The U.S. Preventive Services Task Force recommends adults between the ages of 40 and 75 take a cholesterol-lowering statin drug to help prevent heart attacks and strokes if they are at risk of cardiovascular disease.

One in three Americans die of heart attacks or strokes. And those with no signs or symptoms, as well as no past history of cardiovascular disease, can still be at risk.

The independent panel of medical experts from around the nation said in a news release that statins could help those who have a risk factor for cardiovascular disease — such as high cholesterol or blood pressure, diabetes or those who smoke — and have at least a 7.5 percent risk of having a cardiovascular event in the next 10 years.

The task force also called for more research on the use of prescribing statins for children and adolescents who are at risk of heart disease.

The American Heart Association and American College of Cardiology have been recommending statins in adults for several years. The task force is now making a similar recommendation for primary prevention based on the latest clinical trials and research.

“The task force looked carefully at current data to identify who can benefit the most from taking statins,” said task force chair Albert L. Siu, MD, MSPH, who is also chair of the Ellen and Howard C. Katz Mount Sinai Health System.

“People with no signs, symptoms, or history of cardiovascular disease can still be at risk of heart attack or stroke,” said task force member Douglas K. Owens, MD, a Stanford professor of medicine and director of the Center for Health Policy and Center for Primary Care and Outcomes Research at Stanford Health Policy.

“Fortunately, for certain people at increased risk, statins can be very effective at preventing these events,” said Owens, who emphasizes that adults who fall into those risk and age groups must first consult with their physicians.

The task force said all adults could reduce their risk of cardiovascular disease by not smoking, eating a healthy diet, engaging in physical activity and limiting alcohol use. Managing high blood pressure and high cholesterol and taking aspirin when indicated can also help prevent heart attacks and strokes.

Based on the current evidence, the task force said, it is not yet clear whether taking statins is beneficial for people who are older than 75. But they did find the effectiveness of statins is the same for both men and women.

This is the first time the task force has changed its fundamental approach since 2008, when it recommended screening for abnormal amount of lipids in the blood. While screening remains key, most adults are now routinely screened as part of an overall cardiovascular risk assessment.

Therefore, the task force found the more relevant clinical question is no longer whom to screen for elevated cholesterol, but rather whom to treat with preventive medication once increased cardiovascular risk has been identified in an individual.

The Preventive Services Task Force also announced that there is not enough data and evidence to assess the balance of benefits and harms in screening for high cholesterol in children and adolescents up to age 20.

While some experts have recommended lipid screening in children and teens, the task force found that the evidence shows it’s difficult to predict which children who have high cholesterol will continue to have it as they age.

“There is currently not enough research to determine whether screening all average-risk children and adolescents without symptoms leads to better cardiovascular health in adulthood.” said Task Force Vice Chair David C. Grossman, MD, MPH. “In addition, the potential harms of long-term use of cholesterol-lowering medication by children and adolescents are not yet understood.”

The public can review the findings and comment on the task force website.

Other articles on the recommendation include:

The Associated Press

MedPage Today

Reuters

HealthDay

A new federal proposal would ban smoking in public housing homes — a move that could impact some 1.2 million households across the nation.

Cigarette smoking kills 480,000 Americans each year, making it the leading preventable cause of death in the United States, according to the Center for Disease Control and Prevention.

The Department of Housing and Urban Development announced last week that the proposal is intended to protect residents from secondhand smoke in their homes, common areas and administrative offices on public housing property.

“We have a responsibility to protect public housing residents from the harmful effects of secondhand smoke, especially the elderly and children who suffer from asthma and other respiratory diseases,” said HUD Secretary Julián Castro in a statement, adding the proposed rule would help public housing agencies save $153 million every year in health-care, repairs and preventable fires.

Stanford Law School professor Michelle Mello, who is also a professor of health research and policy and a core faculty member at Stanford Health Policy, has researched and written about this issue extensively, including in this article in The New England Journal of Medicine.

