PERSPECTIVE FR。NTOF· PACKAGE NUTRITION LABELING were true, there still would be nomic status. The IOM is cur- mandate some types of labeling better and worse or more health- rently undertaking an assessment and to restrict others. 4 ful and less healthful foods. The of front-of-package alternatives traffic-light system facilitates such - hence our dismay at the uni- are available with the full text of thi a relative assessment and thus lateral, unscientific, preemptive at NEM.org may promote more informed de- approach taken by the food com- cision making. In addition, the panies. The industry leaders who From Yale University, New Haven, CT(KDB- ): greater value of the traffic-light profess to be responsible part and Emory University, Atlanta 0PK) approach may lie in its ability to ners in preventing and control- motivate manufacturers to refor- ling the obesity epidemic have mulate their food products to an opportunity now to reject this diminish red classifications and, noncollaborative, premature ap-330-6 in so doing, to improve the overall proach and show good faith by 2. Koplan JP, Brownell KD. Response of the Evaluation of the various clas- dosing the best evidence-based 3. Sharma LL, Teret SP, Brownell KD.The ification models for front-of. approach to front-of-package la- food industry and self-regulation: standard package labeling is under way. beling. Otherwise, industry may health failures. Am Public Health 2010 The effectiveness of any given have proven itself untrustworthy 100: 240-6 system may vary with the popu- again2,3 and raised the risk of 4. Pomeranz JL. Front-of-package food and lations nationality, culture, level what it wishes to avoid -govern- and regulation. Am J Prey Med 2011: 40: 382-.5 of health literacy, and socioeco- ment's exercising its authority to Copyright o 2011 Massachusetts Medical Society Nowhere Left to Hide? The Banishment of Smoking from Public spaces James Colgrove, Ph. D, M.P. H, Ronald Bayer, Ph. D, and Kathleen E. Bachynski, M.P.H or pedestrian mall -from Van the city's action may prove influ- longed exposure to secondhand Cortlandt park in the Bronx to ential. it was not radical. Accord- smoke. In 1973. the Civil aero- Brighton Beach in Brooklyn- ing to the American Nonsmokers' nautics Board required airlines to became illegal. The city council Rights Foundation, more than designate nonsmoking sections of passed the ban last fall by a vote 500 municipalities in the United airplanes for domestic flights of 36 to 12, rejecting a compro- States have passed some type of similar rules for interstate buses mise proposal that small areas law banning smoking in outdoor soon followed. Over the next sev remain available to people who recreation areas(see table). Such eral years, cities began requiring ranted to smoke. "I think in the laws have been enacted in 43 that restaurants set aside seats future, "the city's health commis- states, most of them during the for nonsmokers. The stated ra sioner, Thomas Farley, said at a past 10 years. tional for these early measures public hearing, " we will look The elimination of cigarettes was not a paternalistic one-that back on this time and say 'How from parks, beaches, and other smokers must abstain for their could we have ever tolerated smok- outdoor spaces represents the own good - but rather the pro- New York City has often been began four decades ago, when the tection of nonsmoking bystand- Ing in a paI a bellwether for the passage of demarcation of areas where tions were implemented in the public health laws, and there was smoking would be allowed or absence of scientific data that sec- symbolic significance in the fact prohibited emerged as the cen- ondhand smoke posed a health that such iconic public spaces as tral point of conflict for tobac- threat to nonsmokers. Instead, the Central Park and the pedestrian co-control efforts. Initial restric- measures advanced on the prem- N ENGL J MED 364: 25 NEJM.ORG JUNE 23, 2011 2375 Downloaded from nejm. org at Trial- Fudan University on July 25, 2011. For personal use only. No other uses without permission. Copyright o 201 1 Massachusetts Medical Society. All rights reserved
