I know a man who gave up smoking, drinking, sex, and rich food. He was healthy right up to the day he killed himself.
Johnny Carson (1925–2005)1
As the legendary comedian Johnny Carson implies in the previous quote, there is only so much abstinence an individual will suffer. While it can be argued that unbridled hedonism is largely responsible for the leading causes of death in the United States, the reining in of harmful health behaviors by the public health community requires careful consideration of the tactics to employ and the justification for such actions. One of the greatest public health success stories of the last 50 years is the decline in smoking prevalence and resulting declines in associated morbidity and mortality.2 As detailed in a number of articles from this issue of the Journal of Public Health Management and Practice, these declines in the prevalence of smoking have been achieved through a number of means including provision and utilization of quitlines3,4 and clean indoor air policies.5 Other research has shown that increasing taxes on tobacco products positively impacts smoking cessation rates.6 More important, interventions such as clean indoor air policies have been met with increasing public approval7 and without unintended negative effects on employment.5 This month's News From NACCHO outlines current best practice guidelines for tobacco control programs at the local level. The success in reducing smoking behaviors has led many to suggest the adoption of successful tactics from the tobacco literature to improve other health behaviors, specifically eating behaviors.8–10 However, the most relevant comparative example from the last 50 years is not tobacco control but rather the campaign for motorcycle helmet laws. The helmet law campaign has been far less successful and can serve as a cautionary tale for those who seek to regulate eating behaviors.
Katz and Bhatia10 lay out a compelling argument for “putting our money where our mouth is” by utilizing tax incentives and food surcharges to promote healthy eating and (in turn) healthy body composition. In doing so, they also attempt to refute two common arguments against excise taxes; (1) such taxes are regressive and (2) sugar-sweetened beverages can be enjoyed in moderation. However, I would argue that these are not the main arguments that will be levied against such policies. If one considers the well-organized public resistance to motorcycle helmet laws,11 one might conclude that the most likely argument to be made by public advocates and politicians will be less about social justice and much more libertarian in philosophy. Like helmet use, poor food choices ultimately hurt only the individual's health while enacting huge financial burdens on the population as a whole. While an argument can be made for protecting the children, any impact of an excise tax would be moderated by parental decisions. Social effects of eating behavior aside, there is no secondhand effect of poor food choices. While many in public health would argue that paternalism is justified, some will not. I doubt that the majority of the public will share such a sentiment, especially in the current charged political climate of tea parties and angry protests over healthcare reform. Considering that the battle for comprehensive helmet laws began in the 1960s yet helmet use remains at about 60 percent nationally,11 it is not inconceivable that attempts by the public health community to enact such controversial measures as an excise tax will be met with considerable resistance. Furthermore, any accomplishments might ultimately be pyrrhic victories as the backlash of public opinion might hamper effective but less controversial approaches such as environmental and educational approaches aimed at children.
Ultimately, if such policies are to be implemented in a sustainable fashion, the will and desires of the public must be carefully considered or the history of helmet laws may be repeated. Eventually, decisions whether to impose excise taxes on certain foods will be made. If the decision is to move forward with such policies, lessons can be learned from tobacco. For example, careful elucidation that the tax revenue will be used to aid individuals in adopting healthy eating behaviors might engender more positive attitudes toward such taxes, as has been observed in attitudes toward tobacco taxes.12,13 If public health professionals are to make progress in curbing American's thirst for empty calories, it will be through lessons learned not only from our stories of success but also from the cautionary tales of history.
1. Corliss R. Whoooooooo's Johnny? Time Magazine.http://www.time.com/time/columnist/corliss/article/0,9565,1020765-1,00.html
. Published 2005. Accessed March 23, 2010.
2. Polednak AP. Lung Cancer incidence trends in Black and White young adults by gender (United States). Cancer Causes Control.
3. Murphy JM, de Moreno SL, Cummings KM, Hyland A, Mahoney MC. Changes in cigarette smoking, purchase patterns and cessation-related behaviors among low-income smokers in New York state from 2002–2005. J Public Health Manag Pract.
4. Vidrine JI, Rabius V, Alford MH, Li Y, Wetter DW. Enhancing dissemination of smoking cessation quitlines through T2 translational research: a unique partnership to address disparities in the delivery of effective cessation treatment. J Public Health Manag Pract.
5. Klein EG, Forster JL, Erickson DJ, Lytle LA, Schillo B. Economic effects of clean indoor air policies on bar and restaurant employment in Minneapolis and St Paul, Minnesota. J Public Health Manag Pract.
6. Levy DT, Chaloupka F, Gitchell J. The effects of tobacco control policies on smoking rates: a tobacco control scorecard. J Public Health Manag Pract.
7. Zollinger TW, Saywell RM, Alyea JM, et al. Trends in adult attitudes toward secondhand smoke in Indiana 2002 to 2007: the impact of smoking status. J Public Health Manag Pract.
8. Schroeder SA. We can do better—improving the health of the American people. N Engl J Med.
9. Nestle M, Jacobson MF. Halting the obesity epidemic: a public health policy approach. Public Health Rep.
10. Katz MH, Bhatia R. Food surcharges and subsidies: putting your money where your mouth is. Arch Intern Med.
11. Jones MM, Bayer R. Paternalism & its discontents: motorcycle helmet laws, libertarian values, and public health. Am J Public Health.
12. Hamilton WL, Biener L, Rodger CN. Who supports tobacco excise taxes? Factors associated with towns' and individuals' support in Massachusetts. J Public Health Manag Pract.
13. Wilson N, Weerasekera D, Edwards R, Thomson G, Devlin M, Gifford H. Characteristics of smoker support for increasing a dedicated tobacco tax: national survey data from New Zealand. Nicotine Tob Res.