We asked Mello about her views on the federal smoking ban proposal.

What would be the greatest benefit to banning smoking in public housing?

There are lots of benefits, but to me the greatest benefit is to the 760,000 children living in public housing. Although everyone knows that secondhand smoke exposure is extremely toxic, not everyone knows how much children in multiunit housing are exposed — even when no one in their household smokes. Research shows that smoke travels along ducts, hallways, elevator shafts, and other passages, undercutting parents' efforts to maintain smoke-free homes. Also, chemicals from cigarette smoke linger in carpets and curtains, creating hazardous "third-hand smoke" exposure that especially affects babies and small children.

Do most public housing residents want a ban on smoking?

Yes. Exposure to cigarette smoke is a perennial complaint among public housing residents and surveys of residents show that strong majorities support smoke-free policies. They also show residents frequently report smoke incursions into their living spaces, and that these reports are much lower when multiunit housing buildings have 100 percent smoke-free policies than when they have only partial smoke-free policies or no policies. Secondhand smoke in public housing is also a problem because these residents have few housing choices; they generally can't "vote with their feet" by moving to a smoke-free environment.

Could this help tenants who don't have the political will, time, or financial ability, to sue landlords who ignore their claims of respiratory concerns?

Absolutely — not to mention that those lawsuits, even if they were brought, often would fail.  Generally, tenants' rights are whatever local housing codes and lease agreements say they are, and smoke-free buildings aren't typically part of that package. Smoke-free policies aren't a guarantee, of course, and there have been difficulties enforcing them among some of the local public housing authorities that have implemented them.  But when they're in place, housing authorities have more mechanisms and reason to ensure that residents are protected from smoke exposure than they do without the policies.

Many argue that what they do in their own home is their own business.

That argument fails as soon as a puff of smoke escapes their home and wafts into someone else's air supply.  It also fails whenever there's a dependent in the house, whether a child or an adult relative, who doesn't smoke. Let's not forget, nearly half of all public housing households include children. Finally, most smokers desire to quit. About 7 in 10 say they want to quit completely, and in one study, over 90 percent said they wished they had never started. When we're talking about an addiction, particularly one people generally want to kick, the trope of autonomy doesn't have a lot of traction.

There are those who will say this is another attack on low-income Americans — such as banning sugary drinks or limits to what people can buy with their food stamps — and that this smacks of government shaming the poor.

Although it's reasonable to question policies that disproportionately burden the poor, I don't think this is such a policy. The reason is that only a minority of public housing residents are smokers; most of these low-income residents are benefitted, not burdened, by smoke-free policies.  The majority are vulnerable people, including children and the elderly, who have a higher-than-average incidence of respiratory and other health problems — and who want to breathe clean air in and around their homes.

Could this proposal lead to fewer kids smoking that first cigarette?

Yes. Part of the "tobacco endgame" is to further denormalize smoking, to the point that the next generation of kids will not grow up seeing it as something adults do. This is a hard argument to make when a kid smells smoke every time he walks into the hallway of his building and sees groups of residents smoking on stoops. Smoking bans have really helped to marginalize smoking behavior in other settings, like airports, restaurants, hospitals and schools.  Multiunit housing is the next logical step.

Stanford students belong to the first generation that could witness the end of extreme global poverty — in what would be one of humankind's greatest achievements — the head of the World Bank said during a recent talk on campus.

But their generation, he said, is also likely to experience the first global pandemic since the 1918 influenza that killed more than 50 million people.

Jim Yong Kim, president of the World Bank, said innovations in health, education and finance are behind the World Bank's twin goals of ending extreme poverty and boosting shared prosperity for the bottom 40 percent of the global population.

Speaking at the inaugural conference of the Stanford Global Development and Poverty Initiative on Oct. 29, Kim lauded faculty and students for their multidisciplinary approach in tackling poverty and improving public health. He is an infectious disease physician who oversaw World Health Organization initiatives on HIV/AIDS.

