Effective
The Problem:
Illicit drug use is a well-recognized public health problem. Overdose and other less acute harms are associated with the non-medical use of controlled substances. The policy response to illicit drug use in the United States has historically focused on a punitive model. Resulting high rates of incarceration have placed large numbers of non-violent offenders into correctional facilities. Life in prison exposes inmates to numerous health risks. High incarceration rates also strain families and communities particularly in areas already suffering from harms associated with low socioeconomic status. As a result, both illicit drug use and the prevailing policy response aimed at reducing it are sources of harm to population health. Reducing incarceration for non-violent crime – the majority of which involves use and trafficking of small amounts of illicit drugs – is widely recognized as an important policy objective. Congressional Research Service, GAO: Drug Courts.
The Law:
In response to growing evidence of the public health burden of over-criminalization and the failure of the traditional punitive approach to stem illicit drug activity, in the late 1980s, states and localities started experimenting with models aimed more at rehabilitation than retribution. Representing one form of what is often referred to as therapeutic justice, drugs courts emerged as a new model for dealing with minor drug-related crimes. These specialized courts aim to divert convicted drug-offenders into treatment rather than incarceration. Between 1989 and 2009, well over 2000 drugs courts were created in the United States. U.S. Department of Justice. Many drug courts are created though judicial rulemaking. Examples of laws creating drug courts can be found in Mississippi (M.S. Code § 9-23 et seq) and Illinois (730 ILCS 166.1 et seq).
The Evidence:
Wilson, et al., systematically reviewed studies assessing the effect of drug courts on recidivism. David B. Wilson, Ojmarrh Mitchell, And Doris L. Mackenzie, A systematic review of drug court effects on recidivism, Journal of Experimental Criminology (2006) 2:459Y487. The reviewers identified fifty studies that fit their inclusion criteria. Using meta-analytic techniques, the reviewers combined odds-ratios across the studies in a random effects model. The overall summary odds ratio – which was statistically significant – was 1.62. The reviewers’ interpretation of the results from the summary statistic and other correlates in the regression was that recidivism decreased by 26% for offenders in drug courts versus comparison groups. However, methodological weaknesses in the majority of the included studies were noted as a source of caution against this figure. A more conservative estimate of the effect was found when they limited their review to more methodologically sophisticated studies. Overall, however, the authors view the evidence as sufficient to support the effectiveness of drug courts in reducing recidivism.
The Bottom Line:
According to the authors of a peer-reviewed systematic review, there is sufficient evidence to support the effectiveness drug courts in reducing recidivism among individuals convicted of drug-related offenses.
The Problem:
Sexual abuse is a big public health problem. Every year, there are about 90,000 rapes. U.S. Department of Justice, Federal Bureau of Investigation. Victims of sexual abuse suffer extensive physical and emotional harms; the long term sequelae of sexual abuse are associated with a number of health risk factors later in life. Beitchman et al, A Review of the Long-term Effects of Child Sexual Abuse, Child Abuse & Neglect 1992; 16(1): 101-118. A significant portion of sexual crimes are committed by juveniles; research indicates that as much as 80% of adult sexual offenders committed sexual crimes as juveniles. Groth et al, Undetected recidivism among rapists, and child molesters. Crime and Delinquency, 1982; 128: 450-458. This suggests that treatment and rehabilitation of juvenile sexual offenders (JSOs) is important to reducing sexual violence. In 2008, 14,500 children were arrested for sexual offenses not including rape; 3340 children were arrested for rape. U.S. Department of Justice, Office of Juvenile Justice0. Rehabilitation is the primary aim of juvenile criminal justice systems in the United States. However, high rates of recidivism in sexual crimes and the high proportion of sexual crimes committed between juvenile family members challenge policies that otherwise seek to minimize the time that juvenile offenders spend in correctional custody. In this context, JSOs often fail to receive treatment addressing the bio-psychosocial causes of offending.
The Law:
Mandatory treatment is often required as a condition of adjudications or plea bargains for juveniles charged with sexual crimes. The court system presents, in this respect, an important source of leverage for forcing sexual offenders into treatment. Probation and sentencing contingencies may be used to increase compliance with mandated treatment. All judges have discretionary authority to order participation in treatment programs for minors in adjudications involving sexual crimes. Some states mandate treatment in specialized programs for juvenile sexual offenders (Kentucky, KRS 635.515 (1), Alabama, Ala. Code 15-20-27).
