Jamie F. Chriqui

Understanding Evidence-Based Public Health Policy

Public health policy has a profound impact on health status. Missing from the literature is a clear articulation of the definition of evidence-based policy and approaches to move the field forward. Policy-relevant evidence includes both quantitative (e.g., epidemiological) and qualitative information (e.g., narrative accounts). We describe 3 key domains of evidence-based policy: (1) process, to understand approaches to enhance the likelihood of policy adoption; (2) content, to identify specific policy elements that are likely to be effective; and (3) outcomes, to document the potential impact of policy. Actions to further evidence-based policy include preparing and communicating data more effectively, using existing analytic tools more effectively, conducting policy surveillance, and tracking outcomes with different types of evidence.

Assessing the potential effectiveness of food and beverage taxes and subsidies for improving public health: a systematic review of prices, demand and body weight outcomes

Taxes and subsidies are increasingly being considered as potential policy instruments to incentivize consumers to improve their food and beverage consumption patterns and related health outcomes. This study provided a systematic review of recent U.S. studies on the price elasticity of demand for sugar‐sweetened beverages (SSBs), fast food, and fruits and vegetables, as well as the direct associations of prices/taxes with body weight outcomes. Based on the recent literature, the price elasticity of demand for SSBs, fast food, fruits and vegetables was estimated to be −1.21, −0.52, −0.49 and −0.48, respectively. The studies that linked soda taxes to weight outcomes showed minimal impacts on weight; however, they were based on existing state‐level sales taxes that were relatively low. Higher fast‐food prices were associated with lower weight outcomes particularly among adolescents, suggesting that raising prices would potentially impact weight outcomes. Lower fruit and vegetable prices were generally found to be associated with lower body weight outcomes among both low‐income children and adults, suggesting that subsidies that would reduce the cost of fruits and vegetables for lower‐socioeconomic populations may be effective in reducing obesity. Pricing instruments should continue to be considered and evaluated as potential policy instruments to address public health risks.

Soda Taxes, Soft Drink Consumption, And Children’s Body Mass Index

Taxes on sugar-sweetened beverages have been proposed to combat obesity. Using data on state sales taxes for soda and individual-level data on children, we examine whether small taxes are likely to change consumption and weight gain or whether larger tax increases would be needed. We find that existing taxes on soda, which are typically not much higher than 4 percent in grocery stores, do not substantially affect overall levels of soda consumption or obesity rates. We do find, however, that subgroups of at-risk children--children who are already overweight, come from low-income families, or are African American--may be more sensitive than others to soda taxes, especially when soda is available at school. A greater impact of these small taxes could come from the dedication of the revenues they generate to other obesity prevention efforts rather than through their direct effect on consumption.

Associations between state-level soda taxes and adolescent body mass index.

PURPOSE Soft drink consumption has been linked with higher energy intake, obesity, and poorer health. Fiscal pricing policies such as soda taxes may lower soda consumption and, in turn, reduce weight among U.S. adolescents. METHODS This study used multivariate linear regression analyses to examine the associations between state-level grocery store and vending machine soda taxes and adolescent body mass index (BMI). We used repeated cross-sections of individual-level data on adolescents drawn from the Monitoring the Future surveys combined with state-level tax data and local area contextual measures for the years 1997 through 2006. RESULTS The results showed no statistically significant associations between state-level soda taxes and adolescent BMI. Only a weak economic and statistically significant effect was found between vending machine soda tax rates and BMI among teens at risk for overweight. CONCLUSIONS Current state-level tax rates are not found to be significantly associated with adolescent weight outcomes. It is likely that taxes would need to be raised substantially to detect significant associations between taxes and adolescent weight.

