The Origins of Personal Responsibility Rhetoric in News Coverage of the Tobacco Industry

The tobacco industry consistently frames smoking as a personal issue rather than the responsibility of cigarette companies. To identify when personal responsibility framing became a major element of the tobacco industry’s discourse, we analyzed news coverage from 1966 to 1991. Industry representatives began to regularly use these arguments in 1977. By the mid 1980s, this frame dominated the industry’s public arguments. This chronology illustrates that the tobacco industry’s use of personal responsibility rhetoric in public preceded the ascension of personal responsibility rhetoric commonly associated with the Reagan Administration in the 1980s.The notion of personal responsibility is a dominant frame within contemporary political discourse sometimes used to thwart government action on public health issues.1,2 Framing refers to how an issue is portrayed and understood: frames “promote a particular problem definition, causal interpretation, moral evaluation, and/or treatment recommendation.”1^(p52) The personal responsibility frame references any argument that advances this concept or discourages alternatives.1The tobacco industry has deftly used this rhetoric and the related notion of choice to oppose regulation. The industry claims that smoking should be the “free choice” of adult consumers, putting the onus on those who smoke as solely responsible for any health consequences rather than the companies producing or marketing toxic (and deadly) products.2–7Because personal responsibility framing dominates current debates, it is tempting to believe that it has always been a prominent feature of US political discourse and debate about tobacco policy. To better understand its roots, we first studied tobacco industry arguments about responsibility in the news from the early 1950s through 1965,8 when the health hazards of smoking initially stoked national attention and Congress first considered cigarette labeling regulations.5,7 To our surprise, the tobacco industry rarely raised personal responsibility in news coverage then, instead denying that its products harmed health.8We next searched for personal responsibility rhetoric in internal tobacco industry documents dating from 1966 onward, which showed the industry’s inner strategizing and the motivation for its public actions. We found that in the mid 1960s, when Congress was considering federal cigarette labeling regulations, the industry began using legal concepts such as “assumption of the risk” and “common knowledge” in its public relations tactics to defend itself to regulators and the public. Not until the late 1970s and the second wave of litigation throughout the 1980s, culminating in the Cipollone trial,9 did explicit personal responsibility arguments become a cornerstone of the industry’s courtroom strategy to blame the plaintiff and its wider public relations communication strategy.10 Industry executives used arguments evoking smokers’ right to choose as a litigation defense strategy throughout the 1990s and 2000s.6There remains the question of when the tobacco industry first began to use personal responsibility framing in the news between 1966, after the passage of the Federal Cigarette Labeling and Advertising Act (FCLAA), and the Cipollone case in the 1980s, when it was a firmly established legal strategy. News coverage is important because it sets the agenda for policymakers and the public about which issues to address11–14 and influences both what they consider the causes of problems and whom they view as responsible for solving them.15 Understanding the tobacco industry’s use of personal responsibility and choice rhetoric in the news is critical because of its history of trying to manipulate the news to distort scientific evidence about tobacco and to oppose measures to protect the public’s health.16–18     

Tobacco Industry Use of Personal Responsibility Rhetoric in Public Relations and Litigation: Disguising Freedom to Blame as Freedom of Choice

We examined the tobacco industry’s rhetoric to frame personal responsibility arguments. The industry rarely uses the phrase “personal responsibility” explicitly, but rather “freedom of choice.” When freedom of choice is used in the context of litigation, the industry means that those who choose to smoke are solely to blame for their injuries. When used in the industry’s public relations messages, it grounds its meaning in the concept of liberty and the right to smoke. The courtroom “blame rhetoric” has influenced the industry’s larger public relations message to shift responsibility away from the tobacco companies and onto their customers. Understanding the rhetoric and framing that the industry employs is essential to combating this tactic, and we apply this comprehension to other industries that act as disease vectors.Throughout the history of tobacco control, as concerns over health have prompted public calls for reform, the tobacco industry has attempted to combat criticism and influence public health debates through the use of rhetorical techniques that deflect attention from corporate responsibility.1,2 The tobacco industry’s use of personal responsibility frames, or arguments, to protect its business interests against litigation3^{(p870–873),}4^(p820),5–8 and regulation and tobacco control measures9,10^{(p197–198),}11–14^(p406) has been widely recognized. Although previous studies have enumerated and described many of the key frames employed by the tobacco industry and its allies, there is still important work to be done in more rigorously analyzing the relationships between the content of this rhetoric and its origin in either the legal or public relations (PR) context. Such an analysis helps illuminate the importance of subtle variations in the deployment of similar language to convey diverse meanings that can sway public opinion and regulators’ actions.15 This study also can inform efforts aimed at other industries that produce products that have a negative impact on public health, such as sugar-sweetened beverages (SSBs) and junk food, all of which employ techniques the tobacco industry originated and perfected.16Framing refers to the use of key concepts familiar to the listener that help guide the understanding of an issue.17 In particular, frames structure for the audience the cause of social problems and prescribe which actors should and should not act to address them.18 Powerful default frames such as personal responsibility indicate that those who suffer the consequences of consuming certain risky products, such as smokers, are to blame for their injuries and that it is not the role of social institutions such as the government to intervene and protect them.19 Analyzing which frames are present—and absent—in public discourse such as the news is especially valuable as these frames influence policymakers by helping set the agenda for public debates, and signaling which issues are salient and which others are less urgent.20,21The trajectory of the tobacco industry’s use of personal responsibility framing and argumentation began in 1954, when the major US tobacco companies reacted to the release of scientific studies linking smoking and cancer by hiring a PR firm to craft an advertisement called “A Frank Statement to Cigarette Smokers,” which claimed the industry “accept[ed] an interest in people’s health as a basic responsibility, paramount to every other consideration in our business.”9 The industry’s purposely ineffectual efforts to address the dangers of smoking amounted to little more than whitewash and PR rhetoric, with a major emphasis on obfuscation and delay in verifying whether its products were deadly, along with an effort to maintain this as an “open scientific controversy.”In 1964, US Surgeon General Luther Terry released a landmark report that analyzed and evaluated the existing scientific research, concluding that smoking causes disease and death.22 Closely following was the passage of the Federal Cigarette Labeling and Advertising Act (FCLAA) in 1965, which required warning labels on cigarette packages (mandatory warnings for cigarette advertising were later added in 1969) with the tepid and equivocal verbiage “Caution: Cigarette Smoking May Be Hazardous To Your Health.”2,23 At that time the emphasis by the public and regulators was largely on governmental accountability for addressing the problems cigarette smoking caused, while the tobacco industry escaped most culpability and accountability, even weathering the imposition of mandatory warning labels by turning it to its advantage as another way of assigning blame to smokers for their illnesses.24 In 1986, Congress passed the Comprehensive Smoking Education Act, which required rotating warning labels that were phrased unequivocally linking smoking with particular diseases.25In the 1970s, after warning labels were imposed and both governmental agencies and voluntary health organizations had committed massive resources to educating the public about the dangers of smoking, responsibility for avoiding smoking-related illness was generally viewed as a matter of individual responsibility.12 Tipping the scales further in that direction was a growing sentiment in US society that escalating health care costs could only be contained if individuals changed their unhealthy behavior.26 Pushing back against these forces was the effort by public health advocates to highlight the dangers of secondhand smoke, with the result that “the hazards of smoking were relocated from the individual’s risky behavior to that of his or her smoking neighbor, [and] exposure was no longer a matter of choice but was involuntary victimization.”12^(p339) Thus, the onus shifted once more toward government regulation to ban public smoking, with a concomitant call for businesses to ban smoking in their premises in the absence of governmental action. Up to this point, the tobacco industry had largely escaped accountability by either the public or government despite wide recognition and acceptance of cigarettes’ causal responsibility for disease and death.24The tobacco industry’s use of explicit personal responsibility rhetoric reached its height in the 1980s, during a wave of consumer litigation in which the tobacco defendants countered injured smokers’ lawsuits with claims that ultimately the responsibility for the consequences of smoking cigarettes belonged to the smoker who voluntarily consumed them.27 As the 1990s began, particularly negative pressure was brought to bear on the industry when whistleblowers began leaking internal corporate documents that showed a clear conspiracy to produce an addictive product while ignoring the health hazards of which the tobacco companies were well aware, thus confirming corporate responsibility for the harm the industry’s products caused.9,28,29 As a result of the document leaks and in the face of increasing public demand for industry accountability, many of the industry’s usual allies in business and government began to abandon its cause.This led to a flood of litigation against the industry. Cases brought by state attorneys general seeking Medicaid reimbursement for smoking-related illnesses culminated in the 1998 Master Settlement Agreement.29,30 In the late 1990s and into the 2000s, several juries found in favor of injured smokers in private litigation, with damages being awarded in the millions and even billions of dollars.31 These types of cases continue to be litigated, primarily in Florida, where a jury in a class action found the tobacco industry liable, setting the stage for thousands of individual claims.32,33 Despite continuing to use personal responsibility arguments in smokers’ litigation,34 currently the tobacco defendants are losing about two thirds of the Florida cases, with the juries apportioning responsibility between the plaintiff and the defendant in each case.35Adding to existing scholarship, we sought a deeper understanding of the tobacco industry’s framing, rhetoric, and tactics, and their application, based on both content and legal analyses. Our first study examined the early debate about tobacco and the initial scientific revelations that it was harmful (from 1952 to 1965) and found an unexpected lack of personal responsibility rhetoric by any of the speakers but rather an emphasis on the government’s responsibility to address the issue, which culminated in the passage of the FCLAA.24 Our next study focused on determining when the debate shifted and the tobacco industry began explicitly referring to smokers’ individual personal responsibility, which we found began in the 1970s and gained prominence in the late 1980s, during what has been called the “second wave” of tobacco litigation.27In our study, we examined the specific rhetoric used by the tobacco industry to frame personal responsibility arguments in both the media and the courtroom, and analyzed how the 2 influenced each other. This study’s findings have application not only for tobacco control advocates, but also for others focusing on public health issues arising from the consumption of numerous other products that cause avoidable noncommunicable disease and death, such as obesogenic food and beverages,16,36 alcohol,37 electronic gambling machines,38 and firearms,39 because those industries are now replicating and refining successful tobacco industry tactics and rhetoric. Comprehension of the evolution and cross-pollination of corporate litigation and communications strategy and a focus on corporate malfeasance and deceit will furnish public health advocates with ammunition for developing countermarketing strategies to denormalize health-compromising products and the industries that produce them.40–42     