"Seeking transformative solutions to challenges of development and poverty that are necessarily cross-disciplinary is exactly what a great university should be doing," Kim said in his speech at Stanford.

The World Bank announced last month that the number of people living on less than $1.90 a day is expected to drop to 9.6 percent of the global population by the end of the year. That is down from 36 percent in 1990.

The bank has pledged to cut that rate to 3 percent by 2030.

"We expect the extreme poverty rate to drop below 10 percent for the first time in human history," he said. "This is the best news in the world today. And this is the first generation in human history that has been able to see that potential outcome." 

Promoting prosperity

One of the co-founders of Partners in Health, Kim was the keynote speaker at the daylong conference, "Shared Prosperity and Health," which drew together Stanford faculty and researchers, plus government and NGO officials from around the world.

Stanford's global development and poverty effort is a university-wide initiative of the Stanford Institute for Innovation in Developing Economies, known as Stanford Seed, and the Freeman Spogli Institute for International Studies. The conference was held at Stanford's Graduate School of Business, which was a partner in the event.

Kim's talk was optimistic about the newly adopted U.N. Sustainable Development Goals, with an ambitious agenda to end poverty and hunger, ensure healthy lives, empower women and girls and attain quality education for all children by 2030.

While those goals seem lofty, Kim pointed to the accomplishment of bringing down extreme poverty to 10 percent, a figure many had once said was impossible.

Ninety-one percent of children in developing countries now attend primary school, up from 83 percent in 2000, he said. And the number of people on antiretroviral drugs for treatment of HIV in sub-Saharan Africa has increased eightfold in the last decade.

"But we're humbled by the challenges ahead," Kim said. "Rising global temperatures will have devastating impacts on poor countries and poor people – and, as we saw with Ebola, major pandemics are likely to disproportionately affect the poor."

Pandemic threats

Kim said that most virologists and infectious disease experts are certain a pandemic will sweep the world in the next 30 years. He said that would lead to more than 30 million deaths and anywhere from 5 to 10 percent of lost GDP.

He blasted the global community for taking eight months to respond to the Ebola crisis in West Africa, noting that Guinea, Sierra Leone and Liberia had among the fastest growing economies in Africa before the outbreak killed more than 11,000 people – most of whom were poor.

In an effort to speed up financial aid the next time such an outbreak occurs, the World Bank is developing the Pandemic Emergency Facility, which would disburse funding immediately to national governments and responding agencies.

Rajiv Shah, the administrator for the U.S. Agency for International Development from 2010-2015, spoke earlier at the conference about his work leading the U.S. efforts to contain Ebola.

"Three small countries with total population of maybe 30 million people had such weak health systems with so little domestic investment – in one country $6 per capita health investment per year – that when Ebola became a crisis there was no first-line of defense," he said.

By October 2014, the U.S. was pouring hundreds of millions of dollars into containment efforts, including the establishment of a 2,500-personnel military deployment to hit Ebola on the ground. Shah said President Obama "stayed extraordinarily true to the science" of containment at the source.

Image

Stunted children 

Moving beyond containment of epidemics, Kim said the most important investment developing countries could make in their people starts when a woman becomes pregnant. Using a combination of health, nutrition and education will have lifelong benefits for each child, as well as for the country in which each prospers.

The World Bank estimates that 26 percent of all children under age 5 in developing countries are stunted, which means they are malnourished and under-stimulated, risking a loss of cognitive abilities that lasts a lifetime. The number climbs to 36 percent in sub-Saharan Africa, giving those children limited prospects in life."This is a disgrace, a global scandal and, in my view, akin to a medical emergency," Kim said. "Children who are stunted by age 5 will not have an equal opportunity in life. If your brain won't let you learn and adapt in a fast-changing world, you won't prosper and, neither will society. All of us lose."

From 2001 to 2013, the World Bank invested $3.3 billion in early childhood development programs in poor countries. Kim said innovative policymaking and financial tools allowed the bank to help Peru cut its rate of child stunting in half to 14 percent in just eight years.

