How can legislation be used to promote public health?
The cases of smoking and road accidents
Two significantly unhealthy behaviours, namely smoking and reckless driving, are the cause of a considerable disease burden, which fell by 37% in Spain between the years 2000 and 2015. Certain legislative measures that were passed are, partly, responsible for this improvement in the health of Spaniards, but not all the measures were equal in their effectiveness. In contrast with partial regulation, the total regulation of smoke-free spaces had an immediate effect with many smokers cutting down their consumption or quitting. The effects of the driving licence points system on road accident mortality became noticeable with the 2007 reform of the Criminal Code on road safety issues. To legislate effectively against smoking and in favour of road safety, policies based on “nudges” are not sufficient. The effect of the partial laws was weak; only total restriction led to success.
In recent years, one of the problems causing the greatest concern among health economists is ascertaining the most effective form of tackling the disease burden caused by unhealthy behaviours. Many diseases and illnesses that we suffer could be avoided by changing our individual behaviours. Such illnesses are associated with modifiable or preventable high-risk behaviours such as, for example, smoking and reckless driving, which are the subject of analysis in this study. Smoking and reckless driving have very high economic costs, since they consume resources that could be used for other purposes. For this reason, the comparative result of effective action against such behaviours is much higher than that of many other interventions.
According to data from the Institute for Health Metrics Evaluation (IHME), some 25 thousand disability-adjusted life years (DALYs) were lost for every 100 thousand inhabitants in the year 2000 in Spain. The DALY summarises in a single indicator health-related time and quality of life. Losing a DALY is equivalent to losing one year of life in full health (for a review of the methodology and calculation of DALYs we recommend the work of Fox-Rushby and Hanson, 2001). Of the total of all health problems, 15 major groups accumulated 87% of the DALYs lost: first position went to cardiovascular disease, followed by neoplasms (tumours formed by the multiplication or abnormal growth of cells), and mental disorders and substance abuse (graph 1). In tenth position was transport injuries: 4.03% of the total disease burden for the country in that year.
Smoking and driving recklessly or under the effects of alcohol or drugs were directly responsible for the loss of health in many of these illnesses: 14% and 3.41% respectively of the total DALYs lost. For example, in the year 2000, smoking, both active and passive, was considered responsible for 31.19% of the DALYs lost due to neoplasms; 19.65% of those lost due to cardiovascular disease; 43.55% in the case of chronic respiratory disease and a lower percentage for other diseases.
Reckless driving or driving under the influence of alcohol and/or drugs was responsible for 70% of the 739.24 DALYs per 100 thousand inhabitants lost due to transport injuries. So in the year 2000, smoking and reckless driving constituted a public health problem of the highest order in Spain.
2. A short review of the legislative background: from nudge to restriction
If health problems are the result of the surrounding environment, an idea referred to in epidemiology as the social determinants of health, then the responsibility is public. This is the reason behind the decision by the public powers to act by developing different legislative measures in the form of public health policies.
In Spain, legislative activity relating to smoking and road safety issues shows a certain similarity in the process of regulation of these high-risk behaviours. In early 2000, the first measures opted to suggest minor changes in people’s behaviour by trying to correct cognitive biases, but without introducing too many prohibitions and with little punitive action. For example, in the case of smoking, health warnings were incorporated onto labels, advertising and promotion were prohibited and the partial regulation of smoking in public places was implemented (Law 28/2005). In road safety matters, TV campaigns were launched showing harrowing traffic accidents and the driving licence system involving loss of points due to traffic violations was implemented, but with administrative sanctions only (Law 17/2005).
From the viewpoint of behavioural economics, the measures described above preserved freedom of choice, while promoting a more favourable option in health terms. It is what is known as the slight push or “nudge”, a gentle poke intended to remind or mildly warn someone (Thaler and Sunstein, 2008).
Five years and two years later respectively, a new intervention was passed, less ambiguous in its definition and more coercive in sanctions for non-compliance, with a total restriction of smoking in closed public spaces (Law 42/2010) and all reckless driving conducts being classified as criminal offences (Law 15/2007).