Cigarettes Become a Dangerous Product: Tobacco in the Rearview Mirror, 1952–1965

Tobacco control’s unparalleled success comes partly from advocates broadening the focus of responsibility beyond the smoker to include industry and government. To learn how this might apply to other issues, we examined how early tobacco control events were framed in news, legislative testimony, and internal tobacco industry documents. Early debate about tobacco is stunning for its absence of the personal responsibility rhetoric prominent today, focused instead on the health harms from cigarettes. The accountability of government, rather than the industry or individual smokers, is mentioned often; solutions focused not on whether government had a responsibility to act, but on how to act. Tobacco lessons can guide advocates fighting the food and beverage industry, but must be reinterpreted in current political contexts.Tobacco control shines as a beacon of success in public health, having demonstrated unequivocally that policy interventions can improve environments and reduce morbidity and mortality at a population level.1–3 Yet tobacco remains the leading cause of preventable death in the United States4 and worldwide.5Indeed, the tobacco industry continues to resist a wide variety of tobacco control initiatives by insisting that there is no need for government intervention: smoking is a choice, and if smokers want to quit, they should take personal responsibility for their own health and just quit. For example, the Centers for Disease Control and Prevention’s Communities Putting Prevention to Work program, which emphasized tobacco control interventions, came under attack from tobacco industry representatives claiming that,

All across the country, Americans are growing increasingly concerned about the role of government, and it’s believed by a substantial population in this country that the government is overreaching its bounds and getting too involved in our personal lives.6

Indeed, beginning in the 1980s the tobacco industry was instrumental in fomenting conservative activism focused on concerns about the role of government.7 Thus, it is no surprise that public health advocates working on other issues are subject to similar arguments. The food industry, for example, has responded to concerns about obesity with arguments that focus attention on personal responsibility and negate the role of government.8We were interested in better understanding how public health has weathered the drumbeat of personal responsibility rhetoric to inform ongoing tobacco control efforts and emerging public health interventions to address obesity. We know, for example, that successful tobacco control programs such as California’s9^,10 have sought to denormalize tobacco use and the tobacco industry by employing a spectrum of strategies from individually oriented cessation programs to tax policy and environmental changes to reduce exposure to secondhand smoke.11 California’s famously effective media campaign illustrated that comprehensive approach with advertising that ranged from messages reminding smokers that “quitting takes practice” to warning that “the tobacco industry is not your friend.” One set of messages placed responsibility on individuals to quit smoking; the other set placed responsibility on the tobacco industry and government regulation.12 Both discourses exist in tobacco control just as they coexist in society at large, though one or another may dominate the public discussion at any given time.Since the 1970s in the United States, personal responsibility rhetoric has increasingly dominated public policy debate.13,14 President Clinton’s 1996 landmark welfare reform legislation, the Personal Responsibility and Work Opportunity Reconciliation Act,15 and the rise of the Tea Party16 in 2010 are 2 manifestations of this perspective.“Framing” refers to how an idea or issue is defined, portrayed, and understood. Frames operate at the cognitive level, consciously or unconsciously, to construct meaning17 by promoting “a particular problem definition, causal interpretation, moral evaluation, and/or treatment recommendation for the item described.”18^(p52)One of the most enduring frames in American discourse is “rugged individualism,”19 which presents problems as a matter of personal choice or accomplishment independent of—or despite—social, historical, or environmental forces. This frame presumes that individuals or the laissez-faire market, not government or other entities, are the genesis of and appropriate agent for remedy of problems.20 Alternatively, American discourse at times includes frames suggesting collective responsibility in which government or institutions are the source of or solution to social problems.21The precursor to questions about individual responsibility or institutional accountability in tobacco control is this: does smoking harm health? Although for most people this question was definitively answered by the 1964 Surgeon General’s Report, it was doggedly contested by the tobacco industry for another 3 decades.22,23Once the cause of the health harm is established, responsibility can be framed along the continuum from individuals to the environment surrounding them, including society and its institutions. Within the individualism frame, if people experience harm from cigarettes it is because they choose to smoke; to avoid the harm individuals can avoid smoking. A public health approach demands a broader conception that includes shared responsibility between individuals and the forces that shape the environment in which those individuals act. From a public health perspective, responsibility for creating and solving health problems, including from tobacco, can be assigned to individuals and to institutions, either of which may be culpable for the problem or accountable for remedial action. How causality, culpability, and accountability are framed can determine whether society calls upon individuals, industry, or government to take action.Like other social problems, public health problems—and their solutions—are in large part defined by how they are framed and who is influencing the framing.24 Framing takes place in private communications as well as public forums that shape policy decisions, including the news media as well as judicial, regulatory, and legislative proceedings.Decades of communications research show that the news sets the agenda and frames debate for the public and policymakers.25–29 News frames can affect attributions of responsibility for both lung cancer and obesity.30 Although news stories typically contain several frames, on balance, most reinforce an individualistic point of view.17 The power of framing in judicial, regulatory, and legislative forums is less well documented, but may directly affect the policy decisions on controversial public health issues.31–33In addition, different speakers within these public forums may frame issues in conflicting ways.34,35 In the context of a public debate about a controversial topic such as tobacco policy, different actors will frame the issue to serve their own interests.36–38To learn how responsibility for causing and remedying tobacco-related problems has been characterized, we examined how the policy debate was framed during the events leading up to and including the first major national policy in tobacco control, the Federal Cigarette Labeling and Advertising Act (FCLAA) of 1965.39 We examined how arguments about responsibility were framed in tobacco industry internal documents, legislative testimony, and news coverage about tobacco. In our investigation, responsibility could be characterized in 3 ways. Causality addresses whether tobacco—in this era, almost always cigarettes—causes health harms, usually lung cancer. Culpability assumes that smoking is harmful and points to whom or what might be to blame. Accountability frames go further to name who has responsibility for taking action to remedy the problem—individual smokers, government agencies, the tobacco industry, or clinicians. By asking how responsibility for causing health harms from cigarettes was framed, who was blamed for them, and who was held accountable for rectifying them during this early era to control tobacco, we can peer back through a window in time before the tobacco industry—and before government—were both demonized.     

Achieving Population Health in Accountable Care Organizations

Although “population health” is one of the Institute for Healthcare Improvement’s Triple Aim goals, its relationship to accountable care organizations (ACOs) remains ill-defined and lacks clarity as to how the clinical delivery system intersects with the public health system.Although defining population health as “panel” management seems to be the default definition, we called for a broader “community health” definition that could improve relationships between clinical delivery and public health systems and health outcomes for communities.We discussed this broader definition and offered recommendations for linking ACOs with the public health system toward improving health for patients and their communities.WITH THE PASSAGE OF THE Affordable Care Act (ACA),1 the United States has turned its attention to improving the quality of health care while simultaneously decreasing cost. As we move toward alternative and global payment arrangements, the need to understand the epidemiology of the patient population will become imperative. Keeping this population healthy will require enhancing our capacity to assess, monitor, and prioritize lifestyle risk factors that unduly impact individual patient health outcomes. This is especially true, given that only 10% of health outcomes are a result of the medical care system, whereas from 50% to 60% are because of health behaviors.2,3 To change health behaviors, it will be necessary to engage in activities that reach beyond the clinical setting and incorporate community and public health systems.4The Institute for Healthcare Improvement (IHI), a leading not-for-profit organization dedicated to using quality improvement strategies to achieve safe and effective health care, has developed the Triple Aim initiative5 as a rubric for health care transformation. The three linked goals of the Triple Aim include improving the experience of care, improving the health of populations, and reducing per capita costs of health care.6 However, although two of the three aims–experience of care and cost reduction–are self-explanatory, there is little consensus about how to define population health. Words like “panel management,” “population medicine,” and “population health” are being used interchangeably. Berwick et al.6 describe the care of a population of patients as the responsibility of the health care system and use broad-based community health indicators as evidence of improvement. Other recent publications have attempted to describe population health from the hospital,7–10 primary care,11 and community health center perspectives.12 The “clinical view” identifies the population as those “enrolled” in the care of a specific provider, provider or hospital system, insurer, or health care delivery network (i.e., panel population).7 Alternatively, from the public health perspective,8 population is defined by the geography of a community (i.e., community population) or the membership in a category of persons that share specific attributes (e.g., populations of elderly, minority population). In either case, the context of a community and the existing social determinants of health, ranging from poverty to housing, are known to have substantial impact on individual health outcomes. Thus, ensuring the health of a population is highly dependent on addressing these social determinants and requires collaborative relationships with community institutions outside the health care setting.13,14Two key concepts that will greatly influence the definition and actualization of population health in the post-ACA era include the accountable care organization (ACO)15 and the patient-centered medical home (PCMH).16 The ACO represents an integrated strategy at the delivery system level to respond to payment reform.15 These integrated systems of care are poised to manage a population of patients under a global payment model. The PCMH is focused on transforming primary care to better deliver “patient-centered” care and to address the whole patient, including their health and social needs.17,18 Both models will need to identify, monitor, and manage their “population” of patients. However, their ability to extend their definition of population health to encompass the entire community will depend on resources, market share, and the strength and capacity of collaborating community and public health organizations. As integrated delivery systems are asked to do more than focus on their own patients, they will require additional resources. These may come from a realignment of existing programs (community benefits), a return on investment from effective preventive care, or collaborative relationships with existing community and public health organizations.In this article, we discuss two major points regarding ACOs and their approach to population health. First, ACOs should be committed to serving the health of the people in the communities from which their population is drawn, and not just the population of patients enrolled in their care to achieve the population health goal. Second, to achieve this expanded definition of population health, ACOs will need to engage in collaborative efforts with community agencies and the public health system. We describe a “community” definition of population health to be used in lieu of the “panel” definition and then outline the resources needed and strategies for collaboration. Finally, we offer recommendations to assist ACOs in realizing their population health goal.     