n engl j med 364;25 nejm.org june 23, 2011 PERSPECTIVE 2375 were true, there still would be better and worse or more healthful and less healthful foods. The traffic-light system facilitates such a relative assessment and thus may promote more informed decision making. In addition, the greater value of the traffic-light approach may lie in its ability to motivate manufacturers to reformulate their food products to diminish red classifications and, in so doing, to improve the overall healthfulness of the food supply. Evaluation of the various classification models for front-ofpackage labeling is under way. The effectiveness of any given system may vary with the population’s nationality, culture, level of health literacy, and socioeconomic status. The IOM is currently undertaking an assessment of front-of-package alternatives — hence our dismay at the unilateral, unscientific, preemptive approach taken by the food companies. The industry leaders who profess to be responsible partners in preventing and controlling the obesity epidemic have an opportunity now to reject this noncollaborative, premature approach and show good faith by awaiting the IOM report and endorsing the best evidence-based approach to front-of-package labeling. Otherwise, industry may have proven itself untrustworthy again2,3 and raised the risk of what it wishes to avoid — government’s exercising its authority to mandate some types of labeling and to restrict others.4 Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. From Yale University, New Haven, CT (K.D.B.); and Emory University, Atlanta (J.P.K.). 1. Scarborough P, Rayner M, Stockley L. Developing nutrient profile models: a systematic approach. Public Health Nutr 2007;10: 330-6. 2. Koplan JP, Brownell KD. Response of the food and beverage industry to the obesity threat. JAMA 2010;304:1487-8. 3. Sharma LL, Teret SP, Brownell KD. The food industry and self-regulation: standards to promote success and to avoid public health failures. Am J Public Health 2010; 100:240-6. 4. Pomeranz JL. Front-of-package food and beverage labeling: new directions for research and regulation. Am J Prev Med 2011;40:382-5. Copyright © 2011 Massachusetts Medical Society. Front-of-Package Nutrition Labeling Nowhere Left to Hide? The Banishment of Smoking from Public Spaces James Colgrove, Ph.D., M.P.H., Ronald Bayer, Ph.D., and Kathleen E. Bachynski, M.P.H. On May 23, smoking in any New York City park, beach, or pedestrian mall — from Van Cortlandt Park in the Bronx to Brighton Beach in Brooklyn — became illegal. The city council passed the ban last fall by a vote of 36 to 12, rejecting a compromise proposal that small areas remain available to people who wanted to smoke. “I think in the future,” the city’s health commissioner, Thomas Farley, said at a public hearing, “we will look back on this time and say ‘How could we have ever tolerated smoking in a park?’”1 New York City has often been a bellwether for the passage of public health laws, and there was symbolic significance in the fact that such iconic public spaces as Central Park and the pedestrian plazas of Times Square would be closed to smoking. Yet though the city’s action may prove influential, it was not radical. According to the American Nonsmokers’ Rights Foundation, more than 500 municipalities in the United States have passed some type of law banning smoking in outdoor recreation areas (see table). Such laws have been enacted in 43 states, most of them during the past 10 years. The elimination of cigarettes from parks, beaches, and other outdoor spaces represents the most recent phase in a trend that began four decades ago, when the demarcation of areas where smoking would be allowed or prohibited emerged as the central point of conflict for tobacco-control efforts. Initial restrictions focused on enclosed spaces where nonsmokers faced prolonged exposure to secondhand smoke. In 1973, the Civil Aeronautics Board required airlines to designate nonsmoking sections of airplanes for domestic flights; similar rules for interstate buses soon followed. Over the next several years, cities began requiring that restaurants set aside seats for nonsmokers. The stated rationale for these early measures was not a paternalistic one — that smokers must abstain for their own good — but rather the protection of nonsmoking bystanders. Strikingly, these early restrictions were implemented in the absence of scientific data that secondhand smoke posed a health threat to nonsmokers. Instead, the measures advanced on the premThe New England Journal of Medicine Downloaded from nejm.org at Trial - Fudan University on July 25, 2011. For personal use only. No other uses without permission. Copyright © 2011 Massachusetts Medical Society. All rights reserved