The Evidence:
Reiztel and Carbonell conducted a systematic review and meta-analysis of studies evaluating the effectiveness of juvenile sexual offender treatment programs. Lorraine R. Reitzel and Joyce L. Carbonell, The Effectiveness of Sexual Offender Treatment for Juveniles as Measured by Recidivism: A Meta-analysis, Sex Abuse (2006) 18:401–421. Only studies comparing recidivism among groups receiving and not receiving treatment were included; random placement into treatment and control groups was not required. Nine studies satisfied the inclusion criteria. Using a fixed effects meta-analysis of odds ratios across the studies, the reviewers found a statistically significant 0.43 effect size suggesting a sizable protective relationship between treatment and recidivism: for every 43 offenders in the treatment group that recidivate, 100 in the control group do so. Simple un-weighted average recidivism rates between the treatment group (7.37%) and the control group (18.93%) were substantially different. Though cautioning that the treated and untreated groups may have varied in systematic ways, the authors viewed the nine studies as sufficient evidence to conclude that treatment is effective in reducing recidivism.
The Bottom Line:
According to the authors of a peer-reviewed meta-analysis, there is sufficient evidence to support the effectiveness of laws requiring treatment for juvenile sexual offenders in reducing recidivism.
The Problem:
Tobacco use is a source of chronic and fatal illnesses for users and persons with secondary exposure. In the United States, cigarette smoking contributes to one in five deaths and costs more than $193 billion in annual lost productivity and healthcare expenditures. CDC: Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004. Initiation of smoking and other tobacco use generally starts in adolescence; more than 80% of adult smokers started smoking as young children or teenagers. CDC: Youth Tobacco Use Fact Sheet.
The Law:
Pursuant to the 1997 federal “Synar law” states must prohibit the sale of tobacco products to children and take steps to ensure effective enforcement. 42U.S.C. 300x-26, 45 C.F.R. 96.130. States and localities have adopted numerous legal interventions to increase compliance with this prohibition. For example, some states prohibit the handling of tobacco products by minors working in retail and require posting of signs explicitly prohibiting sale of tobacco products to minors (Oklahoma, 37 O.S. §600.1-§600.12). Under age purchasers of tobacco face fines and community service (Washington, RCW 70.155.080). To increase compliance with youth access laws, localities and states also conduct compliance investigations (Missouri: Restricting Youth Access to Tobacco).
The Evidence:
Stead and Lancaster systematically reviewed studies assessing the effect of laws restricting youth access to tobacco and interventions aimed at increasing compliance with youth access laws. Lindsay F Stead and Tim Lancaster. A systematic review of interventions for preventing tobacco sales to minors. Tob Control 2000 9: 169-176. The reviewers identified 27 studies that fit their criteria of employing either experimental or observational designs with data both before and after the adoption of a law or compliance intervention. The studied laws included requirements for compliance checks; the evaluated interventions included experiments with compliance checks and education campaigns with retailers about fines and enforcement of youth access laws. Most of the included studies found reductions in prevalence of smoking among youths or decreases in reported ease of purchasing tobacco for minors. Although the reviewers were cautious because of methodological limitations in the studies such as the inability to control for potentially confounding effects from other youth smoking prevention programs and the possibility that effects wane over time, they view the collective body of studies as sufficient evidence to conclude that laws restricting youth access and interventions aimed at increasing compliance do indeed reduce access to tobacco for minors. The reviewers observed that greater levels of compliance activity – such as personal visits to retailers – were more likely to result in greater reductions in smoking or access.
The Bottom Line:
According to the authors of a peer-reviewed systematic review, there is sufficient evidence to support the effectiveness of youth access laws and interventions aimed at increasing compliance as a means of decreasing access to tobacco for minors.
The Problem:
Firearms are the second leading cause of injury and deaths in the United States, accounting for 30,896 deaths and 71,417 injuries in 2006. More than 80 percent of teen homicides and almost half of teen suicides involved a gun in 2005. CDC: WISQUARS. More than half of all homicides involve a gun. U.S. Department of Justice: Crime Statistics.
The Law:
Much of the burden of gun violence and accidental gun injuries falls upon localities. As a result, localities have been at the vanguard of efforts to find new legal approaches to reducing the harms of unsafe gun practices. Some of these strategies – like local bans on gun possession and efforts to regulate gun retailers under public nuisance laws – have been overturned by courts. As a result, few localities in the United States currently have the authority to pass gun control legislation that address gun safety. Localities do, however, have significant latitude in how they enforce existing gun control laws. Law enforcement strategies for reducing the illegal possession of guns include directed patrols aimed at uncovering and deterring illegal gun possession in specific high risk areas.