Multinational Alcohol Market Development and Public Health: Diageo in India

Alcohol is a risk factor for communicable and noncommunicable diseases, and alcohol consumption is rising steadily in India. The growth of multinational alcohol corporations, such as Diageo, contributes to India’s changing alcohol environment.We provide a brief history of India’s alcohol regulation for context and examine Diageo’s strategies for expansion in India in 2013 and 2014. Diageo is attracted to India’s younger generation, women, and emerging middle class for growth opportunities.Components of Diageo’s responsibility strategy conflict with evidence-based public health recommendations for reducing harmful alcohol consumption. Diageo’s strategies for achieving market dominance in India are at odds with public health evidence. We conclude with recommendations for protecting public health in emerging markets.In India, average adult per capita alcohol consumption increased by 19% from 2005 to 2010.1 In 2010, alcohol consumption ranked among the country’s top 10 leading risk factors for causes of death (350 000 deaths), disability-adjusted life years (n = 14.2 million), and years of life lost (n = 11 million).2 In a population of 1.2 billion,3 approximately 15% of Indians drink alcohol; however, per capita consumption among Indian drinkers is approximately 1.5 times greater than the average among drinkers worldwide.1Alcohol consumption in India is an immediate public health concern, given the national burden of communicable diseases and noncommunicable diseases (NCDs). Each year, one quarter of the world’s incident cases of tuberculosis are in India,4 and because of shifting demographic and socioeconomic factors, NCDs now contribute to half of the country’s deaths.5 Indian studies have documented that alcohol consumption is associated with both communicable diseases and NCDs, including HIV,6–8 tuberculosis,9,10 and cancers,11 as well as violence12,13 and injuries.14,15With this imminent public health crisis and links between industry tactics and public health problems,16–18 there is a need to better understand the role of the global alcohol industry in India’s changing alcohol environment. We provide a brief history of India’s alcohol regulations to contextualize the current alcohol environment. Diageo, the world’s largest spirits marketer, made significant investments in India’s alcohol market between May 2013 and July 2014, and we examine its growth as a case study. We assess how the principal elements of Diageo’s “responsibility strategy” compare with evidence-based public health recommendations for reducing harmful alcohol consumption. We conclude with recommendations for promoting and protecting public health.Opportunities to obtain internal alcohol industry documents or firsthand accounts of its practices are rare, making it challenging to understand its intentions; therefore, we relied on a comprehensive review of sources such as media articles or annual reports over a defined time period. To monitor Diageo’s activities in India, the first author read online media articles for 18 months (July 2013–December 2014), compiled with Google News Alerts related to the following keywords: “alcohol in India,” “alcohol consumption in India,” “Diageo in India,” and “spirits in India.” The News Alerts generated approximately 1500 articles from various regions of the world (e.g., India, the United Kingdom, and the United States), some of which covered similar ground. The same author also monitored alcohol industry–oriented market research such as just-drinks.com.19 We collected additional information from Diageo’s Web site and its 2014 fiscal year annual report.20 We also searched other alcohol industry Web sites, including the International Center for Alcohol Policies (ICAP) main site21 as well as other ICAP sites.22,23 We drew on reviews of the alcohol policy research literature to identify evidence-based policies to compare with Diageo’s responsibility strategy.24–30     

Public Health,Science, and Policy Debate: Being Right Is Not Enough

Public health is usually enacted through public policies, necessitating that the public engage in debates that, ideally, are grounded in solid scientific findings.Mistrust in science, however, has compromised the possibility of deriving sound policy from such debates, partially owing to justified concerns regarding undue interference and even outright manipulation by commercial interests. This situation has generated problematic impasses, one of which is the emergence of an anti-vaccination movement that is already affecting public health, with a resurgence in the United States of preventable diseases thought to have been eradicated.Drawing on British sociologist Harry Collins’ work on expertise, we propose a theoretical framework in which the paralyzing, undue public distrust of science can be analyzed and, it is hoped, overcome.

“As the nation’s leading public health organization, APHA strengthens the impact of public health professionals and provides a science-based voice in policy debates too often driven by emotion, ideology or financial interests. APHA is at the forefront of efforts to advance prevention, reduce health disparities and promote wellness.”—American Public Health Association1“Science, if it can deliver truth, cannot deliver it at the speed of politics.”—Collins and Evans2^(p1)

By definition, public health interventions are enacted on human collectives, and as pointed out by Geoffrey Rose (among many others) decades ago, preventive strategies are most effective in implementing such interventions.3 This situation can—and often does—produce ethical conundrums wherein individual and collective rights clash.4 The key to democratic public policy is the availability of scientific evidence, its effective communication, and the competence of those involved in its formulation to evaluate presented evidence, as made clear by the epigraph of this article, extracted from the website of the American Public Health Association (APHA) in the section in which the association’s mission is defined. Forces that operate against the necessary rational debate are pointed out as well.This passage, however, places a great deal of trust, arguably too much, in science itself and in the credibility and strength of science-based arguments in public debates. It is not difficult to find examples of scientific blunders that have compromised public health, for instance the approval of the commercialization of certain medicines that proved to pose an unjustifiable health risk. This was the case of thalidomide in the past, which turned out to be associated with birth defects, and the more recent case of rofecoxib, which was found to be associated with cardiovascular diseases, some lethal. It is also not difficult to find situations when science itself was distorted, often as a result of commercial interests, with negative implications for public health.5 And, by the same token, it is not difficult to find examples of public mistrust in science, even if such mistrust is totally unjustified.6,7At the same time, contemporary life in most of the world depends on complex technologies that are scarcely, if at all, understood even in superficial terms by most people. These technologies, labeled by British sociologist Antony Giddens as “expert systems,” are nevertheless trusted, in Giddens’ view, through a kind of pragmatic faith.8^(p27)How the general population comes to trust such technologies is partially a matter of their effectiveness, but it also involves the way in which the public discourse about them is constructed. Considering the diversity of scientific and technological domains that are involved in understanding how any given expert system functions, this means that public opinion at some point has to rely on the word of experts. This is particularly true for most public health issues. A majority of health risks, for instance, are not self-evident, and identifying these risks requires a somewhat sophisticated epidemiological machinery that is fully understood by relatively few, even among health professionals. This means that the issue of what to trust usually becomes an issue of whom to trust.This state of affairs brings to the spotlight the role of the expert and how problematic this role can be in a democratic society.9 Harry Collins, a sociologist of science who has consistently studied expertise, points to 2 opposite risks in how society at large interacts with experts: at one extreme, there is what he calls technological fascism, a technocratic view that grants to experts a monopoly of opinion on their specific subjects, effectively excluding proper political negotiations from decisions; at the other extreme (and equally unwanted) is technological populism, which effectively denies any role scientific experts might have in a public policy debate.2Still, according to Collins, a general mistrust of science and scientists has produced a paralyzing form of skepticism that empowers scientific populism.10,11 This mistrust has had disastrous results, as exemplified by the misguided influence of anti-vaccine activism that led to a resurgence in the United States and Europe of infectious diseases that had practically been eradicated (discussed in detail subsequently).10 Belief in bizarre conspiracy theories is not uncommon in the United States5 and elsewhere, constituting yet another obstacle to overcome in communicating scientific findings about health issues.These themes come together in the issue of the potential association between childhood vaccinations and autism. Objections to vaccinations have a long history based on skepticism of the underlying science. Questions have been raised about efficacy (whether vaccines protect against disease) and safety (whether they can do harm to patients).12 Parents have objected to mandatory vaccination requirements for school entry, considering them unwarranted government intrusions on personal freedom.13 Much of this disinformation is spread through the Internet,14 virally spreading to an exponential audience and seriously undermining public confidence in vaccines in general.The most recent impetus for anti-vaccine positions is concern that the number of vaccinations in the current mandatory childhood immunization schedule has a harmful effect on children and that the measles–mumps–rubella (MMR) vaccine is a cause of autism. The key publication fueling these concerns is the report by Wakefield et al. published in the British journal The Lancet. The authors reviewed medical records supplemented by parent interviews for 12 patients diagnosed with autism. Eight of the 12 participating parents associated the onset of their child’s autism with the child having received the MMR vaccine.15There were, however, fatal methodological flaws in Wakefield and colleagues’ article. The sample size of 12 did not have sufficient power for global generalization to all children. Autism is a spectrum disorder with a wide range of symptoms and severity. Also, the small sample was not representative of the population of children with autism. The investigators did not have prospective developmental data, so age of identification of symptoms was probably used to represent age of onset. Although severe symptoms of autism may be manifested in infancy,16 they are more typically first noted at the age of 18 to 24 months,17 roughly coincident with the recommended age for MMR immunization. This temporal coincidence may have been mistaken for a causal connection.The Wakefield et al. article was criticized by, among others, investigative reporter Brian Deer, who found that some of the parents were parties in a lawsuit against a vaccine manufacturer and that Wakefield had a financial connection to that lawsuit. It was also found that Wakefield had engaged in several ethical violations, such as submitting his participants to tests without proper consent. The possibility of conflict of interest was raised.18,19 The journal editors retracted the article, concluding that it should not have been published. As a consequence of the multiple ethical problems, the medical authorities in the United Kingdom opened an investigation that, in the end, resulted in Wakefield losing his license to practice medicine there.It has been hypothesized that thimerosal, the mercury-based preservative added to increase vaccine shelf life, is the mechanism by which vaccines would be associated with autism. This hypothesis has been tested and rejected in multiple studies, including one in Canada that compared the incidence of autism before and after removal of thimerosal from vaccines in a population-based sample of 27 749 participants.20 The Institute of Medicine, among others, has published literature reviews with the same conclusion, that there is no evidence to support the vaccine–autism hypothesis.21,22The anti-vaccine movement continued unabated, having gained official credibility in 2000 when Republican congressman Dan Burton of Texas held hearings in the House of Representatives based on his conclusion that the MMR vaccine causes autism (Burton’s grandson had recently been diagnosed with autism).13 More than a decade later Jenny McCarthy, the leading celebrity voice for the notion that vaccines cause autism, wrote a Huffington Post column titled “In the Vaccine–Autism Debate, What Can Parents Believe?”23 McCarthy correctly pointed out that, according to Wakefield et al., their article had not proved an association between autism and vaccines, and further investigation was needed. She went on, however, to note that eight of the 12 parents associated the onset of behavioral symptoms of autism with the MMR vaccine and added that the vaccine had caused autism in her son as well. The implicit conclusion is that parents can believe other parents, scientific evidence to the contrary. The public health impact of the anti-vaccine point of view is decreasing rates of children who are up to date for immunizations and outbreaks of vaccine-preventable diseases such as measles.24,25The anti-vaccine position is one of certainty, in stark contrast to the way in which scientific evidence is often presented. The committee responsible for the Institute of Medicine literature reviews concluded that “the body of epidemiological evidence favors rejection of a causal relationship between thimerosal-containing vaccines and autism” but recommended “surveillance and epidemiological research, clinical studies, and communication related to these vaccine safety concerns.”21^(p151) This position can be understood as avoidance of certainty: although there is no current evidence to support the hypothesis, further study is needed. The anti-vaccine position became a political movement, fueled in equal parts by discredited hypotheses and paranoid ideology, to an extent that it has created “true believers” impervious to revising their ideas.7,26,27Returning to Collins’ paradigm, in the case of a cause of autism—a diagnosis that can be devastating for parents and is often delivered with certainty but no corresponding authority about etiology, effective treatment, or prognosis—scientific populism provided certainty in the absence of scientific fascism. Anti-vaccination campaigners not only lack the necessary expertise to evaluate the information that is presented to them, but they also lack the meta-expertise needed to adequately acknowledge the expertise of others (or lack thereof), a point made by Collins himself.11The inability of anti-vaccine enthusiasts to correctly gauge their own skills can also be seen as a demonstration of the Dunning–Kruger effect, the tendency of unskilled people to overestimate their own competence in a given area.28,29 When we look at other public health achievements, such as the continuing reductions in population-wide tobacco smoking in the United States, messages about the association of tobacco with diseases such as cancer are clear and unambiguous, despite continued efforts of the tobacco industry to sow doubts about such associations.30 The association between soda consumption and obesity and diabetes is less clear, and efforts to regulate soda consumption very publicly failed in New York City in 2013.To overcome situations such as those just described, it is necessary to consider an apparent conundrum: if experts cannot be blindly trusted, on one hand, but public opinion can be tremendously misguided, on the other hand, how do we have a proper debate on scientific issues of importance to public policy? Once again, Collins’ ideas provide an interesting approach. He has described a number of different ways in which a person can be considered an expert, among which we focus on 2: contributory expertise and interactional expertise.2,11 The first is solely the province of the expert, the kind of expertise necessary to perform an activity with competence; the second refers to people who have mastered the language of the experts and, although lacking practical competence, are capable to engage in meaningful conversation with them. Collins has pointed out that, to become even an interactional expert, one must devote time to and be practically involved with the problem at hand. Merely reading the scientific literature (and, even less so, collecting information on the Internet), which would in any case require previous competence to sort out the wheat from the chaff, is not enough.11Thus, one key component in solving the expertise dilemma is having enough interactional experts in the community of interest (or the general public) who can conduct sensible debates with experts and help shape public policies that adequately consider the necessary scientific knowledge without being dictated by their spokespersons (i.e., scientists).11 As Turner has pointed out, there is no inherent contradiction between expertise and democracy as long as a critical (rather than cynical) stance is sustained; in his words, “to grant a role to expert knowledge does not require us to accept the immaculate conception of expertise,”9^(p146) an idea that converges once again with Collins’ approach. If such an ideal seems unattainable, it should be pointed out that this is precisely the situation in the HIV/AIDS arena, wherein knowledgeable activists became capable interactional experts and thus have been a fundamental part of the response to the epidemic, helping shape sensible and effective policies in many countries.11,31If, however, the solution is apparently so simple, why is the current state of affairs so distant from this model, exceptions notwithstanding? First, as noted, unfortunately there are good, rational reasons to mistrust health information presented to the public. Conspiracy theories are not necessary to realize that there are documented instances in which medical knowledge was deliberately manipulated for commercial gains,32 and medical journals are not exempt from responsibility in those cases.33Second, the media in general, for reasons that are not amenable to discussion in this space, have neglected their role in reporting facts, reducing everything to a “he said/she said” model in which two countering visions must always be presented as having equal footing, even when one side clearly has the entire scientific community behind it and the other is driven by misinformation, deliberate or not.34 With uncomfortable frequency, public relations strategies are mobilized to push deliberately distorted information to the media, which will pass it on, uncriticized, to the general public.5,35Finally, we academics in public health must accept part of the blame. For a number of reasons, chief among them the “publish or perish” mentality, we have concentrated our efforts in communicating with each other, delegating the role of reaching out to the general public to other actors such as the media (whose shortcomings were just discussed), although we certainly need help from the communication experts as well. The “brave new world” of the Internet, in particular, calls for the voice of public health experts to be heard, lest we allow misinformed activists or commercial interests to dictate the debate, to the loss of the public’s health.     

