Is government intrusion into what we eat, drink, and smoke the future of public health?

Wednesday night, New York's city council adopted what will likely be the final controversial public-health dictum of the Bloomberg era, a law that bumps the legal age for buying cigarettes in the city from 18 to 21 (yes, pushing tobacco out of reach of residents who can otherwise drive, vote, and enlist in the military). As The New York Times points out, the city will soon have the strictest limits in the country on purchasing cigarettes, including of the electronic kind.

But this is familiar territory: Under Mayor Michael Bloomberg, New York was also an unabashed frontrunner in banning smoking in bars, restaurants, public parks, beaches, and pedestrian plazas, in trying to post graphic warnings on cigarette displays, and in hiking taxes to discourage buyers. And that's just the smoking front of what's been the most aggressive public-health campaign of any sitting U.S. mayor. In the last decade, New York has also banned excessive trans fats in commercial food, pushed calorie labeling on restaurant menus, and – most recently and infamously – attempted to outlaw giant, sugary sodas.

If you need a score card to keep up, we actually found one here, from the Georgetown Law School's O'Neill Institute.

Every one of these tactics has been hotly contested, along some common themes. The science is inconclusive. The city is infringing on personal freedom. Bloomberg himself has become an excessive meddler. His initiatives open the door to even greater government intrusion. And these reforms trample the rights not just of residents and consumers and low-income minority communities, but also of the companies that sell products to them.

Now, as a counterpoint, here is a radically different argument: Bloomberg has been a pioneer of a new kind of public health that aims at the risk factors for lifestyle-related diseases that are now a greater threat in the U.S. than infectious ones. We're no longer worried about cholera or dysentery. We're worried about obesity and heart disease. Those past public-health challenges demanded that we build sanitary water supplies in big cities, and institutionalize trash pick-up. What if today's challenges instead require curbing calories and building bike lanes (another Bloomberg health legacy)?

This is the argument of Lawrence O. Gostin, a bioethicist and Georgetown professor who's written a methodical (and well-timed) take-down of Bloomberg's critics in the Hastings Center Report, a journal on the ethical, legal and social sides of medicine and health.

All of the objections to Bloomberg's policies, Gostin writes, "are the antithesis of the public health approach, which urges government to act in the face of enduring injury and disease."

To pick apart some of those objections, here is Gostin on the idea that the science is "inconclusive" on how effective policies like smoking bans will be:

Science seldom reaches universal agreement, of course, least of all on the causation of complex, mul-tifactorial diseases. Rarely are policy-makers in other domains expected to demonstrate a certainty, or even a high probability, of “success.” In most policy spheres, such as economic policy, we understand that causal relationships are difficult to demonstrate, but critics often demand it of public health.

Critics also demand, he writes, that each policy be proven in isolation, while the more "rational" question is whether these tactics have a good chance of working in concert. Smoking rates in New York City have dropped significantly in the last decade (from 21.5 percent to 14.8 percent among adults), but it's difficult, for example, to pinpoint how much of that drop is attributable to higher taxes or the smoking ban. And society can't know what works, Gostin says, until ideas are tested.

As for the criticism that these policies are paternalistic:

Bloomberg's policies are not all that intrusive, and certainly not as burdensome as the underlying diseases. Policies to promote good nutrition and physical activity and control the use of tobacco are not morally equivalent to quarantines or forced treatment. Often, they represent nothing more than a return to the social norms of the recent past—such as smaller food portions and more livable spaces.

Nor does he buy that they infringe on personal freedom:

The underlying point here is that personal choice is always conditioned by social circumstances in various ways. The public health approach rejects the idea that there is such a thing as unfettered free will, recognizing instead that the built environment, social networks, marketing, and a range of situational cues drive complex behaviors. There are reasons, beyond personal responsibility, that health outcomes skew drastically by socioeconomic status. The job of public health is to make healthy living the easier choice.

Gostin's core contention co-opts the language of Bloomberg's critics: "The opportunity for a healthy life is the primary freedom," he writes, "as it underwrites so many of life's options."

This idea is unlikely to sway civil libertarians (whose objections are more interesting than those that come from corporations). But Gostin's salvo is built on an intriguing premise: that the end of Bloomberg's term actually marks the beginning of a new paradigm in public health. In other words, the debate over what defines "freedom" here – freedom from illness, or freedom to eat, drink and smoke what we choose – doesn't die down with Bloomberg's departure. Maybe it's just beginning, as the necessary next step in a shifting climate of how we get sick.

Top image:  Carlo Allegri/Reuters

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