PERSPECTIVE THE BANISHMENT OKING FROM PUBLIC SPACES Outdoor Smoking Bans in U.S. unicipalities dismissed as " flimsy"the evidence tising campaigns that depict smok- that secondhand smoke poses a ing as a dirty and disgusting habit. threat to the health of nonsmokers given the addictive nature of Is Banned as of April 1, 2011 in most outdoor settings. Never- nicotine and the difficulty of quit- theless, smoking opponents con- ting smoking, strategies of de tinue to press their case using a normalization raise both prag- Public-transit waiting ar variety of claims, including public matic and ethical concerns. Some ining areas health rationales as well as"pub- tobacco-control experts have ques- lic nuisance"arguments such as tioned whether the denormaliza- tion of smoking may have unwant The arguments put forth at the ed negative effects on the mental bublic hearing on the New York and physical health of smokers por Area Lists, April 2011. (Available City ban last fall exemplified this but fail to lead them to quit.4 oke.org/goingsmokefree-php?id-519 mixture of rationales. Health com- Also relevant are issues of social missioner Farley cited data showing justice. The decline in U.S. smok that 57% of New Yorkers had tested ing rates since the 1960s has co- ise that secondhand smoke was positive for cotinine, a marker of incided with the development of unpleasant and annoying. exposure to tobacco smoke, even a sharp gradient along the lines Epidemiologic research even- though only 16% of city residents of socioeconomic status. Where tually documented associations smoked. He also argued that cig. as about one fifth of all Ameri- between exposure to secondhand anette- related litter accounted for cans are smokers, about one third smoke and a host of health prob- three quarters of all litter on of those with incomes below th lems, including elevated risks of beaches and a third of the litter federal poverty level smoke. These lung cancer, cardiovascular disease, in parks. This claim- based on data are especially pertinent to and acute episodes of asthma; the the counting of individual items the question of bans in parks Environmental Protection Agency of litter rather than overall vol- Since smokers are more likely to classified secondhand smoke as a ume was met with skeptical be poor and therefore dependent Class A carcinogen in 1993. As the questioning by city council mem- on free public spaces for enjoy scientific basis for restrictions bers. Finally, Farley emphasized ment and recreation, refusing to grew, so did the number of places the importance of protecting chil- allow them to smoke in those that became off-limits to smoking, dren from exposure to adult smok- places poses potential problems including schools, stadiums, con- ers who would serve as negative of fairness. vention centers, and private work- role models. " Families, "he said, Antitobacco advocates find should be able to bring their chil- themselves at a crossroads. Smok Parks and beaches are increas- dren to parks and beaches know- ing remains a leading of prohibition are extended from smoking n ,ey won't see others preventable illness and death. Af- ingly joining this list. As the zones ing that the ter several years in which rates of indoor to outdoor spaces, however, This frank statement revealed smoking in the United States have the evidence of physical harm to the extent to which denormaliz. remained stagnant, the most suc bystanders grows more tenuous. ing smoking has become a central cessful policy tools for combating Smoking in partially enclosed out- prong of antitobacco efforts, both the problem, including taxation, door settings such as patio seating as a way of discouraging initia- provision of cessation services, areas in restaurants may be haz- tion of smoking and as a means of and public education campaigns, ardous to servers who spend hours pressuring current smokers to quit. seem to be producing diminishing here. But air-monitoring studies Transforming smoking from a returns. Most health professionals have shown that health risks to desirable behavior that will be agree that an outright prohibition people exposed to secondhand imitated to a stigmatized one that on the sale of cigarettes would smoke outdoors drop off dramati- will be shunned has motivated be unfeasible and would lead to cally when the source of the smoke such efforts as the push to give unwanted consequences such as is more than 2 m away. 2 The edi- movies depicting smoking an"R" black markets and the crime that tor of the journal Tobacco Control rating and cigarette counter-adver hem 2376 N ENGL J MED 364: 25 NEJM.ORG JUNE 23, 2o11 Downloaded from nejm. org at Trial- Fudan University on July 25, 2011. For personal use only. No other uses without permission. Copyright o 201 1 Massachusetts Medical Society. All rights reserved