Black Lives Matter: A Commentary on Racism and Public Health

The recent nonindictments of police officers who killed unarmed Black men have incited popular and scholarly discussions on racial injustices in our legal system, racialized police violence, and police (mis)conduct. What is glaringly absent is a public health perspective in response to these events.We aim to fill this gap and expand the current dialogue beyond these isolated incidents to a broader discussion of racism in America and how it affects the health and well-being of people of color.Our goal is not only to reiterate how salient structural racism is in our society, but how critical antiracist work is to the core goals and values of public health.

“The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.”

—Dr. Martin Luther King, Jr.1“I can’t breathe.” “Hands up.” “Black lives matter.” These statements developed in reaction to the recent deaths of Eric Garner, an unarmed Black man strangled to death by police in Staten Island, New York, and Michael Brown, an unarmed Black adolescent shot to death by police in Ferguson, Missouri.2 To racial scholars, activists, and many community members, these preventable deaths were only two recent examples of the stark racial injustices that have plagued our country’s history. In both instances, the White police officers responsible for the deaths were neither charged with any crime, nor taken to trial.3 However, despite the national and international media attention these cases drew,4 they are by no means isolated incidents.5 Moreover, despite the media’s disproportionate focus on cases involving men,5,6 intersectional analyses demonstrate that racialized police violence and misconduct are inflicted upon women and transgendered persons of color as well.7–11These cases bring to light how racism, defined as a “system of structuring opportunity and assigning value based on race, that unfairly disadvantages some individuals and communities,” and advantages others,12^(p10) affects the daily realities in communities of color. As public health professionals, we are committed to achieving optimal health for all. Thus, these violent, premature deaths of people of color should enrage us because they directly oppose the vision of Healthy People 2020, “A society in which all people live long, healthy lives.”13 Therefore, our commentary calls upon our field to recognize the pervasive role of racism in public health and to reshape our discourse and agenda so that we all actively engage in racial justice work.Our position is not a new one.14–22 In 1998, the American Public Health Association (APHA) released a policy statement on the disproportionate impact of police violence on people of color.20 This statement recommended strategies for reversing the trends; however, to date, there has been no record whether these policy recommendations have been implemented.23 The relevance of the 1998 APHA statement to the most recent incidents of racialized police violence is chilling. Yet, almost two decades later, explicit conversations about racism remain glaringly absent from most mainstream public health discourse.Although our commentary was motivated by the recent nonindictments in the Garner and Brown cases,2-3 we intend to expand the conversation beyond these individual high-profile cases to discuss racism and public health more broadly. Specifically, our goal is to emphasize how race and racism in our society are central to the field of public health. The intent of our commentary is to (1) acknowledge racism as a critical public health concern, (2) distinguish between the constructs of race and racism for public health, (3) discuss the pervasiveness of structural racism in our society, and (4) offer calls to action.     

“We’re Part of the Solution”: Evolution of the Food and Beverage Industry’s Framing of Obesity Concerns Between 2000 and 2012

We investigated how industry claim-makers countered concerns about obesity and other nutrition-related diseases in newspaper coverage from 2000, the year before the US Surgeon General’s Call to Action on obesity, through 2012. We found that the food and beverage industry evolved in its response. The defense arguments were made by trade associations, industry-funded nonprofit groups, and individual companies representing the packaged food industry, restaurants, and the nonalcoholic beverage industry. Individual companies used the news primarily to promote voluntary self-regulation, whereas trade associations and industry-supported nonprofit groups directly attacked potential government regulations. There was, however, a shift away from framing obesity as a personal issue toward an overall message that the food and beverage industry wants to be “part of the solution” to the public health crisis.Since 2001, when the US Surgeon General issued a Call to Action to address obesity,1–3 public health advocates have proposed a range of policies to improve the food and beverage environment. The food industry has strongly opposed many of these initiatives, at times using tobacco industry tactics including corporate social responsibility programs and personal responsibility rhetoric.4–7 Corporate social responsibility can take many forms, including industry adoption of self-policing strategies intended to resolve public health concerns.7–10 The food industry has launched and widely publicized a number of self-regulatory programs,11–14 but research suggests that these initiatives may have done little to mitigate unhealthful food environments.15–28 Past analyses suggest that the food industry also has used personal responsibility rhetoric to shift responsibility for health harms from the industry and its products onto individuals,4 influence how the public addresses obesity, and fight government regulation of its products and marketing practices.4–7News coverage is an important part of the public conversation about social issues such as obesity. The news helps establish which issues appear on the public agenda, and influences how the public and policymakers view these problems and craft potential solutions.29–33 Social problems such as obesity are defined by how they are framed and who is influencing the framing.34 “Framing” refers to how an issue is portrayed and understood, and involves emphasizing certain aspects of an issue to the exclusion of others.35 News coverage is a key site in which framing takes place. Frames in the news are “persistent patterns” by which the news media organize and present stories.36 Frames help readers construct meaning consciously or unconsciously,37 and shape the parameters of public policy debates by promoting “a particular problem definition, causal interpretation, moral evaluation, and/or treatment recommendation for the item described.”^35(p52)Because of the importance of the news in how readers understand contemporary issues,38 news framing is a site of power struggles in which multiple groups contest to shape public perception of an issue.39,40 Different speakers or “claim-makers” quoted in the news frame the same issue in conflicting ways to serve their interests. Examining their claims offers insights into the range of perspectives represented on a particular issue.41–45Among the key claim-makers for the food and beverage industry (hereafter “food industry”) are food companies, trade associations, and industry-funded nonprofit organizations. Individual food and beverage companies include companies that sell packaged food (e.g., Kraft), restaurant meals (e.g., McDonald’s), and nonalcoholic beverages (e.g., Coca-Cola). Individual companies may comment about public policy in the news, but they also form trade associations that advocate the interests of groups of food companies.46–49 Trade associations are the public voice of an industry,50 and often lobby or otherwise influence government decision-making.51–53 Trade associations also engage in public relations to exercise political influence, including advocacy advertising and speaking with the press.51There are numerous food industry trade associations representing the interests of different sectors of the industry such as packaged food manufacturers (e.g., Grocery Manufacturer’s Association), restaurants (e.g., National Restaurant Association), beverage companies (e.g., American Beverage Association [ABA]), and food retailers (e.g., Food Marketing Institute). The food industry also funds nonprofit groups to speak on its behalf. When these groups use names that evoke grassroots consumer advocacy and do not alert the public to their connection with industry they are known as “front groups.”4 The Center for Consumer Freedom (CCF) and Americans Against Food Taxes are 2 primary examples.54To understand how the food industry has presented itself in the news in the context of obesity policy debates, we investigated how key industry claim-makers countered concerns about obesity and other nutrition-related diseases in newspaper coverage. We collected data from 2000, the year before the 2001 US Surgeon General’s Call to Action and the advent of widespread concern about obesity as a public health problem, through 2012, the last full year of data available at the time. Previous studies have tracked news coverage of obesity and childhood obesity over time,55–57 and assessed the degree to which the food industry is framed as a cause of obesity or as a potential point of intervention. These studies documented increases in obesity coverage throughout the early 2000s, and a growing trend toward addressing societal causes of and solutions to the problem of obesity, including food industry actions. However, these previous analyses have not evaluated the actual statements made by food industry claim-makers in the news.55,56For this analysis we compared the claims made by food industry trade associations, industry-funded nonprofit groups, and individual companies. We also examined the nuances among statements made by claim-makers representing the interests of the packaged food industry, restaurants, and the nonalcoholic beverage industry.     

