The Robert Wood Johnson Foundation (RWJF) has committed $500 million to reverse the childhood obesity epidemic by 2015. To accomplish this ambitious goal, RWJF and its partners have developed a movement to tackle childhood obesity as a societal problem, calling for population-based solutions. The movement is borrowing from the "social norm change" approach that has yielded tremendous public health gains in tobacco control. The goal of a social norm change movement is to influence behavior indirectly by creating a social environment and legal climate in which harmful products and conduct become less desirable, acceptable, and attainable. This article explains the social norm change approach that has driven the highly effective tobacco control movement in California, highlights a unique role that lawyers have played in this approach, and describes how lawyers are preparing to play a similar part in the movement to prevent childhood obesity.
Policy makers and advocates hold up the California Tobacco Control Program (CTCP) as a model public health campaign. In November 1988, California voters approved Proposition 99, the Tobacco Tax and Health Protection Act. This landmark legislation imposed a cigarette tax of 25 cents per pack, established the CTCP in the state health department, and earmarked 20% of the new revenues for state and local programs aimed at reducing tobacco use (
In the ensuing 20 years, California has emerged as an international leader in tobacco control. The state achieved a 38% reduction in adult smoking rates between 1988 and 2006: from 22.7% to 14.0% (
We explain the social norm change approach that drives the CTCP and highlight the special role that lawyers have played in this approach to support a wide array of allies in the tobacco control movement. We further describe how lawyers are preparing to play a similar part in the movement to prevent childhood obesity.
The goal of its social norm change approach, according to the CTCP, is to indirectly influence "current and potential future tobacco users" by creating an environment in which "tobacco becomes less desirable, less acceptable, and less accessible" (
The Centers for Disease Control and Prevention (CDC) endorsed the California social norm change approach in its 2007 report,
State and community interventions, including the adoption of laws, that influence societal organizations, systems, and networks and that encourage individuals to make behavior choices consistent with tobacco-free norms.
Health communication interventions that "deliver strategic, culturally appropriate, and high-impact messages in sustained . . . campaigns."
Cessation interventions provided by individual health care providers and quit lines.
Surveillance and evaluation that monitor "tobacco-related attitudes, behaviors, and health outcomes at regular intervals."
Substantial funding, sound fiscal management, and robust capacity within a state health department.
CDC recognizes that adopting and implementing state and local laws are essential to a social norm change approach. Laws not only mandate what is allowable but also influence what is socially desirable, acceptable, and accessible. In California, tobacco control laws have been a key factor in the campaign to denormalize smoking and other tobacco use. Proposition 99 decreased smoking rates in California in 2 ways: it deterred consumption through tax-driven price increases on tobacco products, and it earmarked 20% of the state tax for tobacco control programs (
Lawyers have played a role in many public health campaigns — from gun control (
In 1997, the CTCP founded the Technical Assistance Legal Center (TALC) as a legal resource for the tobacco control movement in California. TALC does not represent clients, bring lawsuits, or negotiate deals. Instead, TALC provides legal technical assistance to community organizations, local and state health department employees, government attorneys, elected officials and their staff, and others working to denormalize tobacco use through state and local legislation. TALC does not drive the agenda. Rather, it follows the lead of grassroots stakeholders and statewide opinion leaders — identifying and addressing legal issues that arise from their policy goals and their experience developing and implementing these goals.
TALC developed a legal technical assistance model that it has tested and refined for more than a decade. This model breaks down into 5 related parts: conducting legal research and writing, developing model ordinances and policies, creating user-friendly tools, providing training, and offering one-on-one legal technical assistance.
The first part of TALC's model involves conducting in-depth research on the law that applies to potential tobacco control policies. For instance, in the 1990s, a main focus of local tobacco control policy in California was restricting storefront advertising. But the 2001 US Supreme Court case of
Second, TALC develops model ordinances for local governments to adopt (and model policies for institutions to adopt) to supplement existing state law and help advocates push the tobacco control agenda forward from the grassroots level. A classic example is TALC's model local tobacco retailer licensing ordinance (
TALC lawyers realized early on that although government attorneys appreciate the depth and technicality of TALC's model ordinances, nonlawyer stakeholders want concise and accessible print resources that highlight available legal and policy options. The third part of TALC's legal technical assistance model involves creating practical tools — including fact sheets on specific legal topics, checklists representing the key components of TALC model ordinances, how-to memos, and a booklet summarizing the tobacco-related laws that affect California; examples are available at http://talc.phi.org. TALC produces these tools with the assistance of graphic designers so that they are visually appealing and memorable to readers.
The fourth part of TALC's legal technical assistance model entails offering group training for its model ordinances and tools. TALC hosts its own teleconference and in-person trainings, and TALC attorneys speak at dozens of conferences each year. In a typical TALC presentation, the speaker walks the audience through a given model ordinance and its accompanying tools and shares lessons learned about what has been effective in the field.