PERSPECTIVE 2376 n engl j med 364;25 nejm.org june 23, 2011 ise that secondhand smoke was unpleasant and annoying. Epidemiologic research eventually documented associations between exposure to secondhand smoke and a host of health problems, including elevated risks of lung cancer, cardiovascular disease, and acute episodes of asthma; the Environmental Protection Agency classified secondhand smoke as a Class A carcinogen in 1993. As the scientific basis for restrictions grew, so did the number of places that became off-limits to smoking, including schools, stadiums, convention centers, and private workplaces. Parks and beaches are increasingly joining this list. As the zones of prohibition are extended from indoor to outdoor spaces, however, the evidence of physical harm to bystanders grows more tenuous. Smoking in partially enclosed outdoor settings such as patio seating areas in restaurants may be hazardous to servers who spend hours there. But air-monitoring studies have shown that health risks to people exposed to secondhand smoke outdoors drop off dramatically when the source of the smoke is more than 2 m away.2 The editor of the journal Tobacco Control dismissed as “flimsy” the evidence that secondhand smoke poses a threat to the health of nonsmokers in most outdoor settings.3 Nevertheless, smoking opponents continue to press their case using a variety of claims, including public health rationales as well as “public nuisance” arguments such as litter abatement. The arguments put forth at the public hearing on the New York City ban last fall exemplified this mixture of rationales. Health commissioner Farley cited data showing that 57% of New Yorkers had tested positive for cotinine, a marker of exposure to tobacco smoke, even though only 16% of city residents smoked. He also argued that cigarette-related litter accounted for three quarters of all litter on beaches and a third of the litter in parks. This claim — based on the counting of individual items of litter rather than overall volume — was met with skeptical questioning by city council members. Finally, Farley emphasized the importance of protecting children from exposure to adult smokers who would serve as negative role models. “Families,” he said, “should be able to bring their children to parks and beaches knowing that they won’t see others smoking.”1 This frank statement revealed the extent to which denormalizing smoking has become a central prong of antitobacco efforts, both as a way of discouraging initiation of smoking and as a means of pressuring current smokers to quit. Transforming smoking from a desirable behavior that will be imitated to a stigmatized one that will be shunned has motivated such efforts as the push to give movies depicting smoking an “R” rating and cigarette counter-advertising campaigns that depict smoking as a dirty and disgusting habit. Given the addictive nature of nicotine and the difficulty of quitting smoking, strategies of denormalization raise both pragmatic and ethical concerns. Some tobacco-control experts have questioned whether the denormalization of smoking may have unwanted negative effects on the mental and physical health of smokers but fail to lead them to quit.4 Also relevant are issues of social justice. The decline in U.S. smoking rates since the 1960s has coincided with the development of a sharp gradient along the lines of socioeconomic status. Whereas about one fifth of all Americans are smokers, about one third of those with incomes below the federal poverty level smoke. These data are especially pertinent to the question of bans in parks. Since smokers are more likely to be poor and therefore dependent on free public spaces for enjoyment and recreation, refusing to allow them to smoke in those places poses potential problems of fairness. Antitobacco advocates find themselves at a crossroads. Smoking remains a leading cause of preventable illness and death. After several years in which rates of smoking in the United States have remained stagnant, the most successful policy tools for combating the problem, including taxation, provision of cessation services, and public education campaigns, seem to be producing diminishing returns. Most health professionals agree that an outright prohibition on the sale of cigarettes would be unfeasible and would lead to unwanted consequences such as black markets and the crime that accompanies them. The banishment of smoking from public spaces Outdoor Smoking Bans in U.S. Municipalities.* Outdoor Places Where Smoking Is Banned Number of Municipalities as of April 1, 2011 Beaches 105 Public-transit waiting areas 210 Dining areas 180 Parks 507 Zoos 50 * Data are from the Americans for Nonsmokers’ Rights, Outdoor Area Lists, April 2011. (Available at www.no-smoke.org/goingsmokefree.php?id=519 #outdoor.) The New England Journal of Medicine Downloaded from nejm.org at Trial - Fudan University on July 25, 2011. For personal use only. No other uses without permission. Copyright © 2011 Massachusetts Medical Society. All rights reserved
