author Information
Corresponding author:
George A. Mensah, MD,
Cardiovascular Health Branch, Division of Adult and Community Health,
National Center for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention,
4770 Buford Hwy, NE, Mailstop K-47 Atlanta, GA 30341-3717. Phone: 770-488-2424. E-mail: ghm8@cdc.gov
Author Affiliations: Richard A. Goodman, MD, JD, MPH, Public Health Law Program, Public Health Practice Program Office, CDC;
Stephanie Zaza, MD, MPH, Office of the Director, NCCDPHP, CDC; Anthony D.
Moulton, PhD, Public Health Law Program, Public Health Practice Program Office, CDC;
Paula L. Kocher, JD, Office of General Counsel, CDC; William H. Dietz, MD,
PhD, Division of Nutrition and Physical Activity, NCCDPHP, CDC; Terry F. Pechacek, PhD, Office of Smoking and Health, NCCDPHP, CDC;
James S. Marks, MD, MPH, NCCDPHP, CDC.
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