"Progress is possible – and it can happen quickly. But we must do even more,"he said.

Kim said the world set a target in 2012 to reduce stunting in children by 40 percent. But that would still leave 100 million children malnourished and undereducated. The bank and world leaders should pledge to end stunting for all children by 2030, he said.

"With partners like the Global Development and Poverty Initiative and the entire Stanford community, I'm full of hope that we can indeed be the first generation in human history to end extreme poverty and create a more just and prosperous world for everyone on the planet."

Read more here about another innovation to improve health in the developing world.

The H5N1 strain of the bird flu is a deadly virus that kills more than half of the people who catch it.

Fortunately, it’s not easily spread from person to person, and is usually contracted though close contact with infected birds.

But scientists in the Netherlands have genetically engineered a much more contagious airborne version of the virus that quickly spread among the ferrets they use as an experimental model for how the disease might be transmitted among humans.

And researchers from the University of Wisconsin-Madison used samples from the corpses of birds frozen in the Arctic to recreate a version of the virus similar to the one that killed an estimated 40 million people in the 1918 flu pandemic.

It’s experiments like these that make David Relman, a Stanford microbiologist and co-director of the Center for International Security and Cooperation, say it's time to create a better system for oversight of risky research before a man-made super virus escapes from the lab and causes the next global pandemic.

“The stakes are the health and welfare of much of the earth’s ecosystem,” said Relman.

“We need greater awareness of risk and a greater number of different kinds of tools for regulating the few experiments that are going to pose major risks to large populations of humans and animals and plants.”

Terrorists, rogue states or conventional military powers could also use the published results of experiments like these to create a deadly bioweapon.

“This is an issue of biosecurity, not just biosafety,” he said.

“It’s not simply the production of a new infectious agent, it’s the production of a blueprint for a new infectious agent that’s just as risky as the agent itself.”

Image

But Relman cited a series of recent lapses at laboratories in the United States as evidence that accidents can and do happen.

“There have been a frightening number of accidents at the best laboratories in the United States with mishandling and escape of dangerous pathogens,” Relman said.

“There is no laboratory, there is no investigator, there is no system that is foolproof, and our best laboratories are not as safe as one would have thought.”

The Centers for Disease Control and Prevention (CDC) admitted last year that it had mishandled samples of Ebola during the recent outbreak, potentially exposing lab workers to the deadly disease.

In the same year, a CDC lab accidentally contaminated a mild strain of the bird flu virus with deadly H5N1 and mailed it to unsuspecting researchers.

And a 60 year-old vial of smallpox (the contagious virus that was effectively eradicated by a worldwide vaccination program) was discovered sitting in an unused storage room at a U.S. Food and Drug Administration lab.

Earlier this year, the U.S. Army accidentally shipped samples of live anthrax to hundreds of labs around the world.

Similar problems have been reported in labs around the world. The United Kingdom has had more than 100 mishaps in its high-containment labs in recent years.

It’s difficult to judge the full scope of the problem, because many lab accidents are underreported.

Studying viruses in the lab does bring important potential benefits, such as the promise of universal vaccines, as well as cheap and effective ways of developing new drugs and other kinds of alternative defenses against naturally occurring diseases.

“It’s a very tricky balancing act,” Relman said.

“We don’t want to simply shut down the work or impede it unnecessarily.”

However, there are safer ways to conduct research, such as using harmless “avirulent” versions of the virus that would not cause widespread death and injury if it infected the general public, Relman said.

Developing better tools for risk-benefit analysis to identify and mitigate potential dangers in the early stages of research would be another important step towards making biological experiments safer.

Closer cooperation among diverse stakeholders (including domain experts, government agencies, funding groups, governing organizations of scientists and the general public) is also needed in order to develop effective rules for oversight and regulation of dangerous experiments, both domestically and abroad.

“We believe that the solutions are going to have to involve a diverse group of actors that has not yet been brought together,” Relman said.