PERSPECTIVE THE BANISHMENT OF SMOKING FROM PUBLIC SPACES Yet steadily winnowing the responded, "I'm not prepared to Disclosure forms provided by the authors spaces in which smoking is le- answer that. " are available with the full text of this article at NEJM.org gally allowed may be leading to In the absence of direct health a kind of de facto prohibition. risks to others, bans on smoking From the Mailman School of Public Health Smoking bans imposed by states in parks and beaches raise ques- and municipalities have been ac- tions about the acceptable limits This article(10.1056/NEJMpl104637)was companied by comparable mea- for government to impose on con- published on May 25, 2011, at NEJM.org sures in the private sector. Some duct. In 2008, legal scholar Robert 1. The New York City Council. Transcript ofthe employers and property owners Rabin, the former program direc- minutes of the Joint Committees on Heal prohibitsmokersfromcongre-torfortherobertWoodJohnson(http://legistar.council.nyc.gov/legislatiOr gating in building doorways; col- Foundations Tobacco Policy Re- Detail. aspx?ID-773185&GUID-FD6CB044 leges and universities have banned search and Evaluation Program, .E7FC-497B-A487-789457D760FC&Options smoking on their campuses; commented, "We should not lose condominiums, apartments, and perspective on the question of how other multi-unit dwellings have restrictive a society we want to particles. J Air Waste Manag Assoc 2007: 57 passed requirements for smoke- create-that is, how far we want 3. Chapman S Should smoking in outside free apartments. As the historian to go in reducing individual au- public spaces be banned? No BM) 2008: 337 Allan Brandt has noted, smokers tonomy, including what can be a2804 may soon have nowhere left to perceived as self-destructive be- ma and public health: rethinking the rela hide. Pressed by a city council havior. "5 This question should be tions. Am JPublic Health 2006: 96: 47-50 member about where he believed central as we pursue the critically 5. Rabin R Tobacco control strategies: pa people should be allowed to important goal of reducing rates fficacy an Law Rey 2008 smoke in New York City, Farley of smoking Coa÷3 Omise. Loyola Los Angel sachusetts Medical Society. The Independent Payment Advisory Board-Congress's “ Good deed Henry J. Aaron, Ph. D A ming et ef mesisiativer sates. den estahleshinad vise lepard videl rcrostartine their own indi- manship is self-abnegation-the (IPAB)in section 3403 of the Af- Medicare's founding legislation willingness of legislators to ab- fordable Care Act(ACA), Congress stated that"Nothing in this title tain from meddling in matters may once again have shown such shall be construed to authorize they are poorly equipped to man- statesmanship. For several rea- any Federal officer or employee age. The law creating the Federal sons, however, it is too early to to exercise any supervision or con- Reserve embodied that virtue. be sure. The board must surmount trol over the practice of medi Congress recognized the abiding major challenges- first to sur. cine. "2 Duly warned, Medicare temptation to use monetary pol- vive and then to function effec- administrators have largely for icy for political ends and realized tively. Harold pollack has neatly borne from using coverage policy that it would, at times, prove irre- summarized the problem, the so- or financial incentives to discour sistible. To save themselves from lution, and the problem with that age ineffective or needlessly cost- themselves, wise legislators creat- solution: "Every Democratic and ly methods of care. Members of ed an organization whose fund- Republican policy expert knows the legislative branch have not ing and operations were largely that we must reduce congressional however, displayed similar re beyond the reach of normal leg- micromanagement of Medicare straint. They have pressured those islative controls. Short of repeal- policy. Unfortunately, every Demo- same administrators on coverage ing the law, Congress denied it- cratic and Republican legislator policies and passed laws to im- self the power to do more than knows that mechanisms such as pose them. kibitz about monetary policy IPaB that might do so would In the view of many observers, N ENGL J MED 364: 25 NEJM.ORG JUNE 23, 2011 2377 Downloaded from nejm. org at Trial- Fudan University on July 25, 2011. For personal use only. No other uses without permission. Copyright o 201 1 Massachusetts Medical Society. All rights reserved