The Role of Corporate Credibility in Legitimizing Disease Promotion

Objectives. We explored what corporate “credibility” means to tobacco companies to determine why it matters to companies and what a lack of credibility means to them.Methods. We collected documents from an online tobacco industry document archive and analyzed them with an interpretive approach.Results. Tobacco companies conceptualized credibility not as being worthy of belief or confidence but as inspiring it. Thus, credibility was understood primarily as altering public perception of the industry. “Truth” was largely absent from tobacco industry conceptualizations of credibility, which were linked with “responsibility” and “reasonableness.” However, industry research found that the public regarded credibility and responsibility differently, expecting these to entail truth telling, advertising reductions, less harmful products, apologies for deception, making amends, or exiting the tobacco business altogether. Overall, industry credibility-building projects failed repeatedly.Conclusions. Public health discourse increasingly attends to the roles of corporations in promoting disease. Industries such as tobacco and alcohol have been identified as profiting from harmful products. Yet corporations'' ability to continue business as usual requires sustaining an implicit societal assent to their activities that depends on corporate credibility. For public health to address corporate disease promotion effectively, undermining corporate credibility may be strategically important.Increasingly, a strand of public health discourse has diverged from traditional “risk” discourse, which tends to draw attention to individual or community-level behavior, to explicitly highlight the roles played by the “supply side”: corporations whose activities create or contribute to ill health.^1–4 Numerous industries have been identified as “antihealth” because of the effects of their products or activities, including the alcohol, chemical, firearms, food, oil, automobile, and tobacco industries.^5–10 Their continued operation depends, in part, on achieving and maintaining corporate “credibility”; without it, companies may face regulatory constraints, political disadvantage, and public disgrace. If credibility problems are severe, a corporation might ultimately lose its license to operate.Researchers have examined how various industries attempt to build credibility by, for example, creating image-building campaigns or imposing self-regulation.^6,9,11,12 However, no previous studies have analyzed how any particular industry conceptualizes corporate credibility, how it relates to other concepts such as “responsibility,” and whether the public shares corporate interpretations of credibility. We addressed this gap by examining the tobacco industry''s conceptualizations of credibility across time and across companies. Our analysis has implications for public health efforts to challenge other industries'' health-damaging practices.     

Old Myths,New Myths: Challenging Myths in Public Health

Myths are widely held beliefs and are frequently perpetuated through telling and retelling. We examined 10 myths in public health research and practice. Where possible, we traced their origins, interrogated their current framing in relation to the evidence, and offered possible alternative ways of thinking about them. These myths focus on the nature of public health and public health interventions, and the nature of evidence in public health. Although myths may have some value, they should not be privileged in an evidence-informed public health context.Myths are “beliefs held to be true despite substantial refuting evidence.”1^(p447) They are frequently perpetuated through telling and retelling and periodically there is a need to “bust” myths by examining them in relation to current evidence. In the public health context, this has been done for myths about systematic reviews,2,3 tobacco control,4 and obesity.1     

A Qualitative Content Analysis of Cigarette Health Warning Labels in Australia,Canada, the United Kingdom,and the United States

The legislation of health warning labels on cigarette packaging is a major focus for tobacco control internationally and is a key component of the World Health Organization’s Framework Convention on Tobacco Control. This population-level intervention is broadly supported as a vital measure for warning people about the health consequences of smoking. However, some components of this approach warrant close critical inspection. Through a qualitative content analysis of the imagery used on health warning labels from 4 countries, we consider how this imagery depicts people that smoke. By critically analyzing this aspect of the visual culture of tobacco control, we argue that this imagery has the potential for unintended consequences, and obscures the social and embodied contexts in which smoking is experienced.Visual imagery of the health effects of smoking has a long history in the context of antitobacco campaigns. Such images featured prominently in Victorian era antismoking literature,1,2 and visual representations of the deleterious effects of smoking on the body have been a continuous thread in modern-day tobacco control and public health iconography. The first warning labels mandated on cigarette packaging were text-based only, enacted in the United States a year after the 1964 Surgeon General’s Report decisively linked smoking to cancer and other adverse health outcomes.3 In 1965, the US Federal Cigarette Labeling Act required cigarette cartons and packs to carry the warning, “Caution: cigarette smoking may be hazardous to your health.”4^(p13) The addition of pictures to warning labels on tobacco packaging is a relatively recent phenomenon, legislated first in Canada in 2000.5 Following Canada’s lead, many other countries have since followed suit, with text and picture-based warnings required in 63 countries worldwide as of 2012.6 The use of visual imagery (referred to specifically as “health warning labels”) on tobacco packaging has been driven by the World Health Organization’s Framework Convention on Tobacco Control and is based on the premise that “a picture says a thousand words.”6^(p1) Article 11 sets out clear standards for health warning labels, which are expected to cover “as much of the principal display areas as possible.”7^(p34)For tobacco control advocates, the impetus for visually based warning labels was clearly protection and empowerment against the tobacco industry’s tactics—for children and youths, who were seen as particularly susceptible to “prosmoking” media imagery, and for consumers, who had been subject to industry “fraud” and misinformation about the health risks and consequences of smoking.5^(p356) However, although the ostensible purpose of the visual imagery used on health warning labels is to educate smokers about the effects of smoking, it draws some of its impetus from the assumption that the subjective emotional response the images may provoke will force smokers into “realizing the harm done to their bodies.”8^(p358) In other words, the transition from text-based to visual warning labels reflects a growing awareness that the labels could be used not just to transmit information but to affect behavioral change. Indeed, health warning labels on cigarette packages are seen to be even more effective than traditional print and television campaigns because they “potentially reach smokers every time they purchase or consume tobacco products.”7^(p23) The underlying assumption is that, in contrast to similar messages presented in other mediums, the warnings are unavoidable. From a public health standpoint, a third goal of such labels is to facilitate tobacco denormalization by challenging the social and cultural acceptability of smoking, especially the glamorization of tobacco in media and popular visual culture.9 In this respect, the visual culture of tobacco control has been heavily influenced by the tobacco industry, and aims to use its strategies and practices against it.10Numerous studies support the view that hard-hitting graphic labels are more effective than text-based warning labels in stimulating awareness of tobacco-related health risks and increasing motivation and intentions to quit smoking.8,11,12 Plain cigarette packaging is seen to be particularly effective in reducing the appeal of smoking and focusing attention on the image and text of the health warning labels.13 Australia’s introduction of plain cigarette packaging requirements in December 2012 has generated considerable interest in such legislation. However, one limitation of the available research is that responses to cigarette packages are studied in a context in which the ordinary coordinates of smoking are absent, making effectiveness very difficult to judge.14Critical approaches to health promotion challenge the assumption of a simplistic or unidirectional relationship between public health campaigns and their intended targets, in which audiences are passive recipients of health information. Contrary to a didactic model of health education and its emphasis on individual behavioral change, critical approaches recognize the structural context of smoking and the social, historical, and political circumstances in which antismoking messages are deployed. Thus, multiple readings and responses on the part of message recipients are inevitable. In the arena of smoking cessation, this includes the potential for negative responses, ranging from context dissonance15 to defiance or resistance.16–18 This recognition challenges mainstream and top-down approaches in health promotion, which may assume that health-related behavior change is merely a matter of better education for at-risk individuals and groups (i.e., that programmers and policymakers just need to get the message right). These approaches also highlight the need for public health policies to move beyond an exclusive emphasis on questions of efficacy to consider the ethics of the strategies employed (i.e., even if they do work, at what cost?). Without careful consideration of the ethical implications and unintended consequences of such messaging, the “war against smoking” may instead become a counterproductive “war against smokers.”Our analysis of health warning labels on cigarette packaging has been informed by previous research on the visual culture of public health, which suggests that health promotion and education campaigns are constitutive of deeply embedded cultural understandings of health, illness, and social relations of power.19–21 From this standpoint, it is useful to consider how health-related imagery presented as scientific and objective privileges particular ways of seeing and defining both the bodies and identities of those who are “healthy” and pathological bodies at risk for illness.22–24 As critical public health scholars suggest, health promotion campaigns not only reinforce a normative imagery of health but can also contribute to social exclusion, stigmatization, and dehumanization when graphic and confronting images designed to provoke disgust are used.16,25 These tendencies have been explored in the context of issues such as injury prevention and disability,26,27 HIV/AIDS,22,28,29 obesity,25 and substance use, including alcohol30 and smoking.31,32 For example, analyses of antitobacco messages for pregnant women33 and campaigns directed toward adolescent girls34 suggest that the former promote the notion of the “bad mother” and neglect smoking by fathers and other men, whereas the latter reinforce the idea that what is most valuable about women is their external, physical appearance.35We analyzed the visual culture of tobacco control as represented by cigarette health warning labels in the context of 4 countries, and interpreted what this reveals about smoking as a social identity and practice. Such labels provide openings through which to see the “densely elaborated iconography”36^(p107) of tobacco control and how it conceptualizes smoking and people labeled as smokers. We contend that the currently used and proposed sets of health warning labels ground understandings of smoking and its effects in ways that obscure certain dimensions of the practice while foregrounding and prefiguring others. In particular, they frame smoking as an individual risk behavior, one entirely isolable from its social context. Our approach is critical of such framing, and cuts against both its emphasis on a biomedical imagery of the “diseased and dying” body and its diminishment of agency.9     