“We need new approaches for governance in the life sciences that allow for these kinds of considerations across the science community and the policy community.”

You can read more about Relman’s views on how to limit the risks of biological engineering in this article he wrote for Foreign Affairs with co-author with Marc Lipsitch, director of Harvard’s Center for Communicable Disease Dynamics.

The increasing resistance to antimicrobial drugs is a growing public health concern, particularly in low- and middle-income countries that require high out-of-pocket payments for prescription drugs.

“Understanding the drivers of antibiotic resistance in low- to middle-income countries is important for wealthier nations because antibiotic-resistant pathogens, similar to other communicable diseases, do not respect national boundaries,” said Marcella Alsan, MD, PhD, MPH, the lead author of the study, which was published July 9 in The Lancet Infectious Disease.

Alsan is an assistant professor of medicine at Stanford, an investigator at the Veterans Affairs Palo Alto Health Care System and a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research.

“Out-of-pocket health expenditures are a major source of health-care financing in the developing world,” said Jay Bhattacharya, MD, PhD, senior author of the study and a professor of medicine, a senior fellow at the Freeman Spogli Institute for International Studies and another core faculty member at CHP/PCOR.

Read the full article here.

Image

Hua Tang, Stanford Associate Professor of Genetics, visited SCPKU as a faculty fellow in March 2015.  Below are the highlights of a conversation Professor Tang had with SCPKU in which she shares more details about her research and the contributions SCPKU made to her work in China.

Q: Describe your research and its connection to China

My research aims to develop statistical and computational methods for elucidating the genetic basis of human complex diseases. My current focus is on two related themes: identifying disease risk factors by integrating functional genomic information, and understanding factors that contribute to differential disease prevalence across human populations. My SCPKU faculty fellowship has given me the opportunity to explore new dimensions related to both themes.  Through connections I have made with scholars at Peking University (PKU), I will be able to combine biological knowledge and population-based association evidence in my efforts to identify genetic risk factors for complex diseases.  I also plan to compare epidemiologic data based on the East Asian population in the U.S. and epidemiological studies in China to understand the role of life-style risk factors, such as diet and physical activities, in ethnic health disparity.

Q: What got you interested in the study of human complex diseases?

I have always enjoyed mathematics, but it is very important to me that my work has direct benefit to people. Luckily, in college and during graduate school, I discovered that statistical and population genetics are areas in which I could use mathematical tools to gain insights relevant to human health. We are living in an era of big data; combining novel statistical models, efficient computational tools and large-scale biomedical data offers fantastic opportunities to make real contributions to medicine and public health.

Q: Why did you decide to apply for an SCPKU Faculty Fellowship?

I wanted to connect better with the scientific community in China.  I had already started communicating remotely with a PKU professor at PKU, whose research shares common goals with mine but who takes complementary approaches. The SCPKU faculty fellowship would allow me to travel to China and strengthen ties with faculty at PKU.  I also look forward to the opportunities of interacting with students at PKU.

Q: How valuable was SCPKU's team in supporting your fellowship at SCPKU?

Extremely valuable!   I got a nice office on the courtyard level, great IT and staff support. Also, I had the opportunity to interact with faculty from other departments for collaborations.

Q: What were your fellowship objectives and were they met?  Also, if applicable, aside from the fellowship, how did SCPKU help you to achieve your objectives?

My first visit to SCPKU in March was very productive and I was able further my research on the two themes I mentioned earlier.  I also taught a lecture in a concurrent SCPKU graduate seminar, through which I got to know the work of Professor Randall Stafford from the Stanford Prevention Research Center.  Professor Stafford was also an SCPKU faculty fellow and taught a graduate seminar at SCPKU this past spring focused on chronic disease in China.  I was able to participate in the seminar and establish new ties with instructors and participants of this  multidisciplinary seminar including Chinese scholars, health practitioners and government representatives from the Chinese Center for Disease Control and other health-related organizations. 