The Evidence:
Koper and Mayo-Wilson systematically reviewed 4 studies that assessed the impact of directed patrol law enforcement strategies for decreasing gun-related crimes. Koper & Mayo-Wilson. Police crackdowns on illegal gun carrying: a systematic review of their impact on gun crime. Journal of Experimental Criminology 2006; 2:227-261. The four studies reported on a total of 7 nonrandomized tests. In 6 of the tests, directed patrols were associated with reductions in firearm crimes. Notwithstanding the small number of studies and limited study designs, the authors interpreted the review findings as evidence that directed patrols reduced gun crime in high-crime areas.
The Bottom Line:
According the authors of a peer-reviewed systematic review, there is strong evidence supporting the effectiveness of directed patrols as an intervention aimed at reducing gun-related crime in high risk areas.
The Problem:
In 2006, approximately two-thirds of adults and one-fifth of children in the United States were either overweight or obese. Each condition increases the risk of heart disease, diabetes, stroke, and some cancers. Kahn LK, et al. Recommended community strategies and measurements to prevent obesity in the United States. MMWR 2009;58(RR-07):1-26. Regular physical activity reduces the risk of obesity and has many other health benefits. Yet, only 25 percent of adults in the United States get the recommended amount of physical activity. CDC. Community interventions to promote healthy social environments: early childhood development and family housing. MMWR 2002;51 (RR-1):1-8.
The Law:
Some local governments have attempted to promote exercise at the community level through careful modifications to zoning regulations and building codes. These efforts involve, for example, locating commercial stores, places of work, or schools within walking distance of residential communities to facilitate commuting by foot or bicycle. For example, a Sacramento Ordinance available at the California Healthy Eating Active Living Cities Campaign sets out zoning standards to ensure that streets provide ample space for walking and bicycling. The National Policy and Legal Analysis Network to Prevent Childhood Obesity (NPLAN) has created model “complete street” state laws and ordinances, which are aimed at creating safe environments for walking, jogging and other non-vehicle commuting.
The Evidence:
Heath et al. reviewed 12 studies that measured the impact of community-scale urban design and land use policies on levels of physical activity. Heath G, et al. The effectiveness of urban design and land use and transport policies and practices to increase physical activity: a systematic review. Journal of Physical Activity and Health. 2006;3 (Suppl 1):S55-S76. The authors limited their review to studies that focused on physical activity outcomes, measured by incidence of walking or biking for transportation as well as overall physical activity and outdoor active play. The reviewers found evidence that community level urban design and land-use policies increase physical activity. Across all studies, there was a 161 percent median improvement in at least one measure of physical activity (e.g., number of walkers or bicyclists).
The Bottom Line:
According to a Community Guide expert panel, there is considerable evidence supporting the effectiveness of community-scale urban design and land use policies as public health interventions to promote physical activity.
Additional Information:
For a short summary of research related to the importance of designing communities to promote health, refer to this research brief by Active Living Research (ALR).
The Problem:
Violence is a major public health problem. There were more than 5 million violent crimes in 2007, including 248,280 sexual assaults and 597,320 robberies. USDOJ: Criminal Victimization in the United States, 2007. There were 16,272 deaths from murder or non-negligent manslaughter in 2008. U.S. Bureau of Justice Statistics. In addition to directly causing acute injuries, emotional harm, and deaths, crime may undermine population health through indirect mechanisms. For example, high rates of crime make outdoor exercise unsafe, contributing to lower levels of physical activity. Crime also adds to the burden of stress for people living in high crime areas.
The Law:
The law prohibits violent crime, but implementation varies. “Hot spot policing” is a law enforcement strategy that focuses limited police resources on street corners, alleys or other places in a neighborhood where crime is particularly prevalent. For more information on hot spot policing, see U.S. Dept of Justice: Hot Spot Policing.
The Evidence:
Braga systematically reviewed nine studies that assess the impact of hot spot policing on crime. Braga. The effects of hot spots policing on crime. Campbell Systematic Review 2007:1. The studies evaluated three types of hot spot policing interventions: (1) enforcement of problem-oriented policing interventions; (2) directed and aggressive patrol programs; and (3) police crackdowns and raids. Of the nine studies, five employed randomized experimental designs and four employed quasi-experimental designs. Seven of the nine studies found hot spot policing to be associated with reductions in crime and disorder. A meta-analysis conducted on the five randomized studies found a statistically significant 67 percent reduction in reported calls for police assistance. There was not enough evidence to determine the relative effectiveness of the three different intervention types. Displacement of crime – a concern with hot spot policing – was examined in five of the studies. None of the studies observed a substantial displacement effect. However, Braga and the authors of the underlying studies caution that displacement is a difficult phenomenon to measure and that more sophisticated measures may be needed to fully assess whether displacement occurs. Braga interpreted the results of the meta-analysis of the five studies and the evidence in all nine studies collectively as “fairly robust evidence that hot spots policing is an effective crime prevention strategy.”