n engl j med 364;25 nejm.org june 23, 2011 PERSPECTIVE 2377 Yet steadily winnowing the spaces in which smoking is legally allowed may be leading to a kind of de facto prohibition. Smoking bans imposed by states and municipalities have been accompanied by comparable measures in the private sector. Some employers and property owners prohibit smokers from congregating in building doorways; colleges and universities have banned smoking on their campuses; condominiums, apartments, and other multi-unit dwellings have passed requirements for smokefree apartments. As the historian Allan Brandt has noted, smokers may soon have nowhere left to hide. Pressed by a city council member about where he believed people should be allowed to smoke in New York City, Farley responded, “I’m not prepared to answer that.”1 In the absence of direct health risks to others, bans on smoking in parks and beaches raise questions about the acceptable limits for government to impose on conduct. In 2008, legal scholar Robert Rabin, the former program director for the Robert Wood Johnson Foundation’s Tobacco Policy Research and Evaluation Program, commented, “We should not lose perspective on the question of how restrictive a society we want to create — that is, how far we want to go in reducing individual autonomy, including what can be perceived as self-destructive behavior.”5 This question should be central as we pursue the critically important goal of reducing rates of smoking. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. From the Mailman School of Public Health, Columbia University, New York. This article (10.1056/NEJMp1104637) was published on May 25, 2011, at NEJM.org. 1. The New York City Council. Transcript of the minutes of the Joint Committees on Health and Parks & Recreation, October 14, 2010. (http://legistar.council.nyc.gov/Legislation Detail.aspx?ID=773185&GUID=FD6CB044 -E7FC-497B-A487-7B9457D760FC&Options =&Search=.) 2. Klepeis NE, Ott WR, Switzer P. Real-time measurement of outdoor tobacco smoke particles. J Air Waste Manag Assoc 2007;57: 522-34. 3. Chapman S. Should smoking in outside public spaces be banned? No. BMJ 2008;337: a2804. 4. Bayer R, Stuber J. Tobacco control, stigma, and public health: rethinking the relations. Am J Public Health 2006;96:47-50. 5. Rabin R. Tobacco control strategies: past efficacy and future promise. Loyola Los Angel Law Rev 2008;41:1721-68. Copyright © 2011 Massachusetts Medical Society. The banishment of smoking from public spaces The Independent Payment Advisory Board — Congress’s “Good Deed” Henry J. Aaron, Ph.D. Among the most important attributes of legislative statesmanship is self-abnegation — the willingness of legislators to abstain from meddling in matters they are poorly equipped to manage. The law creating the Federal Reserve embodied that virtue. Congress recognized the abiding temptation to use monetary policy for political ends and realized that it would, at times, prove irresistible. To save themselves from themselves, wise legislators created an organization whose funding and operations were largely beyond the reach of normal legislative controls. Short of repealing the law, Congress denied itself the power to do more than kibitz about monetary policy. In establishing the Independent Payment Advisory Board (IPAB) in section 3403 of the Affordable Care Act (ACA), Congress may once again have shown such statesmanship. For several reasons, however, it is too early to be sure. The board must surmount major challenges — first to survive and then to function effectively. Harold Pollack has neatly summarized the problem, the solution, and the problem with that solution: “Every Democratic and Republican policy expert knows that we must reduce congressional micromanagement of Medicare policy. Unfortunately, every Democratic and Republican legislator knows that mechanisms such as IPAB that might do so would thereby constrain their own individual prerogatives.”1 Medicare’s founding legislation stated that “Nothing in this title shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine.”2 Duly warned, Medicare administrators have largely forborne from using coverage policy or financial incentives to discourage ineffective or needlessly costly methods of care. Members of the legislative branch have not, however, displayed similar restraint. They have pressured those same administrators on coverage policies and passed laws to impose them. In the view of many observers, The New England Journal of Medicine Downloaded from nejm.org at Trial - Fudan University on July 25, 2011. For personal use only. No other uses without permission. Copyright © 2011 Massachusetts Medical Society. All rights reserved