Being physically at SCPKU this past spring really helped to stimulate my research program. The fellowship has opened up many possibilities for interacting with scholars at Peking University and the broader scientific community in Beijing. I hope to expand these relationships by making several more trips to SCPKU. I am also very interested in organizing an SCPKU graduate seminar for the near future.
 

Q: Describe some highlights of your stay in China/SCPKU. 

Aside from meeting with my PKU contacts to further my research, I enjoyed participating in (both as an observer and teaching a lecture) Dr. Stafford’s graduate seminar on chronic diseases in China. I made many new connections in the Beijing science community and will host a visiting student in early 2016.  I also attended an SCPKU-hosted happy hour which included a Chinese rice wine tasting and musical performance on a Chinese zither or “guzheng.”

Q: List at least THREE words or thoughts that come to mind which best describe your experience at SCPKU. 

Adventure, exploration, collaboration.
 

Q: Any future plans in China? 

I plan to use the remaining funds from my SCPKU fellowship in the fall, and continue interaction with faculty at PKU and SCPKU.

Photo courtesy of Stanford University

Rates of obesity in the United States remain extremely high. New statistics show that nearly two-thirds of adults are at an unhealthy weight and that – for the first time ever – obese Americans now outnumber those who are merely overweight.

Two Stanford public health law experts say one of biggest culprits of the obesity epidemic – on top of fast foods and our sedentary lifestyle – are sugary drinks.

And they believe the sweet spot for public health law in curbing the adverse effects of sugar-sweetened beverages (SSBs) lies in the strategic use of measures such as higher SSB taxes, limits on advertisements targeting kids, and restrictions on soft drinks and sugar-sweetened teas and sports drinks in government institutions, such as public schools.

“It’s always possible to get more and better evidence about the effectiveness of public health laws,” says David Studdert, a professor of medicine at the Stanford School of Medicine, professor at the Stanford Law School and core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research.

Image

“But enough is already known about the promise of some legal interventions to curb SSB consumption – significant tax hikes and advertising restrictions are two good examples – to be fairly confident that they would make a difference.”

Studdert is the lead author of a review paper published July 7 in PLoS Medicine, entitled, “Searching for Public Health Law’s Sweet Spot: The Regulation of Sugar-Sweetened Beverages.”

Studdert and senior author Michelle Mello, professor of law and professor of health research and policy at the School of Medicine, and co-author Jordan Flanders, a former Stanford Law School student, argue that sugary drinks are a substantial, yet preventable contributor to the global burden of obesity and associated health conditions.

A new study published June 29 in the American Heart Association journal Circulation linked the consumption of sugary drinks to an estimated 184,000 adult deaths each year, with more than 25,000 of those Americans. The study, conducted by researchers from Tufts University, found that the beverages are responsible for an estimated 133,000 of those deaths from diabetes, 45,000 from cardiovascular disease and 6,450 from cancer.

While Americans’ consumption of sugary drinks has plateaued, according to the Tufts study, about three-fourths of the deaths due to SSBs are now in developing countries. Mexico leads with 24,000 total deaths. The United States still ranks fourth, however, just behind South Africa and Morocco.

The Stanford researchers say the evidence shows that sugary drinks are contributors to the global obesity epidemic, but the appropriate reach of regulation to curtail SSB consumptions remains highly contested.

The main regulatory approaches to SSBs are higher taxes, restrictions on the availability of the sugar-sweetened drinks in schools, restrictions on advertising and marketing, labeling requirements and government procurement and benefits standards.

Image

“Finding public health law’s sweet spot requires regulatory approaches that are capable both of achieving measurable improvements to public health and of winning victories in courts of law and public opinion,” the researchers write.

Over the last decade, many national, state, and local governments have introduced laws aimed at curbing consumption of sugar-sweetened beverages (SSBs), especially by children. The main regulatory approaches have been taxes, restrictions on the availability of SSBs in schools, calls for controls on advertising and marketing, labeling requirements, and government procurement and benefits standards.