Weight status among adolescents in states that govern competitive food nutrition content

OBJECTIVES: To determine if state laws regulating nutrition content of foods and beverages sold outside of federal school meal programs (“competitive foods”) are associated with lower adolescent weight gain. METHODS: The Westlaw legal database identified state competitive food laws that were scored by using the Classification of Laws Associated with School Students criteria. States were classified as having strong, weak, or no competitive food laws in 2003 and 2006 based on law strength and comprehensiveness. Objective height and weight data were obtained from 6300 students in 40 states in fifth and eighth grade (2004 and 2007, respectively) within the Early Childhood Longitudinal Study–Kindergarten Class. General linear models estimated the association between baseline state laws (2003) and within-student changes in BMI, overweight status, and obesity status. Fixed-effect models estimated the association between law changes during follow-up (2003–2006) and within-student changes in BMI and weight status. RESULTS: Students exposed to strong laws at baseline gained, on average, 0.25 fewer BMI units (95% confidence interval: −0.54, 0.03) and were less likely to remain overweight or obese over time than students in states with no laws. Students also gained fewer BMI units if exposed to consistently strong laws throughout follow-up (β = −0.44, 95% confidence interval: −0.71, −0.18). Conversely, students exposed to weaker laws in 2006 than 2003 had similar BMI gain as those not exposed in either year. CONCLUSIONS: Laws that regulate competitive food nutrition content may reduce adolescent BMI change if they are comprehensive, contain strong language, and are enacted across grade levels.

Banning All Sugar-Sweetened Beverages in Middle Schools: Reduction of In-School Access and Purchasing but Not Overall Consumption

OBJECTIVE To determine whether state policies that regulate beverages in schools are associated with reduced in-school access and purchase of sugar-sweetened beverages (SSBs) and reduced consumption of SSBs (in and out of school) among adolescents. DESIGN Cross-sectional. SETTING Public schools in 40 states. PARTICIPANTS Students sampled in fifth and eighth grades (spring 2004 and 2007, respectively). MAIN EXPOSURES State policies that ban all SSBs and state policies that ban only soda for 2006-2007. MAIN OUTCOME MEASURES In-school SSB access, in-school SSB purchasing behavior, and overall SSB consumption (in and out of school) in eighth grade. RESULTS The proportions of eighth-grade students who reported in-school SSB access and purchasing were similar in states that banned only soda (66.6% and 28.9%, respectively) compared with states with no beverage policy (66.6% and 26.0%, respectively). In states that banned all SSBs, fewer students reported in-school SSB access (prevalence difference, -14.9; 95% CI, -23.6 to -6.1) or purchasing (-7.3; -11.0 to -3.5), adjusted for race/ethnicity, poverty status, locale, state obesity prevalence, and state clustering. Results were similar among students who reported access or purchasing SSBs in fifth grade compared with those who did not. Overall SSB consumption was not associated with state policy; in each policy category, approximately 85% of students reported consuming SSBs at least once in the past 7 days. Supplementary analyses indicated that overall consumption had only a modest association with in-school SSB access. CONCLUSION State policies that ban all SSBs in middle schools appear to reduce in-school access and purchasing of SSBs but do not reduce overall consumption.

The Impact of State Laws and District Policies on Physical Education and Recess Practices in a Nationally Representative Sample of US Public Elementary Schools

OBJECTIVE To examine the impact of state- and school district-level policies on the prevalence of physical education (PE) and recess in a nationally representative sample of US public elementary schools. DESIGN Analyses from annual, nationally representative, cross-sectional surveys of school administrators in the United States. SETTING Data were collected through surveys conducted between February and June during the 2006-2007 through 2008-2009 school years. State laws and district policies were compiled annually by researchers at the University of Illinois at Chicago using established legal research techniques. PARTICIPANTS The sample size was 47 states, 690 districts, and 1761 schools. MAIN EXPOSURES State- and school district-level PE and recess-related laws. MAIN OUTCOME MEASURES Twenty minutes of daily recess and 150 min/wk of PE. RESULTS The odds of schools having 150 min/wk of PE increased if they were located in states (odds ratio [OR], 2.8; 95% CI, 1.3-5.7) or school districts (OR, 2.4; 95% CI, 1.3-4.3) having a law or policy requiring 150 min/wk of PE. Schools located in states with laws encouraging daily recess were significantly more likely to have 20 minutes of recess daily (OR, 1.8; 95% CI, 1.2-2.8). District policies were not significantly associated with school-level recess practices. Adequate PE time was inversely associated with recess and vice versa, suggesting that schools are substituting one form of physical activity for another rather than providing the recommended amount of both recess and PE. CONCLUSION By mandating PE or recess, policy makers can effectively increase school-based physical activity opportunities for youth.

State Sales Tax Rates for Soft Drinks and Snacks Sold through Grocery Stores and Vending Machines, 2007

Junk food consumption is associated with rising obesity rates in the United States. While a “junk food” specific tax is a potential public health intervention, a majority of states already impose sales taxes on certain junk food and soft drinks. This study reviews the state sales tax variance for soft drinks and selected snack products sold through grocery stores and vending machines as of January 2007. Sales taxes vary by state, intended retail location (grocery store vs. vending machine), and product. Vended snacks and soft drinks are taxed at a higher rate than grocery items and other food products, generally, indicative of a “disfavored” tax status attributed to vended items. Soft drinks, candy, and gum are taxed at higher rates than are other items examined. Similar tax schemes in other countries and the potential implications of these findings relative to the relationship between price and consumption are discussed.

Application of a rating system to state clean indoor air laws (USA)

Objective: To develop and implement a system for rating state clean indoor air laws. Design: The public health interest of state clean indoor air laws is to limit non-smoker exposure to environmental tobacco smoke (ETS). Current estimates of health risks and methods available for controlling ETS provided a framework for devising a ratings scale. An advisory committee applied this scale to each of seven site specific smoking restrictions and two enforcement related items. For each item, a target score of +4 was identified. The nine items were then combined to produce a summary score for each state. A state that achieved the target across all nine items would receive a summary score of 36 points and be eligible to receive an additional 6 points for exceeding the target on six of the nine items, resulting in a maximum summary score of 42 points. Individual scores were also adjusted to reflect state level preemption measures. Each states law was evaluated annually from 1993 through 1999. Setting: USA. Main outcome measure: A summary score measuring the extensiveness of the states clean indoor air law. Results: State laws restricting smoking in the seven individual locations of interest were relatively weak. The overall mean score across the location restrictions ranged from 0.72 in 1993 to 0.98 in 1999. Mean scores were higher for the enforcement items than for the location restrictions. Summary scores ranged from 0 to 20 in 1993 and 0 to 31 in 1994 through 1999. Average summary scores ranged from 8.71 in 1993 to 10.98 in 1999. By the end of 1999, scores increased for 22 states; however, between 1995 and 1997 there were no changes in the summary scores. Three states scored zero points across all years. From 1993 through 1999, there was a 41% increase in the number of states that had in place state level preemption measures. Conclusion: The number of newly enacted state clean indoor air laws has remained relatively stagnant since 1995. With a few exceptions, as of the end of 1999, progress in enacting state laws to meet specified public health targets for reducing exposure to ETS was relatively low. Thus, state laws in the USA provide, on average, only minimal protection in specified areas and, given the increase in preemption, are increasingly undermining those passed in localities.

State medical marijuana laws: understanding the laws and their limitations

Significant attention has been given to the debate regarding allowances for medical marijuana use since the 1996 California and Arizona ballot initiatives. State medical marijuana allowances, however, have existed since the mid-1970s. Much of the current debate stems from confusion about the various ways states approach the issue. In this paper, we present original legal research on current state medical marijuana laws identifying four different ways states statutorily enable the medical use of marijuana. We discuss the tension these approaches have with federal law as well as their implications regarding real access for patients. In addition, we present information on how a small number of states are trying to deal with the issue of access within the context of their medical marijuana laws, and discuss the implication of various supply approaches on the enforcement of other state marijuana laws.