Local Public Health Systems and the Incidence of Sexually Transmitted Diseases

Objectives. We examined the associations of local public health system organization and local health department resources with county-level sexually transmitted disease (STD) incidence rates in large US health jurisdictions.Methods. We linked annual county STD incidence data (2005–2008) to local health department director responses (n = 211) to the 2006 wave of the National Longitudinal Study of Local Public Health Systems, the 2005 national Local Health Department Profile Survey, and the Area Resource File. We used nested mixed effects regression models to assess the relative contribution of local public health system organization, local health department financial and resource factors, and sociodemographic factors known to be associated with STD incidence to county-level (n = 307) STD incidence.Results. Jurisdictions with local governing boards had significantly lower county-level STD incidence. Local public health systems with comprehensive services where local health departments shoulder much of the effort had higher county-level STD rates than did conventional systems.Conclusions. More integration of system partners in local public health system activities, through governance and interorganizational arrangements, may reduce the incidence and burden of STDs.US annual sexually transmitted disease (STD) incidence rates have not declined despite the identification of effective surveillance and prevention methods.1–5 For example, after decreasing annually since 1999, gonorrhea infection rates among adolescents increased 2% from 2004 to 2005, from 421.9 to 431.8 per 100 000, and then increased 6% again from 2005 to 2006, from 431.8 to 458.8 per 100 000.6,7 Untreated STDs can have serious long-term health effects, such as cervical cancer, infertility, and pregnancy complications.8 STDs are among the largest Black–White racial disparities in health,9 which are heavily influenced by social determinants (i.e., area-level sociodemographic factors).9–12It is a widely accepted view that local health departments and their system partners play a critical role in controlling the spread of STDs.13–15 Local health departments differ dramatically in size, organizational structure, and available resources, and these factors can influence the reach and effectiveness of local STD prevention strategies. Previous studies indicate that larger local health departments, better resourced local health departments (as measured by expenditures per capita), and jurisdictions with local boards of health with policymaking authority more consistently provide a diverse set of essential public health functions,16–19 including diagnosing and preventing health problems and informing and educating the public about health issues. Moreover, recent evidence indicates that increases in STD prevention funding are associated with reductions in gonorrhea20 and syphilis21 incidence rates. This suggests that resources available to local health departments and their system partners can affect the “reach” of STD prevention programs.The contribution of community partner organizations to performing essential public health functions18 may also influence the reach and effectiveness of STD prevention and treatment programs. For example, low integration of local health departments with their local system partners, including physician organizations, community health centers, and faith-based organizations, can impinge on the effectiveness of local STD prevention and treatment efforts.15 Given that rescreening previously infected individuals is increasingly viewed as central to controlling the spread of STDs,22 local health departments that have low integration with their health care delivery system partners might face more difficulties curtailing the spread of STDs. It may be difficult for local health departments that have limited integration with system partners to communicate surveillance data and to generate action to combat emerging health epidemics.Little research, however, has assessed organizational and market determinants of local public health system effectiveness using population health indicators.17–19 Although several studies have assessed the relationship of county-level sociodemographic factors and STD rates,23,24 to our knowledge, no study has ever assessed the relationship of local public health system organization and STD incidence rates. Consequently, the extent to which the scope of local health department services and their integration with their local health system partners is associated with STD incidence rates remains unclear. Using responses to the National Association of County and City Health Officials (NACCHO) 2005 National Profile of Local Health Departments in the United States (NACCHO Profile) and county-level data from the Area Resource File, we examined the extent to which local health department financing per capita, the existence of a local governing board of health, and integration among key system partners are associated with county-level incidence rates of gonorrhea and chlamydia.Consistent with previous research examining public health spending and medical care expenditures,25 we hypothesized that local health departments with greater total expenditures per capita have lower STD incidence rates when controlling for county-level sociodemographic and other local health department characteristics. Local boards of health are increasingly considered central to improving community-based linkages and setting priorities for jurisdictions. Accordingly, we hypothesized that county-level STD rates would be lower in jurisdictions where local boards of health have governance responsibility than in those having no local board of health. The integration of local health departments with local public health system partners can influence the dissemination of preventive health care information and epidemiologic data to target interventions. We hypothesized that local health departments with a higher integration with system partners, as measured by the recent typology of local public health systems,26,27 have lower STD incidence rates, controlling for other factors. Finally, we examined the role of social determinants of STD incidence relative to measurable local public health system factors.     

History,Biology, and Health Inequities: Emergent Embodied Phenotypes and the Illustrative Case of the Breast Cancer Estrogen Receptor

How we think about biology—in historical, ecological, and societal context—matters for framing causes of and solutions to health inequities. Drawing on new insights from ecological evolutionary developmental biology and ecosocial theory, I question dominant gene-centric and ultimately static approaches to conceptualizing biology, using the example of the breast cancer estrogen receptor (ER).Analyzed in terms of its 4 histories—societal, individual (life course), tumor (cellular pathology), and evolutionary—the ER is revealed as a flexible characteristic of cells, tumors, individuals, and populations, with magnitudes of health inequities tellingly changing over time.This example suggests our science will likely be better served by conceptualizing disease and its biomarkers, along with changing magnitudes of health inequities, as embodied history—that is, emergent embodied phenotype, not innate biology.How we in public health think about biology—in historical, ecological, and societal context—has everything to do with how we frame causes of and solutions to health inequities. The dominant paradigm for the past century has placed genes and gene frequency at the center of biological phenomena, including disease and disease rates.1–5 Reflecting this orientation, funding priorities for the US National Institutes of Health (NIH) emphasize genomics,6,7 even for social inequalities in health. For example, within the 46 pages on “Minority Health and Health Disparities” allotted in the NIH’s most recent biennial 732-page report to the US Congress, the terms “genome,” “genomic,” “genetic,” and “gene” appear 87 times, whereas “social determinants of health” and “discrimination” each occur once, “socioeconomic” 7 times, “poverty” twice, and “racism” not at all.6During the past 2 decades, however, a fast-emerging body of biological research has been challenging the dominant gene-centric paradigm, which emphasizes that genome composition is determined at conception, by providing robust novel evidence that nothing in biology makes sense except in the light of history8: evolutionary, developmental, ecological, and societal.1–4,9–14 Termed “ecological evolutionary developmental biology” (or “eco-evo-devo”),1 a central thesis, building on ideas of norms of reaction,1–4,9,10 is that “the same genotype can generate different phenotypes depending on what cues are present in the environment”1^(p10)—hence, “bodies express ecology.”9^(p3) Providing novel evidence that environments not only “select” (or filter) variation but also construct it,1–4,9,10 well-known “textbook” nonhuman illustrations of developmental plasticity in embryos and phenotypic flexibility in adults range from temperature-dependent sex determination in turtles1,2,10 to socially induced sex change in adult fish1,2,15 to massive changes in adult migratory birds’ gizzard size and muscle type depending on where they are in the course of their migratory cycle.9 Among humans, one salient example is the differential adult health status exhibited by identical twins reared together but whose social class trajectories in adult life diverge.16What relevance, if any, might this broader, more historical and more dynamic framing of biology—only just now making headway into the public health literature1,5,11–13—have for understanding and addressing health inequities? To foster discussion and debate, I consider the illustrative case of the breast cancer estrogen receptor (ER), selected because it offers a useful example for thinking through issues of history, biology, and health inequities more generally (see the box on the next page).

Four Sets of Historically Informed Questions to Ask When Investigating Embodied Health and Disease Biomarkers and Outcomes, as Framed by the Construct of “Emergent Embodied Phenotype”

“It’s Not a Priority When We’re in Combat”: Public Health Professionals and Military Tobacco Control Policy

Tobacco use is prevalent among service members, but civilian public health groups have not effectively addressed military tobacco control policy issues. We conducted focus groups in 2010 and 2012 with participants from public health and tobacco control organizations regarding their understanding of the military and of tobacco use in that context. Misperceptions were common. Military personnel were believed to be young, from marginalized populations, and motivated to join by lack of other options. Tobacco use was considered integral to military life; participants were sometimes reluctant to endorse stronger tobacco control policies than those applied to civilians, although some believed the military could be a social policy leader. Engaging public health professionals as effective partners in tobacco-free military efforts may require education about and reframing of military service and tobacco control policy.Tobacco use prevalence is high among service members1 and military tobacco policy conveys mixed messages about tobacco use. For example, military personnel have access to comprehensive cessation services2 but stores on military installations sell tobacco products at discounted prices.3 Though the harms of smoking have been known since the 1950s, civilian public health groups have not effectively addressed military tobacco control policy issues. In 2009, the Institute of Medicine called for the Department of Defense to phase in policies that would lead to a tobacco-free military.2 However, this call was rejected by then–Secretary of Defense Robert Gates.4 More surprisingly, public health and tobacco control leaders were largely silent, the exception being the American Lung Association.5 Recently, Secretary of the Navy Ray Mabus, supported by Secretary of Defense Chuck Hagel,6 proposed eliminating tobacco sales from Navy and Marine Corps commissaries and exchanges.7 The leading voluntary health organizations supported the move,8 but there has been little public activism or engagement to counter efforts in Congress to block the Navy initiative.9 This is only the latest in a long history of efforts by the military to strengthen its tobacco control policies that have been prevented by congressional action while public health groups remained uninvolved.10–12Effectively framing a problem is crucial to gaining support for a proposed solution. Frames define a problem and implicitly or explicitly suggest the solution.13 For example, personal responsibility frames for public health issues suggest that they are the fault of individuals who must solve their problems themselves. The tobacco industry has framed tobacco control advocates as moralizing zealots and tobacco control policies as interfering with civil liberties.14 Industry frames emphasize the freedom of citizens “to pursue happiness . . . by making their own choices,”14^(p321) a value shared by many, including tobacco control advocates. The tobacco industry has also used alliances with veterans’ organizations to help frame military tobacco control issues. Veterans’ groups (sometimes using language crafted by the tobacco industry)15 have opposed clean indoor air laws by referencing rights, freedom, or sacrifice. For example, supporters of legislation mandating smoking areas in veterans’ hospitals argued that veterans had “fought for the right of all Americans, themselves included, to be free from unwarranted interference in their lives by government.”16 This framing can be difficult for civilian groups to counter.Previous research showed that public health and tobacco control leaders were unfamiliar with military tobacco control developments and the role that their organizations might play.17 Although they supported policies such as prohibiting smoking in uniform, they opposed prohibiting tobacco use altogether, as a violation of personnel’s rights. Some believed that policies had to be developed democratically, despite the authoritarian structure of the military. Leaders of organizations who advocate policies may either follow initiatives that arise from the membership, or attempt to educate or persuade the membership to support their own proposals. In either case, for an organization to act effectively on an issue, the opinions and understandings of leaders and membership should agree. To gain further insight into the absence of public health action on this issue, and to explore whether leaders’ perceptions were reflective of those held by public health professionals more generally, we conducted focus groups with members of public health and tobacco control organizations.     