The intention of this study is to identify the different impacts that the legislative measures passed over the course of the fifteen-year-period from 2000-2015 on smoking and road safety, prohibitive measures and partial or total regulation, have had on changes in individual behaviours among Spaniards. The aim, therefore, is to compare nudges to restrictions.
3. Evaluation of the effectiveness of the legislative measures
Contrasting the effectiveness of the legislative measures requires knowledge of the causal relationships between interventions and the results attributable to them. The type of methodology used depends mainly on the data generated or available and the purpose of the research.
This study uses the data from two key indicators to measure the effectiveness of the legislative measures considered in relation to smoking and road safety: tobacco sales and road accident deaths on inter-urban routes. With regard to tobacco sales, the data correspond to the monthly series (between January 2000 and December 2015) of sales of manufactured cigarettes and rolling tobacco published by the Tobacco Market Commission of the Spanish Treasury, for the Spanish mainland and the Balearic Islands. The data on road accident mortality rates (with the same monthly periodicity, from January 2000 to December 2015) are published by the Spanish Traffic Agency (Dirección General de Tráfico).
The analysis of the changes, within the respective time series, before and after the entry into force of each piece of legislation, makes it possible to assess whether the intervention has had a significant impact. In cases where there has been an impact, one would expect a change in the series tendency or a jump, either upwards or downwards, between the observations prior to and subsequent to the intervention.
With regard to laws on smoking, it is seen that sales of cigarettes declined considerably between 2000 and 2015. Graph 2 shows that the first intervention (Law 28/2005) did not have a significant effect on the change in the series level, registering only a change in tendency, which acquires a negative slope: cigarette sales start to fall. The entry into force of Law 42/2010 causes a change in series level, which represents a sharp fall of 9.41% in cigarette sales, but without significant changes in the evolution of the tendency.
With the aim of ordering the effects of the main variables influencing the variation in cigarette sales by importance, graph 3 shows the weight or percentage of the explanation for each of these in the variability of sales over the course of the period analysed. The most important variable corresponds to the entry into force of Law 42/2010, which explains 16.55% of the variation in sales, whereas the first intervention (Law 28/2005) explains only 6.81% of the change. Next, changes in the minimum tax provide an explanation for 14.85%, followed by seasonality and tendencies of the series, at 14.16% and 13.93% respectively. It should not be forgotten that cigarette sales are highly seasonal, with significant peaks in December and in the summer months, due to greater leisure time and sales to tourists. Also, the higher the tax burden the higher the price, a fact which, combined with a reduction in disposable income, has a negative effect on cigarette sales.
In relation with the possible effect of road safety laws over the course of the period analysed, it is seen that mortality due to road traffic accidents has declined year after year. In accordance with the adjustment shown in graph 4, the entry into force of the driving licence points system does not significantly affect the behaviour of the series, neither accelerating nor slowing down the reduction in mortality; the changes appear two years later. The reform of the Penal Code that entered into force in December 2007 caused a sharp reduction, with a change of level which, deducted from the tendency of the series itself, stands at 14% of mortality due to road traffic accidents.
In the road safety model, the variable analysed (deaths due to road traffic accidents) is adjusted according to number of vehicles registered; furthermore, the following control variables are incorporated into the series tendency: seasonal variations and changes in fuel prices and in the average disposable income of Spanish families.
The percentage of explanation of each variable is shown in graph 5. The most important variable, with 24.63% of explanation of the variance in the mortality rate due to road traffic accidents, is the series tendency, an effect that is confused with the entry into force of the licence points system. The Spanish population appears to be increasingly aware regarding traffic and road safety issues, which is expressed as a continual decline in mortality. However, there continue to be deaths, mainly in the summer months, due to the increase in the number of road journeys. Seasonality explains 17.63% of the changes in the mortality rate. Also bearing relation to the volume of road journeys are changes in fuel prices and in family incomes. The higher the price of fuel or the lower the family income, the lower the number of road journeys taken. The changes in these two variables explain 10.58% and 10.26%, respectively, of the variance. Finally, the reform of the Penal Code of 2007 explains 13.34% of the fall in mortality due to road traffic accidents in the period analysed.
