In his current biography The Passage of Power, Robert Caro recalls how four days after the Kennedy assassination, Lyndon Johnson had to decide if he would make a major civil rights push in his transition address to Congress the following week. Cautioned by his aides that it might be too controversial, he said, "Well, what the hell’s the presidency for?"
I was thinking of this last week when the New York Times editorial page called last week’s proposed removal of sugary drinks larger than 16 ounces in restaurants, theaters, stadiums and food carts by Mayor Bloomberg and Health Commissioner Farley “A Ban Too Far.” They applaud other anti-obesity efforts but claim that “too much nannying with a ban might cause people to tune out.” That statement does not seem to be particularly compelling itself, but how should population health advocates evaluate when regulation is appropriate or not?
There are two issues considerations in play here: 1) which problems to tackle (since if population health is everything it could be nothing and 2) which incentive strategies to use. With regard to the former, communities consider a range of issues when setting priorities for action: What is the magnitude and severity of the issue? What is its relative contribution to health outcomes, what (if any) evidence-based interventions are available and feasible, and, what is the impact on disparities, cost effectiveness, and public demand? On most of these points, obesity would seem to qualify as well as being worth tackling; Farley claims that sweetened drinks are responsible for up to half of the increase in city obesity over the past 30 years. The evidence on the effectiveness and cost effectiveness of this particular regulation is certainly unknown however Farley has cited evidence from behavioral economics that the portion size available has been shown to influence consumption.
Given the assessment that sugar-sweetened beverages are a policy priority, which tools should be used? Population health incentives have been divided into three broad classes:
- remunerative or financial incentives are those where an agent can expect some form of material reward — especially money — in exchange for acting in a particular way
- moral incentives are those where a particular choice is widely regarded as the right thing to do, or as particularly admirable, or where the failure to act in a certain way is condemned as indecent
- regulatory or coercive incentives are those where a person can expect that the failure to act in a particular way will result in physical force being used against them by others in the community — for example, by imprisonment or by confiscating or destroying their possessions
New York City has already used moral incentives in its tough anti-obesity advertising campaigns, and tried to use financial incentives with a soda tax and food stamp restrictions; these were blocked by the state and Federal governments respectively. The current proposal is perhaps a joint financial and regulatory effort; the sale of such sizes is prohibited, but the penalty is a fine -- hardly the physical force described above. It is also relatively weak in that additional purchases of smaller sizes as well as free refills would be allowed.
So is it a “Ban too Far”? From my perspective, we need to try many new approaches to combat this epidemic, and all incentive categories need to be considered. Careful population health policy analysis would have to consider the industry claim that jobs might be lost; if true, this competing socioeconomic effect on health might be important. However, just getting this level of attention and discussion has considerable value, and Bloomberg and Farley are to be commended for pushing the limits of what is possible politically and under their control as regulators. Time and careful evaluation will have to tell if this particular approach has a reasonable return on investment, measured in health improvement, for the financial and political capital expended.
David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health. Follow him on twitter: @DAKindig.