Grassroots Movement Building and Preemption in the Campaign for Residential Fire Sprinklers

Home fires account for 85% of fire deaths in the United States, the majority in 1- or 2-family homes lacking fire sprinklers. Since 1978, however, a grassroots movement has successfully promoted more than 360 local ordinances mandating sprinklers in all new residential construction, including 1- and 2-family homes. The homebuilding industry has responded by seeking state preemption of local authority, a strategy previously used by other industries concerned about protecting their profits. From 2009 through 2011, 13 states adopted laws eliminating or limiting local authority over residential fire sprinklers. This study of the residential sprinkler movement adds to our understanding of grassroots public health movements and provides additional evidence that preemption can have a negative impact on public health and safety.On March 25, 1911, a fire in the Triangle Shirtwaist factory in New York City killed 146 workers. Although an effective fire sprinkler had been patented in 1874, the building did not have sprinklers. The commission that convened to study the fire recommended that, in the future, sprinklers be installed “in all factory buildings over seven stories or 90 feet in height in which wooden floors or wooden trim are used.”1^(p44)Although an increasing number of jurisdictions mandated sprinklers in commercial structures following the Triangle Shirtwaist fire, it was not until the 1970s that advocates initiated a successful campaign for local laws requiring sprinklers in all new residential construction, including 1- and 2-family homes.2 Concerned about the success of the grassroots sprinkler movement, trade associations representing homebuilders began lobbying for state laws limiting or eliminating local authority over residential fire sprinklers, a strategy known as “preemption.”Preemption occurs when a higher level of government (federal or state) limits the authority of lower jurisdictions (state or local) over a given matter.3 For practical purposes, the effect of state preemption is the same as federal preemption: if laws at higher and lower levels conflict with one another, the higher level laws will typically prevail.3,4 Among public health practitioners (and most researchers), the term “preemption” usually refers to “ceiling preemption,” by which higher jurisdictions limit the power of lower jurisdictions to adopt stronger protections.5 On the other hand, setting minimum federal or state public health standards, which can be referred to as “floor preemption,” is rarely controversial in the public health community. According to the Institute of Medicine, “the presumption should be that ‘floor’ preemption is the more appropriate option in the area of public health.”4^(p50) Therefore, we use the term “preemption” to signify ceiling preemption and recommend that, for the sake of clarity, other public health practitioners and researchers use this nomenclature as well.Advocates working on numerous different public health issues, including alcohol policy,6 gun violence prevention,7 obesity prevention,8 tobacco control,9,10 and illegal drugs policy,11 have expressed concerns about preemption.3,5 Preemption can halt state or local innovation,11 eliminate the flexibility to respond to the needs of diverse communities,7 undermine grassroots movements,6 prevent or delay changes in social norms,10 and concentrate the power of industry lobbyists in Washington and the state capitals.12Of course, there are circumstances under which federal or state preemption in public health is either necessary or a valid option. However, these circumstances are rare.3 According to the Institute of Medicine,

In a few areas of public health, federal preemption seems highly appropriate. For example … the federal ban on smoking on airplanes—the interstate nature of airline flight makes this area ideally suited to federal preemption.4^(p49)

The valid desire to implement strong, consistent national standards can usually be achieved by adopting minimum standards (i.e., floor preemption) without abrogating state or local authority to adopt stronger public health or safety protections.We have focused on residential fire sprinklers for 2 reasons: (1) from 1978 until the present, there has been a growing grassroots movement for residential fire sprinkler mandates; and (2) between 2009 and 2011, 13 states passed preemptive legislation to hinder the grassroots sprinkler movement. We studied the factors that led to success in the fire sprinkler movement and the impact of state preemption on that movement. Preemption in this case appears to fit a historic pattern in which industries have used preemption to thwart public health or safety movements.3,6,12Public health innovations and reforms in the United States often rely on grassroots efforts.13,14 A grassroots public health movement is a type of social movement formed to address threats to the health and safety of the community, led by activated individuals and organizations that devote resources to building grassroots capacity. A grassroots movement is typically built around a single issue or concern that energizes individuals who join together in a common cause13–15 and can be focused on policy change at any level of government. Social movement theory suggests that grassroots public health movements are most likely to succeed when entrepreneurs in the movements are able to take advantage of political opportunities, have available institutional structures that will support action, and can frame their issues in ways that facilitate a shared understanding of the problem and that motivate action.16The existence of structural opportunities for “concerted political action” creates the possibility for mobilization to influence policy.17 To move an issue through the political process, however, advocates must frame their issue in such a way that they are reflecting, influencing, or activating public opinion.18 Thus, successful grassroots efforts either are supported by majority opinion or are advocating in a field in which the majority of people do not yet hold strong opinions. In the latter case, the social movement, if it is visible in its efforts, can educate the public to adopt the movement’s understanding, or framing, of an issue.19One of the most accessible points for health advocacy in the US political system is at the local level.3,12 At the local level, an informal network of those desirous of policy change—often volunteers—can work together more readily. Their voices are more likely to be heard at the local level, because they may have a personal connection with local decision makers, whereas state or national interest groups may be perceived as outsiders and thus are less likely to be able to capture local government.20 In addition, the framing of an issue can be local and personal and thus more salient to community residents.21At higher levels of government, the advantages enjoyed by public health advocates diminish in relation to their generally better funded and better connected opposition.12 Groups that can afford paid lobbyists and make campaign donations are more likely to achieve their goals at higher levels.22 These groups frame preemption as a necessary antidote to inconsistent local ordinances that stifle business,9 with few competing voices to point out that local problems need local solutions. Public health advocates have generally lacked the access and resources needed to counteract these better funded and organized interests at higher levels of government.3 Thus, preemption serves as a repressive force, eliminating local opportunity for “concerted political action.”17For powerful interest groups, the advantages of preemption are clear. Preemption forces public health legislation into the venues where the institutional structures and political opportunities favor those with money and professional lobbying operations. At higher levels of government, consistency and uniformity are used to argue for preemption. What is lost is the ability of local communities to serve as laboratories of innovation where they can develop and test tailored solutions to address local problems. Only when the array of solutions is tested can an informed discussion on a single standardized set of rules begin. Issue frames that emphasize the importance of a consistent or standardized set of rules make more sense at higher levels, whereas those that emphasize local solutions do not.3In the early 1970s, it was estimated that fires in the United States killed nearly 12 000 people, caused 300 000 injuries, and resulted in property damage of more than $11 billion annually. To accurately assess the extent of the human costs and property damage associated with fires and recommend solutions, Congress created the National Commission on Fire Prevention and Control in 1971.23 America Burning, a report published by the commission in 1973, energized fire prevention efforts, especially in the fire service.2,24Although fire deaths and injuries have declined since the 1970s, most residential fire deaths and injuries are preventable.25 In 2010, fires in the United States caused 3120 deaths (exclusive of firefighters), 17 720 injuries, and $11.6 billion in property loss. Approximately 85% of all fire deaths occur in 1- and 2-family homes.26The Federal Emergency Management Agency has concluded that automatic fire sprinklers are the “most effective fire loss prevention and reduction measure with respect to both life and property”25^(p17) Sprinkler systems are relatively inexpensive to install, especially in new construction. On average, the installation of sprinklers in new homes costs $1.61 per square foot (and as low as $0.55 in some cases), and the presence of fire sprinklers can lower the cost of fire insurance.27–29 Retrofitting existing homes with fire sprinklers is more expensive than is installing them in new home construction, although communities have considered lower cost retrofitting options.30In 1896, the National Fire Protection Association (NFPA) published the first installation standard for automatic sprinkler systems, which ultimately evolved into NFPA Standard 13. In 1975, the NFPA published a standard specifically developed for 1- and 2-family homes and mobile homes: NFPA 13D. At a 2008 meeting of the International Code Council (a membership association that develops model building and fire prevention codes, including the International Residential Code [IRC]; most US jurisdictions rely on the IRC in updating their building codes), a requirement for fire sprinklers in all new 1- and 2-family dwellings was added to the 2009 edition of the IRC.31 The IRC is a model code, and not a statute or regulation, and must therefore be adopted by state or local jurisdictions to carry the force of law.     

