State political systems and public health policy: An examination of how direct democracy, preemption, and other political system factors impact tobacco and alcohol policies

Policies that benefit public health frequently come into conflict with the objectives and profit motive of private industry. For example, despite the overwhelming scientific evidence that smokefree policies benefit public health, do not cause economic harm, and are supported by the public, as of January 2012 only 23 states have comprehensive statewide smokefree laws. Similarly, states were slow to adopt .08 g/dl per se blood alcohol concentration (BAC) laws in the 1990's despite evidence supporting their effectiveness. It was not until Congress tied Federal Highway Funds to passage of the law that all 50 states adopted .08g/dl BAC laws in 2006. Understanding the factors that impact the advancement of popular and evidence-based public health policies despite industry opposition is of significant public health importance. State political system factors such as the presence of the ballot initiative process (where citizens vote directly on specific proposals) and preemption (which limits the ability of local governments to enact certain policies) may have a significant effect on policy outcomes, but there has yet to be any quantitative examination of the impact of these factors on the enactment of public health policies. We examine the impact that key state political systems factors have had on the advancement of statewide smokefree and BAC policies using longitudinal, multilevel, and time to event analysis. We control for numerous other political, economic, and demographic factors using data from 1970-2010 and discuss the implications of our findings for public health advocates seeking to advance pro-health policies.