Finally, TALC attorneys are available to provide direct technical assistance to stakeholders who write or call. Requests for technical assistance from advocates and others range from basic questions about, for example, the legality of an ordinance banning tobacco billboards in a locality to more in-depth requests for help tailoring a model ordinance to the needs of a given community.
Through TALC's 5-part model of legal technical assistance, public health attorneys have strengthened the capacity of stakeholders in the California tobacco control movement to use the law to create social norm change in their communities.
In 2007, the Robert Wood Johnson Foundation (RWJF) announced a $500 million commitment to reverse the childhood obesity epidemic by 2015 (
To inform the design of NPLAN, PHLP conducted a needs assessment that included more than 100 in-person and telephone interviews and a survey completed by 2,300 stakeholders from sectors and disciplines dealing with nutrition and physical activity (
The tobacco control movement is engaged in a focused campaign against the use of a single product that is addictive and is categorically harmful when used as intended (
The tobacco control movement gained traction from highlighting the negative effects of secondhand smoke on innocent bystanders (
The state of the science is another major difference between the 2 movements. Tobacco researchers have generated research findings on nicotine pharmacology, the health effects of tobacco smoke, the economic and marketing tactics of the tobacco industry, and the effectiveness of different policy interventions (
An additional distinction relates to the perception of industry. Whereas tobacco control advocates have almost uniformly viewed industry as the enemy (
Finally, TALC provides legal technical assistance statewide to a strongly managed and synchronized campaign. NPLAN will offer legal technical assistance nationally to a movement that has yet to coalesce around an advocacy agenda. Many stakeholders in the childhood obesity prevention arena have to be convinced of the value of legal technical assistance in a social norm change campaign.
NPLAN's design takes into account the challenges identified in the needs assessment. Three "learning communities" constitute a core component of the NPLAN organization. Each learning community is made up of research scientists, community and school leaders, and policy experts from around the country, whom NPLAN convenes in monthly conference calls and regular in-person meetings. The learning communities are charged with collaborating on 1 of 3 policy goals: reducing junk food marketing to children, improving food choices and physical activity opportunities in the preschool through high school settings, and enhancing access to healthy food and physical activity in neighborhoods where children live. NPLAN's learning communities serve as a microcosm of the national childhood obesity prevention movement, providing forums to talk about the movement's priorities, opportunities, and constraints. Moreover, the learning communities help NPLAN attorneys anticipate and meet the movement's policy development needs, fostering accountability between NPLAN and the broader constituencies it is set up to serve. By bringing a range of perspectives to the table and creating new alliances, NPLAN's learning communities will drive policy innovation and ensure that all of NPLAN's resource materials are practical, responsive, current, and effective. NPLAN also has appointed an advisory board of national leaders in fields related to childhood obesity prevention to provide strategic guidance and oversight for the new network.
After a year of research and development in conjunction with the learning communities, NPLAN began providing legal technical assistance to the childhood obesity prevention movement in the fall of 2008. NPLAN operates using the basic 5-part model TALC developed in the context of the California tobacco control movement, as exemplified by NPLAN's work on model joint-use agreements. One of the policy priorities that emerged from the needs assessment is to open up school facilities for after-hours recreational use by children and their families, especially in low-income communities that lack safe places to play. NPLAN produced 2 research articles relating to this issue: an in-depth 50-state analysis of tort law that applies to after-hours recreational use of school facilities (aimed at allaying school officials' concerns about liability in the case of injuries) (
NPLAN is creating similar types of resources to support a range of policy goals. These resources include promoting farmers' markets, community gardens, and healthy mobile vending; requiring fast-food restaurants to post calorie information on menu boards; encouraging schools and other public facilities to have vending contracts for healthy food and beverages; limiting junk food advertising on public school campuses; promoting Complete Streets (which provide safe transportation by ensuring a network of sidewalks, bike lanes, and public transit features); and setting physical activity standards for child-care centers.
It is too early to reach any conclusions about NPLAN's success. NPLAN has engaged an evaluator to conduct evaluations on use and outcomes by using qualitative and quantitative methods to measure indicators of NPLAN's progress toward its goal of empowering stakeholders to support policy innovation and implementation to prevent childhood obesity. Ultimately, the evaluator will provide analytic feedback for the formative development of NPLAN products and services.
Given the severity of the childhood obesity epidemic in the United States, reversing the epidemic is a challenge that requires a comprehensive social norm change approach. As communities across the nation consider new policies that support healthy eating and physical activity, access to sound, practical legal resources will be essential. By empowering stakeholders to use legal approaches to achieve their aims, NPLAN will be an integral part of RWJF's historic and ambitious effort to reverse the obesity epidemic by 2015.
This article highlights ideas generated at the Symposium on Epidemiologic, Ethical, and Anthropologic Issues in Childhood Overweight and Obesity, sponsored by the Robert Wood Johnson Foundation and the Health Promotion Research Program, a project of the Windward Islands Research and Education Foundation, operated by faculty in the Department of Public Health and Preventive Medicine in the School of Medicine of Saint George's University, Saint George, Grenada.
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