Concerns about the effects of smoking, obesity, and other risk factors for chronic health problems have led policymakers to propose a range of new public health interventions, from banning large sugary drinks to putting graphic warnings on cigarette packaging and calorie counts on restaurant menus.(a)
Despite vocal criticism of some of these policies as “nanny state” interventions, our research shows that most Americans support government action to address chronic health problems like diabetes, obesity, and tobacco and alcohol use. This is particularly true when such action takes the form of less intrusive interventions that nudge rather than compel people to make healthier choices.
Traditionally, public health efforts have largely focused on addressing communicable diseases or environmental toxins, for example, by requiring childhood vaccinations, containing the spread of HIV and foodborne illnesses, or banning leaded paints. The legitimacy of government intervention in these areas is based on the idea that communicable diseases and environmental toxins can put the public at risk. Today, however, many of our most significant health problems are noncommunicable illnesses like heart disease and cancer, often caused or exacerbated by personal behaviors such as smoking, obesity, and lack of exercise.
While addressing noncommunicable disease isn’t entirely new to public health, the emphasis on so called “lifestyle behaviors” represents a new frontier for the field, and raises the question of what role government should play in pushing people to change their behaviors and improve their personal health. Some advocates believe government has a responsibility to improve the well-being of its citizens as well as control healthcare costs. Critics suggest that government intervention in individual health and behavior is intrusive and an illegitimate use of public funds.
To better understand what the American public thinks about these questions, we conducted a survey of over 1800 adults.1 We found that large majorities (70-90%) support government action to address noncommunicable diseases and behavioral risk factors like heart disease, cancer, diabetes, obesity, and tobacco and alcohol use. When asked about specific policy proposals, people show greater support for less restrictive or invasive measures and are less likely to endorse more coercive approaches.2
For example, more than 80% of respondents favor efforts to make fresh fruits and vegetables more affordable and laws requiring restaurants to post the amount of calories in their foods. A much smaller share of people (less than 40%) supports banning children from bringing soda and junk food to school or charging obese people more for health insurance.(b) These findings suggest policymakers will likely receive greater buy-in from the public by continuing the current focus on using law to shape health environments and encourage better choices, rather than exerting direct pressure on individual behavior.
Perhaps not surprisingly, we found that a person’s political ideology predicts how likely he or she is to support these efforts. People who identify as conservative are less likely to endorse the general idea of government action on a range of public health issues, like cancer and obesity, and are also less supportive of many specific policy interventions. The same is true for respondents who believe that health is “strongly controllable through individual action.”
We were surprised, however, that we didn’t see large differences in support by geography.(c) In particular, though New York City has been at the forefront of many new public health interventions, area residents are no more likely to support these interventions than people from other parts of the country (once we controlled for factors like age, race, and political ideology).(d) This suggests that many of New York’s interventions could have success in other geographic areas.
What should these findings mean for policymaking moving forward? Our study shows broad support – perhaps broader than previously understood – for government action on chronic health problems, even among potential targets of interventions, such as people who are overweight or have diabetes. As a political matter, we find that policymakers will face the least resistance in advancing interventions that encourage rather than compel people to make healthier choices. The dilemma, however, is that the least coercive options may not always be the most effective.
Our research also suggests that the policymaking process itself can be key to public buy-in and compliance. Among the belief measures we tested, the strongest predictor of support for interventions was an individual’s perception that “people like me” can influence government priorities in public health. Policymakers should take public opinion on health issues into consideration because people are more likely to comply with regulations they view as legitimate and are also more likely to view efforts as legitimate if they feel they have a say in the process.
- Stephanie Morain and Michelle M. Mello (2013) “Survey Finds Public Support For Legal Interventions Directed At Health Behavior To Fight Noncommunicable Disease,” Health Affairs, 32(3): 486-496.
- We find that strong majorities (more than 70%) of people support initiatives to make fruits and vegetables more affordable, require restaurants to post calorie counts, bar food stamps from being used to purchase sugary drinks, teach public school students about the risks of obesity, increase the amount of time students spend doing physical activity in school, provide free nicotine patches, and require food producers and restaurants to reduce sodium levels in food. Moderate majorities (50 to 70%) support efforts to screen students’ BMIs and other health indicators, track blood sugar levels in people with diabetes, and display graphic images on cigarette packaging. Less than 40% of people support charging higher health insurance premiums for individuals who are obese, banning all soda and junk food in schools, allowing employers to fire employees for smoking, and banning smoking in private places.
- (a) One of the latest high-profile efforts is New York City’s proposal to ban the sale of large sugary drinks at restaurant, theaters, and street carts. It was recently overturned in state court, though the city plans to appeal.
- (b) When purchasing individual health insurance, people who are obese pay an average of 22% more for their policies, and those who smoke pay 14% more. Starting in 2014, the Affordable Care Act will bar insurance companies from charging people more based on their weight, though price differences for smokers will still be allowed.
- (c) We did see one interesting geographical difference: Individuals in the Northeast are significantly less likely to support restrictions on alcohol.
- (d) New York City Mayor Michael Bloomberg has been at the forefront of implementing initiatives to address tobacco use and obesity. In 2002, New York was the first major city to outlaw smoking in restaurants and bars. In 2006, the city banned transfats in restaurant food and began requiring chain restaurants to post calorie counts on all their food. His latest battle was a proposed ban on large sugary drinks recently overturned by the courts.