The Bottom Line:
According to the author of a Campbell Collaboration systematic review and meta-analysis, the current evidence supports the effectiveness of hot spots policing as a crime prevention strategy.
The Problem:
The maltreatment of children is a tragically common occurrence in the United States with a devastating impact on the health of young Americans. The direct effects of child maltreatment for victims include injuries and a host of stress-induced harms including poor psychological health, obesity, eating disorders and suicide. Child maltreatment also indirectly harms public health by creating generational cycles of abuse; a significant portion of victims of child abuse become child abusers. In 2007, there were 3.2 million cases of child abuse in the U.S. Centers for Disease Control: Child Maltreatment Fact Sheet. While primary prevention strategies focus on identifying risk factors to stop child abuse before it occurs, establishing secondary prevention methods to limit the harms of abuse is also of great importance.
The Law:
Kinship care is a legal arrangement in which a child welfare agency places a maltreated child under the direct care of a family member or family friend with a suitably extensive pre-existing relationship with the child. The Personal Responsibility and Work Opportunity Reconciliation Act (1996) required states to give preference to family members when placing a child outside the home. 42 U.S.C. 671(a)(19). More recently, the Adoption and Safe Families Act (1997) reaffirmed the federal commitment and support for kinship care. Although states have adopted slightly different definitions of family and kin, kinship care is widely preferred among jurisdictions. For examples of kinship laws, see CA Welf. & Inst. Code § 361.3 (California) and CO Rev. Stat. §§ 19-3-508; 19-3-605 (Colorado).
The Evidence:
In a study sponsored by the Campbell Collaborative and also published in the Cochrane Guide database, Winokour et al. performed a meta-analysis on 62 studies that evaluated the well-being of children placed in formal kinship care versus those placed in traditional foster homes. Winokour et al. Kinship care for the safety, permanency, and well-being of children removed from the home for maltreatment. The Campbell Collaboration. January 2009. Their analyses showed that children in kinship care have better mental health functioning, behavioral development and placement stability than children in non-kinship care. No differences were found in the rate of reunification with biological parents or in educational attainment. Children in non-kinship care also accessed mental health services and support groups slightly more than kinship care children, though it is unclear, according to Winokour et al., whether this benefit was the result of need or accessibility.
The Bottom Line:
According to a systematic review and meta-analysis sponsored by the Campbell Collaboration, kinship care placement produces better outcomes than non-kinship care for children that have been subject to maltreatment at home.
Additional Information:
The Children’s Bureau of the U.S. Department of Health and Human Services has compiled a guide on state kinship laws: Placement of Children with Relatives: Summary of State Laws.
The Problem:
Tobacco use is a source of chronic and fatal illnesses for users and persons with secondary exposure. In the United States, cigarette smoking contributes to one in five deaths and costs more than $193 billion annually in lost productivity and healthcare expenditures. CDC: Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004. It has been suggested that workplace smoking bans aid in smoking cessation efforts by changing how individuals view tobacco use. CDC: Smoke-Free Workplaces Reduce Smoking.
The Law:
Smoking bans and restrictions prohibit smoking in specified areas. These restrictions aim to eliminate or reduce exposure to secondhand smoke. Smoking bans and restrictions are found in state and local laws as well as regulations governing workplace safety. For examples of state smoking bans, see ARS 36-601.01 (Arizona), Utah Health Code § 26.83.3 (Utah), VT Health Code § 1742 (Vermont), and RI Health & Safety Code § 23-20.10-3 (Rhode Island).
The Evidence:
Fichtenberg and Glantz systematically reviewed and conducted a meta-analysis of 26 studies that assessed the impact of workplace smoking bans on tobacco consumption using a fixed effects meta-analysis. Fichtenberg & Glantz, Effect of smokefree workplaces on smoking behaviour: systematic review. BMJ 2002; 325: 188. The authors limited their analysis to primary studies that assessed the effect of total smoking bans, and excluded studies examining the effects of laws limiting smoking to specific areas. The 26 studies were conducted in Australia, Canada, the United States and Germany. Each of the included studies employed a cross-sectional design and measured both prevalence of cigarette smoking and quantity of cigarettes smoked before and after the introduction of a workplace smoking ban. Meta-analysis of the studies revealed a 3.8 percent reduction in prevalence of cigarette smokers and a reduction of 3.1 cigarettes a day per continuing smoker. The meta-analysis also found that the bans were associated with the consumption of 1.3 fewer cigarettes a day per employee.
The Bottom Line:
According to the authors of a peer-reviewed meta-analysis, there is substantial evidence that workplace smoking bans effectively reduce the prevalence of smoking, the quantity of cigarettes smoked, and exposure to second hand smoke.
Publication Date: 02/15/2011
The Problem:
Alcohol consumption is a risk factor for various public health harms. Impaired driving is one of the largest contributors to motor vehicle crashes. Each year in the United States roughly 13,400 people die and an additional 255,500 are injured in motor vehicle crashes involving an alcohol-impaired driver. In 2006, these crashes accounted for almost a third of all U.S. traffic-related deaths. CDC: Impaired Driving Factsheet. Alcohol consumption is also a risk factor for cancer and other chronic conditions such as cirrhosis.
The Law:
Tax law is a mechanism for reducing consumption of unhealthy products. Both the federal government and the states have used taxes as a means of increasing the cost of products associated with health risks. Taxes can be levied upon the production and or sale of alcohol. The former are often described as excise taxes. According to the Federation of Tax Administrators, almost every state taxes the sale or production of beer, liquor and wine. For examples of state laws taxing alcohol, see Ca Revenue & Taxation Code §§ 32201-32203 (California) and Pa Code §§ 74.1-74.21 (Pennsylvania).
The Evidence:
Wagenaar et al. systematically reviewed studies that assessed the relationship between alcohol prices, alcohol taxes, consumption, and sales. Wagenaar et al. Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies. Addiction 2009; 104(2): 179-190. The reviewers identified 112 studies that met their inclusion criteria. These studies contained 1003 estimates of the relationship – or elasticity – between price or tax amount and consumption of a specific type of alcohol. Wagenaar et al. calculated mean elasticities for specific kinds of alcohol and conducted a random effects meta-analysis on an entire collection of estimates. The mean elasticities for beer, wine and spirits were all negative and statistically significant, meaning that increases in price are associated with substantial decreases in consumption. The meta-analysis of all 1003 estimates revealed large inverse relationships between consumption and increases in taxes or prices for all types of alcohol.
The Bottom Line:
According to the authors of a peer-reviewed meta-analysis, taxes that increase the price of alcohol effectively reduce overall alcohol consumption.
Publication Date: 02/02/2011
The Problem:
Tobacco use is a source of chronic and fatal illnesses for users and persons with secondary exposure. In the United States, cigarette smoking contributes to one in five deaths and costs more than $193 billion annually in lost productivity and healthcare expenditures. CDC: Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004. Nearly 25 percent of annual deaths related to cardiovascular disease in the United States can be attributed to smoking and cigarette smokers are 2 to 3 times more likely to die from cardiovascular disease than non-smokers. CDC: The Health Consequences of Smoking. Complete Report. 2004
The Law:
Smoking bans and restrictions prohibit smoking in specified areas. These restrictions aim to eliminate or reduce exposure to secondhand smoke. Smoking bans and restrictions are found in state and local laws as well as regulations governing workplace safety. For examples of state smoking bans, see ARS 36-601.01 (Arizona), Utah Health Code § 26.83.3 (Utah), VT Health Code § 1742 (Vermont), and RI Health & Safety Code § 23-20.10-3 (Rhode Island).
The Evidence:
Meyers et al. performed a systematic review and meta-analysis of 11 studies that assessed the impact of public smoking bans (including workplaces) on the incidence of acute myocardial infarction (AMI) on the general population. Meyers et al. Cardiovascular effect of bans on smoking in public places: A systematic review and meta-analysis. J Am Coll Cardiol, 2009; 54:1249-1255. Studies were drawn from the United States, Canada, Italy, and Scotland. The authors used a random effects meta-analysis to control for differences in study population size and duration of observations. The meta-analysis found that public smoking bans reduce the risk of AMI by 17 percent, and this risk continues to decrease each year after ban implementation. Meyers et al. suggest that the duration of the post-ban effect may be explained by greater compliance to bans, decreased prevalence of smoking, improved air quality, and reduced environmental exposure to tobacco.
The Bottom Line:
According to a peer-reviewed systematic review and meta-analysis, substantial evidence suggests that public smoking bans effectively reduce the risk of acute myocardial infarction.
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Public Health Law Research is a national program of the Robert Wood Johnson Foundation. It is housed at the Temple University Beasley School of Law.