In 2015, according to data from the IHME, smoking was responsible for 9.63% of the total disease burden in Spain, while driving recklessly or under the effects of alcohol and drugs was responsible for 1.09%. In relation with data from the year 2000, in 2015 some 1,400 disability-adjusted life years per 100 thousand inhabitants were no longer lost due to these two high-risk behaviours. The disease burden resulting from these behaviours was reduced by 37%. The legislative measures passed between 2000 and 2015 for the prevention and control of smoking, and to guarantee road safety are, in part, responsible for this improvement in the health of Spanish people.
The regulation of smoke-free spaces without exception ensured that many smokers found an incentive to reduce or quit their cigarette consumption, as the existence of smoke-free environments contributes noticeably to the quitting process (Farkas et al., 1999). Furthermore, as the number of adult smokers diminishes and smoke-free spaces grow, the social perception of smoking also changes among minors. Ultimately, it is question of time available: the cigarettes that cannot be smoked at the workplace or during leisure times, due to smoke-free bars and restaurants, are difficult to make up for at other times. A lack of occasions to smoke makes consumption decline.
In road safety matters, penalising the violation of traffic regulations increases social awareness regarding the importance of responsible driving. However, this penalisation only achieves changes in behaviours when accompanied by a deterrent sentence. The entry into force of the driving licence points system in 2005 represented a turning point with regard to the penalty system. However, the measure did not start to see results until accompanied by a real and effective penalisation of violations. With the reform of the Penal Code in 2007, the number of prosecution proceedings due to road safety offences increased considerably, from 37,697 court proceedings in 2006 to 43,926 in 2007 and 87,755 in 2008, stabilising at around 110,000 from 2010 onwards (Spanish Attorney General’s Office, 2015). The reform of the Penal Code came into force in December 2007. It is not just a case of a punishment for the violation committed but also to prevent, while the sentence lasts, the offender from re-offending. Following the 2007 reform, the number of penalties involving loss of driving licence increased by 115%.
Today, in many Western countries healthcare policies are emerging based on “nudges”, a form of non-obtrusive paternalism in which alternatives are not blocked. The Spanish experience in legislative measures against smoking and road safety offers an example of how this route is not sufficient for these two high-risk behaviours. In the short term, the policies lost their initial impact. The partial regulation of smoke-free spaces and a driving licence points system, with only administrative penalisation of violations, did not generate sufficient incentives for citizens to understand the nudge and change their behaviour.
Years later, this prior failure forced the modification of the initial laws in order to adopt a more coercive perspective, with the total prohibition of smoking in closed public spaces and the sanctioning via criminal proceedings of behaviours that previously only merited administrative sanctions, such as driving above certain speed limits or certain blood alcohol levels. The new laws were not in fact justified by convincing the individual that it is for his or her own good, but by the reduction in conditions that are expensive for the healthcare system and, in general, cause a deterioration in the population’s health. Partial laws had a weak effect; only total restriction worked successfully.
Comisionado para el Mercado de Tabacos (2000-2015): Ventas de cigarrillos manufacturados y picadura de liar.
Dirección General de Tráfico (2000-2015): Mortalidad por accidentes de tráfico.
Fiscalía General del Estado (2015): Memoria Anual.
Fox-Rushby, J. y K. Hanson (2001): «Calculating and presenting disability adjusted life years (DALYs) in cost-effectiveness analysis». Health Policy Plan. 16(3): 326–331.
Institute for Health Metrics Evaluation. http://ghdx.healthdata.org/gbd-results-tool
Thaler, R. H., y C. R. Sunstein (2008): Nudge: Improving decisions about health, wealth, and happiness, New Haven, Conn.: Yale University Press.
Farkas, A.J., E.A. Gilpin, J. Distefan y J. Pierce (1999): «The effects of household and workplace smoking restrictions on quitting behaviours». Tobacco Control. 8: 261-265.