Aggressive Policing and the Mental Health of Young Urban Men

Objectives. We surveyed young men on their experiences of police encounters and subsequent mental health.Methods. Between September 2012 and March 2013, we conducted a population-based telephone survey of 1261 young men aged 18 to 26 years in New York City. Respondents reported how many times they were approached by New York Police Department officers, what these encounters entailed, any trauma they attributed to the stops, and their overall anxiety. We analyzed data using cross-sectional regressions.Results. Participants who reported more police contact also reported more trauma and anxiety symptoms, associations tied to how many stops they reported, the intrusiveness of the encounters, and their perceptions of police fairness.Conclusions. The intensity of respondent experiences and their associated health risks raise serious concerns, suggesting a need to reevaluate officer interactions with the public. Less invasive tactics are needed for suspects who may display mental health symptoms and to reduce any psychological harms to individuals stopped.The criminal justice system has been recognized increasingly as a threat to physical and mental health.1–3 Changes in policing practices in the past 2 decades have brought a growing number of urban residents into contact with the criminal justice system,4 making the consequences of such contact increasingly important to understand. In the past 20 years, many cities have shifted to a proactive policing model in which officers actively engage citizens in high-crime areas to detect imminent criminal activity or disrupt circumstances interpreted as indicia that “crime is afoot.”5One way proactive policing is sanctioned constitutionally is through a tactic known as Terry stops,6 in which police temporarily detain and perhaps frisk or search persons they suspect are, were, or are about to be engaged in criminal activity. Between 2004 and 2012, the New York City Police Department recorded more than 4 million such stops.7 Large cities such as Philadelphia, Pennsylvania,8 and Los Angeles, California,9 have experienced similar practices, and a survey of Chicago, Illinois, public school students10 found that police had stopped and questioned about half and “told them off or told them to move on.” A quarter to a third of these students reported having been searched by police. Overall, the burden of police contact in each of these cities falls predominantly on young Black and Latino males,8,10,11 with significant disparities in police conduct across neighborhoods.12,13Recent studies suggest that Terry stops are often harsh encounters in which physical violence, racial/ethnic degradation, and homophobia are commonplace,14,15 raising the potential for adverse mental health effects. We examined associations between involuntary police contact and mental health among young men in New York City, where Terry stops and proactive policing (commonly known as “stop and frisk” activity) have been the subject of contentious debate and litigation.11,16,17Public perceptions of stop and frisk vary widely, with some observers raising concerns about the aggressive nature of many stops18 and their shaky constitutional grounds.19 Others dismiss these concerns as outweighed by the benefit of crime deterrence20 or as inconveniences that should be accepted as a “fact of urban life.”21Most of what is known about New Yorkers’ police contact is derived from observational incident-level data,12,16 journalistic accounts,18,19,21 or convenience samples22 and suggests a complex and conflicted relationship between community members and the police. However, such accounts provide only limited insight into the broader implications of the practice. We have advanced understanding of the cumulative experiences of young men with these police encounters using a population-based survey.     

Improving State Health Policy Assessment: An Agenda for Measurement and Analysis

We examine the scope of inquiry into the measurement and assessment of the state public health policy environment. We argue that there are gains to be made by looking systematically at policies both within and across health domains. We draw from the public health and public policy literature to develop the concepts of interdomain and intradomain policy comprehensiveness and illustrate how these concepts can be used to enhance surveillance of the current public health policy environment, improve understanding of the adoption of new policies, and enhance evaluations of the impact of such policies on health outcomes.The 2011 Institute of Medicine report For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges called public policy “among the most powerful tools to improve population health.”1^(p18) However, the institute’s recommendation that legislators and government agencies “familiarize themselves with the array of legal and policy tools available”1^(p68) poses substantial challenges in the absence of conceptual and methodological clarity on how these tools should be measured, classified, adopted, and used, especially at the state level.2–4 Categorizing and assessing different provisions of state policies is a complex task, made even more difficult by the absence of standardized methods.5,6 Different approaches to operationalizing policy measures have also led, in some cases, to conflicting evidence of their effectiveness.7–9 Furthermore, these assessments have largely treated public health issues as independent silos, with little reference to how policies may work in concert or at odds with one another either within or across public health domains.10Several authors have highlighted the important limitations of existing studies that fail to account for the full range of policies that may have contributed to the outcome in question.10,11 To date, however, there is still relatively little systematic surveillance of the complete set of public health policies adopted by states across multiple public health arenas, and there has been even less of a focus on the evolution and impact of these different combinations of policies on health outcomes.We argue here that an integrated and systematic assessment of public health policies within and across health domains is necessary for measuring the effectiveness of any individual health policy or law. Such an assessment is also necessary to understand how and why US states and localities have constructed vastly different health policy landscapes over time. Note that by “policy” we refer to the enactment or modification of laws, the development or modification of regulatory measures, and the setting of funding priorities, including the development of specific public sphere programs. By “health policy landscape,” we refer to the total number of health policies in place in a given jurisdiction at any given time.Our objective is to respond to growing interest among policymakers and advocates in understanding the ways policy tools can be used to improve population health both within and across health areas.3 Indeed, findings from a 2007 Association of State and Territorial Health Officials (ASTHO) survey indicated that state health agencies ranked “developing effective health policy” among their top 5 priorities.12 Our argument is thus meant to engage researchers and advocates in considering how to apply a more thorough approach to their work in policy development and analysis and to assist them in communicating these ideas to policymakers.In developing a framework for conceptualizing the broader state health policy landscape, we begin by introducing 2 new constructs: intradomain policy comprehensiveness and interdomain policy comprehensiveness. We discuss the ways in which these constructs aid in illuminating the composition of different state policy landscapes and discuss how they may influence the study, measurement, and effects of public health policies. To illustrate our arguments, we construct a data set of 27 public health policies in all 50 states between 1980 and 2000 and discuss observed patterns in public health policy adoption. We then review the literature on internal and external determinants of policy adoption and diffusion and consider the ways these determinants may be associated with the comprehensiveness of states’ health policy landscapes. We end with a series of research questions that stem from our approach.     

Income Inequality, Trust, and Population Health in 33 Countries

Objectives. I examined the association between income inequality and population health and tested whether this association was mediated by interpersonal trust or public expenditures on health.Methods. Individual data on trust were collected from 48 641 adults in 33 countries. These data were linked to country data on income inequality, public health expenditures, healthy life expectancy, and adult mortality. Regression analyses tested for statistical mediation of the association between income inequality and population health outcomes by country differences in trust and health expenditures.Results. Income inequality correlated with country differences in trust (r = −0.51), health expenditures (r = −0.45), life expectancy (r = −0.74), and mortality (r = 0.55). Trust correlated with life expectancy (r = 0.48) and mortality (r = −0.47) and partly mediated their relations to income inequality. Health expenditures did not correlate with life expectancy and mortality, and health expenditures did not mediate links between inequality and health.Conclusions. Income inequality might contribute to short life expectancy and adult mortality in part because of societal differences in trust. Societies with low levels of trust may lack the capacity to create the kind of social supports and connections that promote health and successful aging.Social inequalities in health are closely aligned with individual differences in income. At every level of socioeconomic status, health tends to be better on the level above and poorer on the level below, even among those who are not poor and enjoy equal access to health services.^1,2 Research also shows that health problems that are associated with socioeconomic status are more common in societies that have wider distributions of personal income.³ It is well-documented that international differences in income inequality (i.e., size of the gap between rich and poor) are associated with rates of mortality⁴ and with various mental and physical health problems.^5–8Opinions are divided regarding the contextual mechanisms that might account for the association between income inequality and health. One line of research focuses on the psychosocial impact of inequality and the breakdown of “social capital,” which is defined as features of social organization—such as networks, norms, and interpersonal trust—that facilitate coordination and cooperation for mutual benefit.^2,9 Wilkinson, Kawachi, and others have suggested that large income differences intensify social hierarchies and increase class conflict and feelings of relative deprivation while simultaneously reducing levels of interpersonal trust, social cohesion, and other dimensions of social capital that promote health.^3,10–12 The alternative “neomaterialist” hypothesis suggests that income inequality inhibits public expenditures on important services and infrastructure that promote health.^13–17 In the United States, for instance, state expenditures on public health and education negatively correlate with income inequality and adult mortality.^13,16 It remains undetermined whether international differences in public expenditures account for the association between income inequality and health.The neomaterialist and social capital hypotheses are not mutually exclusive. Kawachi and Kennedy observed that US state populations with low levels of trust are also characterized by values that support a minimal role for government in reducing health inequalities.¹⁸ Putnam''s index of health and health care in the United States (which included expenditures on health care) was highly correlated with an index of social capital.⁹ Therefore, it could be the case that more equal, more trusting societies are also more willing to support government spending on goods and services that advance the common good, compared with less equal, less trusting societies.It is important to understand which factors account for the association between income inequality and population health. A piecemeal evidence base shows inconsistent findings for mediation by psychosocial and neomaterial paths. Inconsistencies among studies with regard to sample selection criteria, tests of mediated effects, and measures of income inequality have made it difficult to weigh the evidence in favor of either hypothesis.^11,19–21 As a result, previous claims that the relationship between income inequality and poor health is mediated by trust, social capital, or public expenditures²²—or that the relation is simply a statistical artifact caused by confounding effects of individual income,²³ race,²⁴ or education²⁵—have not all been based on rigorous tests of statistical mediation.One issue in particular muddies the water when testing mediated effects: small changes in a regression slope or correlation coefficient that occur when a third variable is controlled can easily cause the statistic to change from significance (P < .05) to nonsignificance (P > .05), even when the third variable does not account for a significant proportion of shared variance. Negligible change from significance to nonsignificance does not, in itself, establish mediation.²⁶ Kawachi et al. addressed this issue by using path analysis to show significant mediated effects of income inequality (via social capital) on mortality¹¹ and births to adolescents.²⁰ However, these studies did not include similar mediation analyses of public expenditures.There has not been a direct comparison of psychosocial and neomaterial paths in accounting for the association between income inequality and health. Therefore, my aim in the current study was to test the association between income inequality and 2 indicators of population health—healthy life expectancy and adult mortality—and then test how much this association was mediated by differences in a proxy indicator of social capital (interpersonal trust) and by public expenditures on health. Of course, trust is just a single aspect of social capital that could mediate links between inequality and health, and expenditures on services other than health might also relate to health. But by using a consistent set of data on income inequality and population health, I explored whether their association (if significant) was better explained by a psychosocial path or a neomaterial path. In disadvantaged populations, healthy life expectancy (also referred to as “disability-free life expectancy”) represents the burden of ill health better than total life expectancy does, according to the World Health Organization,²⁷ so I used healthy life expectancy as an indicator of population health. Adult mortality was used as a general indicator of population health.