Policy and Position Statements


Prevention Policy Statement

Each year, chronic diseases and injuries contribute to more than 1.8 million deaths in the United States,1 cost more than $1.5 trillion in lost productivity and healthcare expenditures,2,3 and have a substantial impact on our health and economy. State and territorial health agencies are strategically positioned to provide leadership for the development, implementation, and coordination of comprehensive, evidence-based approaches to promote wellness and prevent chronic diseases and injuries.

Several national resources provide guidance for state and territorial health agencies to implement prevention efforts. Healthy People 2020 establishes 10-year national objectives for health promotion and disease prevention. To achieve these objectives, the National Prevention Strategy4 and several other national and federal strategies, such as the National Stakeholder Strategy for Achieving Health Equity,5 the 2014 National Drug Control Strategy,6 and Ending the Tobacco Epidemic: A Tobacco Control Strategic Action Plan for the U.S. Department of Health and Human Services, 7 describe how to address the many challenges facing our communities and nation.

Modifiable behavioral risk factors, such as tobacco use, poor diet, physical inactivity, alcohol consumption, and drug abuse, remain the top contributors to U.S. mortality rates.Most deaths (nearly 70%) are caused by chronic diseases, such as cancer, stroke, heart disease, diabetes, chronic lower respiratory illness, and unintentional injuries.1 The leading cause of death among people 1-44 years of age is unintentional injuries, such as those sustained in motor vehicle-related crashes or that result from poisoning and prescription drug misuse.1 ,10 Three-quarters of all deaths among young people are attributed to injuries and violence, such as homicide or suicide.10 A continued focus on the prevention of injury-related death and disability, and a strong infrastructure are required to sustain efforts to prevent and reduce injuries.

The impact of these challenges is staggering; while national health expenditures increased to $2.7 trillion in 2010, more than 75 percent of these healthcare costs are due to chronic conditions.2 Much of this cost is due to the risky behaviors of individuals that increase susceptibility to long-term health complications. For example, more than 42.1 million adults in the United States smoke (about 1 in 5)12 and about 38 million adults in the United States report binge drinking an average of four times a month.13 Annually, missed work days are due to chronic diseases and co-morbid conditions result in a loss of productivity. In a study from 2012 to 2013, the annual cost of lost productivity due to absenteeism was $84 billion.19 Of this worker population, 77 percent were either above normal weight or had been diagnosed with at least one chronic condition, reporting about one extra unhealthy day and one-third of a day more missed work each month.19 Injuries in the United States account for more than $192 billion annually in medical costs and lost productivity, including hospitalizations and emergency department visits.21 Furthermore, nonmedical use of prescription painkillers, for example, costs health insurers up to $72.5 billion annually in direct healthcare costs.14

To reduce these adverse outcomes, it is essential to promote an environment based on principles of wellness and healthy lifestyle choices. It is necessary to invest in programs and implement policies that foster healthy and safe lives and communities. Priority attention is required to ensure health equity for everyone through public and private sector initiatives and partnerships and to help racial and ethnic minorities and other underserved populations reach their full health potential.5 To this end, it is critical to address social determinants of health, including economic, social, and geographic conditions that influence the health of populations and contribute to chronic diseases and injury.

State and territorial health agencies must continue to be national leaders in the promotion of chronic disease and injury prevention education, programming, and policy. Some essential functions of health agencies include assessment, surveillance, reporting, policy development, and targeting of resources for optimal health of the people they serve. State and territorial health agencies approach this mission by fostering environments, programs, policies, and relationships that will reduce and help eliminate the incidence and burden caused by chronic diseases and injuries.

To accomplish these goals, ASTHO encourages state and territorial health agencies to utilize evidence-based interventions recommended in the National Prevention Strategy, peer-reviewed studies, and other consensus reports to:

  • Develop and implement comprehensive and systematic approaches to prevention.
  • Build and sustain internal and external collaborations and partnerships.
  • Make the “business case” for the value of prevention.
  • Encourage development, expansion, and preservation of healthy communities.
  • Lead by example, e.g., offer employee wellness programs for staff, which serve as models for others.


Increasing the focus on prevention in our communities will help improve America's health, quality of life, and prosperity. For example, seven out of 10 deaths among Americans each year are from chronic diseases, such as cancer and heart disease, and almost one out of every two adults has at least one chronic illness, many of which are preventable.20,21 Health domains intersect, for example, dental diseases affect not just oral health but also general health status. Studies show some association between oral infections and heart disease, diabetes, respiratory infections, and the birth of premature, low birth weight babies.22 Focusing comprehensively on preventing disease and illness before they occur will create healthier homes, workplaces, schools, and communities so that people can live long and productive lives and reduce their healthcare costs.30 ASTHO supports:

  1. Developing and sustaining state, territorial, local, and federal public funding streams that permit efficient collaboration across and within agencies to address prevention in a comprehensive manner.
  2. Developing and sustaining federal funding for states, territories, and tribal nations that permits the flexible use of resources to address unique needs as they arise (e.g., Preventive Health and Health Services Block Grant), rather than prescriptive programs that may not reflect a state’s health priorities or challenges.
  3. Encouraging the development of public health programs that build on the individual strengths of states, territories, local entities, and tribal nations while leveraging efforts to target behaviors and social determinants of health.
  4. Sustaining public-private partnerships among state, territorial, and local governmental public health agencies and other stakeholders to implement proven strategies and improve health outcomes in communities.
  5. Developing public health surveillance systems that inform prevention activities and decision-making.
  6. Emphasizing the reduction or elimination of racial, ethnic, and socioeconomic health disparities where they exist.


Large employers, insurers, and others have a major financial stake in the health and wellness of their constituencies. The health expertise, surveillance capacity, and leadership provided by state and territorial health agencies are valuable assets for other partners. To address the many dimensions of chronic disease and injury prevention, ASTHO supports:

  1. Collaboration within state and territorial health agencies coupled with efforts to engage tribal nations; other sectors such as transportation, education, agriculture, and energy; other partners such as healthcare, mental health and substance abuse; the private sector; local governmental entities, such as city councils and mayors; as well as other key stakeholders.
  2. Interdepartmental collaboration for federal, state, local, and territorial public health grant programs.
  3. Sustained collaboration among chronic disease and injury prevention programs and other stakeholders to develop comprehensive solutions to these public health challenges.
  4. Demonstration of the value of prevention investments as a crucial component of any transformative national health agenda to the private sector, insurers, medical providers, researchers, and elected officials.


The annual cost of poor health on the U.S. workforce was estimated at $1.8 trillion in 2008, according to the U.S. Bureau of Labor Statistics. State and territorial health agencies have documented how small investments in prevention have yielded significant cost savings for medical treatment and lost productivity.23-26 Adequately funded programs are essential to make a health impact and cost savings. For example, investments in tobacco control are directly correlated with decreases in smoking rates, and therefore, increases in life expectancy. In a study using data from 1964-2012, this relationship was demonstrated yielding an increase in 30 percent and 29 percent life expectancy for men and women, respectively.27 A study in Washington state found that from 2000- 2009, the state’s tobacco prevention and control program prevented nearly 36,000 hospitalizations, saving $1.5 billion compared to the $260 million spent on the program (a 5-to-1 return on investment).26 Moreover, a study at Harvard University analyzing the literature on costs and savings associated with prevention programs in the workplace found that medical costs were reduced by $3.27 and absenteeism costs were reduced by $2.73 for every $1.00 spent on comprehensive workplace wellness and prevention programs.29 The private sector shares a similar interest in reducing costs and promoting wellness among its workforce. ASTHO supports “making the business case for prevention” among health agencies and their external partners, by:

  1. Educating policy makers at the federal, state, territorial, and local levels about the significant cost savings that result from modest increases in prevention funding.
  2. Educating private sector and insurance executives about the potential savings and increased productivity that can result from employers and insurers promoting wellness and prevention.


ASTHO supports state and territorial health agency efforts to:

  1. Foster healthy communities through land use policies that include walkable and bike-friendly transportation design, mixed-use development, healthy food access, and safe routes to school and work.
  2. Work with community leaders, planners, transportation professionals, and developers to create mixed-use, healthy communities that are safe and accessible, have comprehensive tobacco free policies, and provide opportunities for physical activity and access to healthy foods for their residents.


State governments are the largest employer in many states; state and territorial health agencies have an obligation to set examples by implementing comprehensive wellness policies, increasing healthy food choices, and developing safe, healthy work environments. ASTHO supports the development of policies within health agencies that provide incentives to foster healthy environments at their workplaces and in communities.  


A greater emphasis on prevention in our country can significantly reduce the burden of disease and injury among Americans, resulting in better health, a longer lifespan, and improved quality of life for succeeding generations. We envision a 21st century nation that prioritizes prevention and wellness; includes healthier environments and lifestyles that create healthy communities; provides, at a minimum, preventive and primary health care for every person; eliminates inequities in health status; and protects people and communities from existing and emerging health threats.15


Social determinants of health: The economic and social conditions that influence the health of individuals, communities, and jurisdictions as a whole.16

Health disparities: A particular type of health difference that is closely linked with social or economic disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social and/or economic obstacles to health and/or a healthy environment based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation; geographical location; or other characteristics historically linked to discrimination or exclusion.”17

Health equity: “Attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities.”18

Approval History

Prevention Policy Committee review and approval: January 2015
Board of Directors review and approval: March 2015
Ratified by the ASTHO Assembly of Members: September 2015

Policy Expires: September 2018

ASTHO policies are broad statements of enduring principles related to particular policy areas that are used to guide ASTHO’s actions and external communications.


  1. Centers for Disease Control and Prevention. Deaths: Leading causes for 2010. National Vital Statistics Reports. 2013; 62(6): 1-97. http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_06.pdf. Accessed January 09, 2015.
  2. Chatterjee A, DeVol R, Kubendram S, King. Checkup time: chronic disease and wellness in America – measuring the economic burden in a changing nation. 2014. Medical Expenditure Panel Survey, National Health Survey, Milken Institute. http://assets1b.milkeninstitute.org/assets/Publication/ResearchReport/PDF/Checkup-Time-Chronic-Disease-and-Wellness-in-America.pdf. Accessed January 12, 2015.
  3. Kochanek KD, Murphy SL, Xu JQ, Arias E. Mortality in the United States, 2013. NCHS data brief, no 178. Hyattsville, MD: National Center for Health Statistics. 2014.  NCHS data accessed at: http://www.cdc.gov/nchs/data/databriefs/db178_table.pdf#1.  Note: Calculation of $2.7M used statistic from the reference (17.9% of GDP in 2010 toward healthcare costs – the majority of that due to chronic conditions) combined with the GDP from 2010 ($14.96 trillion).
  4. National Prevention Council, National Prevention Strategy, Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2011.
  5. Beadle MR, Graham GN. National Partnership for Action to End Health Disparities. National Stakeholder Strategy for Achieving Health Equity. Rockville, MD: U.S. Department of Health and Human Services, Office of Minority Health, 2011.
  6. Office of National Drug Control Policy. National Drug Control Strategy. 2014. Washington, DC: Executive Office of the President. http://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/ndcs_2014.pdf. Accessed January 9, 2015.
  7. U.S. Department of Health and Human Services. Ending the Tobacco Epidemic: A Tobacco Control Strategic Action Plan for the U.S. Department of Health and Human Services. Washington, DC: Office of the Assistant Secretary for Health, November 2010.
  8. Johnson, N.B., et al. CDC National Health Report: Leading Causes of Morbidity and Mortality and Associated Behavioral Risk and Protective Factors –United States, 2005-2013. 63(04); 3-27. 2014. http://www.cdc.gov/mmwr/preview/mmwrhtml/su6304a2.htm?s_cid=su6304a2_w. Accessed on January 09, 2015.
  9. Centers for Disease Control and Prevention. Deaths: Leading causes for 2007. National Vital Statistics Reports. 2011; 59(8): 1-96. http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_08.pdf. Accessed Nov. 10, 2011.
  10. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System [WISQARS]. Available at: http://www.cdc.gov/injury/wisqars/index.html. Accessed November 9, 2011.
  11. Centers for Medicare and Medicaid Services. National Health Expenditures, 2010. https://www.cms.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp#TopOfPage. Accessed Oct. 28, 2011.
  12. US Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2014. http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf. Accessed February 7, 2014.
  13. Kanny D, Liu Y, Brewer RD, Garvin WS, Balluz L. Vital signs: Binge drinking prevalence, frequency, and intensity among adults—United States, 2010. MMWR Morb Mortal Wkly Rep. 2012; 61:14-19. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a4.htm?s_cid=mm6101a4_e%0d%0a. Accessed April 9, 2014.
  14. Centers for Disease Control and Prevention. Vital Signs – Prescription Painkiller Overdoses in the U.S. November 2011. http://www.cdc.gov/vitalsigns/PainkillerOverdoses/index.html. Accessed Nov. 15, 2011.
  15. Association of State and Territorial Health Officials. A Transformed Health System for the United States in the 21st Century. Position Statement, 2008. