Stephen P. Teret

The Food Industry and Self-Regulation: Standards to Promote Success and to Avoid Public Health Failures

Threatened by possible government regulation and critical public opinion, industries often undertake self-regulatory actions, issue statements of concern for public welfare, and assert that self-regulation is sufficient to protect the public. The food industry has made highly visible pledges to curtail childrens food marketing, sell fewer unhealthy products in schools, and label foods in responsible ways. Ceding regulation to industry carries opportunities but is highly risky. In some industries (e.g., tobacco), self-regulation has been an abject failure, but in others (e.g., forestry and marine fisheries), it has been more successful. We examined food industry self-regulation in the context of other self-regulatory successes and failures and defined 8 standards that should be met if self-regulation is to be effective.

Compulsory vaccination and conscientious or philosophical exemptions: Past, present, and future

Compulsory vaccination has contributed to the success of immunisation programmes in the USA and Australia, yet the benefits from compulsory vaccination are not universally recognised. Some people--experts and the public alike--believe that the benefits of compulsory vaccination are outweighed by the associated ethical problems. A review of vaccination legislation in the UK, Australia, and the USA raises four main points. First, compulsory vaccination may be effective in preventing disease outbreaks, reaching and sustaining high immunisation coverage rates, and expediting the introduction of new vaccines. Second, to be effective, compulsory programmes must have a reliable supply of safe and effective vaccines and most people must be willing to be vaccinated. Third, allowance of exemptions to compulsory vaccination may limit public backlash. Finally, compulsory vaccination may increase the burden on governments to ensure the safety of vaccines. Nevertheless, although compulsory immunisation can be very effective, it might not be acceptable in some countries where high coverage has been achieved through other approaches or efforts, such as in Sweden, Norway, Denmark, the Netherlands, and the UK. These factors should be considered when compulsory vaccinations are being introduced or immunisation laws refined. Lessons learned from compulsory vaccination could be useful to other public-health programmes.

Support for New Policies to Regulate Firearms — Results of Two National Surveys

BACKGROUND New policy options are emerging in the debate regarding the regulation of firearms in the United States. These options include the treatment of firearms as consumer products, the design of which can be regulated for safety; denial of gun ownership to those convicted of misdemeanors; and strategies to curtail the illegal sale of guns. The publics opinion of these innovative gun-policy options has not been thoroughly assessed. METHODS We conducted two telephone surveys of 1200 adults each in the United States in 1996 and 1997-1998. Cognitive interviews and pretests were used in the development of the survey instruments. Potential participants were then contacted by random-digit dialing of telephone numbers. RESULTS A majority of the respondents favored safety standards for new handguns. These standards included childproofing (favored by 88 percent of respondents), personalization (devices that permit firing only by an authorized person; 71 percent), magazine safeties (devices that prevent firing after the magazine or clip is removed; 82 percent), and loaded-chamber indicators (devices that show whether the handgun is loaded; 73 percent). There was strong support for policies prohibiting persons convicted of specific misdemeanors from purchasing a firearm. Support for such prohibitions was strongest for crimes involving violence or the illegal use of a firearm (83 to 95 percent) or substance abuse (71 to 92 percent). There was also widespread support for policies designed to reduce the illegal sale of guns, such as mandatory tamper-resistant serial numbers (90 percent), a limit of one handgun purchase per customer per month (81 percent), and mandatory registration of handguns (82 percent). Even among the subgroup of respondents who were gun owners, a majority were in favor of stricter gun regulations with regard to 20 of the 22 proposals covered in the poll. CONCLUSIONS Strong public support, even among gun owners, for innovative strategies to regulate firearms suggests that these proposals warrant serious consideration by policy makers.

Exemptions to School Immunization Requirements: The Role of School-Level Requirements, Policies, and Procedures

OBJECTIVES Our goal was to determine whether school-level variability in implementation of immunization requirements is associated with the likelihood of a child having received an exemption to school immunization requirements. METHODS We surveyed 1000 school immunization personnel in Colorado, Massachusetts, Missouri, and Washington. We explored associations between school implementation of immunization requirements and the likelihood of a child having an exemption using logistic regression models. RESULTS School policies associated with an increased likelihood of children having exemptions included lack of provision of written instructions for completing the school immunization requirement before enrollment, administrative procedures making it easier to claim an exemption, and granting of philosophical exemptions. In the 2 states we surveyed where philosophical exemptions are not authorized (Massachusetts and Missouri), 17.0% and 18.1% of schools reported permitting philosophical exemptions. CONCLUSIONS Inconsistencies in the interpretation and implementation of school immunization laws contribute to variability in rates of exemptions. School policies should be reviewed to ensure consistency with the intent of state laws.

Alcohol and drowning: an analysis of contributing factors and a discussion of criteria for case selection

We test the hypothesis that there are host or environmental factors that significantly affect the likelihood of alcohol involvement in drownings. Our results are based on records of 234 drownings that meet predetermined eligibility criteria designed to exclude cases with postmortem blood alcohol concentrations (BACs) that do not reflect the BAC at the time of immersion. Cases are drawn from a total of 442 drownings occurring in Sacramento County, California, from 1974 to 1985. Overall, 41% of deaths were alcohol-associated; among these only one victim was under 15 years old. Among older persons, increasing age generally suggested a higher likelihood of alcohol involvement, and particularly of a BAC greater than 200 mg/dl. Other associated factors were male gender (OR = 2.5; 95% CI = 1.6, 3.8), activity (for land motor-vehicle occupants vs. all others, OR = 3.3; 95% CI = 2.6, 4.3), and time of year (January-June vs. July-December, OR = 2.1; 95% CI = 1.6, 2.8). A lower likelihood of alcohol involvement was seen for drownings in bathtubs (OR = .16; 95% CI = .04, .57) and swimming pools (OR = .47; 95% CI = .27, .82). Race was not a factor. Differing eligibility criteria have been used in studies of alcohol and drowning. After a critical review of the experimental literature, we propose that the following be adopted in future such studies: (i) death must occur within six hours of the onset of immersion, unless an antemortem sample is available and, unless evidence to the contrary exists, death can be assumed to have occurred within a few minutes of immersion; (ii) blood must be drawn for BAC determination within 24 hours of death.

Litigating for the public's health.

Three products that have enormous impact on the publics health are now the subject of substantial product liability activity--air bags, cigarettes, and guns. Regulatory action involving these products has not been satisfactory with regard to prevention of disease and injury. Public health advocates have therefore turned to the courtroom for progress. Although the first patent for an air bag was issued in 1953, and the product was highly developed by the late 1960s, the public has not had the option of availing itself of this lifesaving technology. The automobile industry has bitterly fought against a mandate for air bags in cars, even though the device was proven sufficiently effective. Based upon the failure of legislative and regulatory attempts to require the installation of air bags in cars, the plaintiffs trial bar was urged to litigate in the interest of the publics health. One lawsuit is cited in this article where the plaintiff sued the Ford Motor Company for failure to provide an air bag in the car, which would have reduced the severity of her injuries. After ten days of trial, Ford Motor Company settled the case by the payment of

Innovative Legal Approaches to Address Obesity

1.8 million. Wide publicity was given to this settlement, not only within the legal and health professions, but to the lay public as well. This engendered many more air bag cases. In November, 1985, Ford Motor Company announced that it will offer air bags as optional equipment on some 1987 models. Since then, other car makers have stated that they will sell air bag-equipped cars.

Child restraint laws: an analysis of gaps in coverage.

CONTEXT The law is a powerful public health tool with considerable potential to address the obesity issue. Scientific advances, gaps in the current regulatory environment, and new ways of conceptualizing rights and responsibilities offer a foundation for legal innovation. METHODS This article connects developments in public health and nutrition with legal advances to define promising avenues for preventing obesity through the application of the law. FINDINGS Two sets of approaches are defined: (1) direct application of the law to factors known to contribute to obesity and (2) original and innovative legal solutions that address the weak regulatory stance of government and the ineffectiveness of existing policies used to control obesity. Specific legal strategies are discussed for limiting childrens food marketing, confronting the potential addictive properties of food, compelling industry speech, increasing government speech, regulating conduct, using tort litigation, applying nuisance law as a litigation strategy, and considering performance-based regulation as an alternative to typical regulatory actions. Finally, preemption is an overriding issue and can play both a facilitative and a hindering role in obesity policy. CONCLUSIONS Legal solutions are immediately available to the government to address obesity and should be considered at the federal, state, and local levels. New and innovative legal solutions represent opportunities to take the law in creative directions and to link legal, nutrition, and public health communities in constructive ways.

Understanding and informing policy implementation: a case study of the domestic violence provisions of the Maryland Gun Violence Act.

The limiting effects of exemptions to the coverage of child restraint laws were estimated by determining the extent to which the laws would have applied to child motor vehicle occupants, ages 0-5 years, killed before the laws were passed (1976-80). The 50 state laws would have exempted about 39 per cent of child motor vehicle occupants less than 6 years of age killed in the years immediately preceding enactment of the laws. Of those children killed in pre-law years who were within the age limits set by the subsequent state laws, about 21 per cent would not have been covered. The gaps in the laws are unnecessary, and proper amendments based on these data can save lives.

Rethinking first response: Effects of the clean up and recovery effort on workers at the World Trade Center disaster site

The Maryland Gun Violence Act, enacted into law in 1996, explicitly authorized courts to order batterers to surrender their firearms through civil protective orders. It also vested law enforcement with the explicit authority to remove guns when responding to a domestic violence complaint. In order to assess how these laws were implemented, we designed a case study and collected data from in-depth, key informant interviews, court observations, and relevant documents. We present findings from this study and recommend how to increase the likelihood that policies designed to separate batterers and guns are implemented in a way that will result in greater protections for victims of domestic violence.