But efforts to regulate the drinks often encounter stiff opposition, including claims that the laws are inequitable, do not achieve their goals, and have negative economic effects.

New York City’s attempt to ban the sale of jumbo-sized sugary drinks sold in city restaurants, theaters and food carts triggered international headlines and a firestorm of opposition. The soft drink industry embarked on a multimillion-dollar campaign to block the proposal championed by former Mayor Michael Bloomberg.

The proposal died last year when the New York State Court of Appeals ruled that the city’s Board of Health had “exceeded the scope of its regulatory authority.”

Taxes on SSBs, the most commonly adopted measure, vary widely, the authors write. A few countries, most notably several South Pacific island nations, where obesity rates are among the highest in the world, have introduced very high taxes on sugary drinks.

But most sugar-sweetened beverage taxes add between 5 and 9 cents per liter. This is well short of the level that experts argue is needed to significantly affect consumption and weight outcomes: a sales tax of at least 20 percent of the container’s price or a specific excise tax of 1 cent per ounce.

“In the United States, there have been many government proposals to introduce or raise taxes – most unsuccessful,” the authors write. “The beverage industry has invested heavily in public relations firms and `grassroots’ organizations to oppose the initiatives.”

Image

Berkeley, Calif., recently became the first U.S. city to pass an SSB tax, a penny-per-ounce excise on soda distributors, but a similar ballot measure in nearby San Francisco failed. At least 22 states have proposed SSB taxes since 2010, but only one state, Washington, passed a measure at the level recommended by economists – and it was repealed the following year in a voter referendum.

Yet U.S. childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years, according to the Centers for Disease Control and Prevention. More than one-third of children and adolescents are overweight or obese.

“There is broad consensus in the public health community that reducing the influence of advertising is a critical step in addressing the spread of childhood obesity,” the authors say.

The United States and Canada have sought to regulate advertisers through a soft approach — mainly via voluntary guidelines and pressure to self-regulate, the authors write.

“These appear to have had only a modest impact on marketing practices,” they said. “U.S. regulators face considerable legal barriers in going further, including courts’ increasingly expansive interpretations of the scope of protected commercial speech under the First Amendment. Unless judicial currents shift, it will remain extremely difficult to impose restrictions on SSB advertising.”

Mello said low- and middle-income countries should anticipate that SSB companies will increasingly target them as promising markets, and that those developing countries should start crafting their regulatory responses now.

“Our experience with tobacco control teaches us that lower- and middle-income countries need to become wary when product regulation in the U.S. tightens,” Mello said. “Like squeezing a balloon, it pushes companies to intensify their marketing efforts overseas, and our public health problems get exported."

And, the authors note, while policy nudges have become fashionable, “there are dangers in treading too lightly.” “Strategies such as calorie labels, portion caps, and small beverage taxes preserve consumer freedom but are typically too modest to affect consumer behavior – and such modesty can be recast as arbitrariness. Industry opposition will come whether the intervention is modest or aggressive but should be easier to combat if officials can show their policy is effective,” they wrote.

“One somewhat surprising message that comes from reviewing how courts have handled challenges to SSB laws is that regulators can run greater risks of having their laws struck down if they are too timid,” Studdert said.

“Courts weigh effectiveness, and modest attempts to change behavior are often ineffective,” he said. “So one piece of advice regulators in this area should consider is to ‘go big or go home’.”

Noncommunicable diseases (NCDs) have become the leading causes of death worldwide and China's increased NCD prevalence is of growing concern. Randall Stafford, Professor of Medicine in the Stanford Center for Research in Disease Prevention and SCPKU Faculty Fellow, led a symposium at the center last fall.  Entitled "Tackling China's Noncommunicable Diseases: Shared Origins, Costly Consequences, and the Need for Action," the symposium focused on China's NCD threats to public health and the urgent need for solutions.  The symposium summary was published earlier this month in the Chinese Medical Journal.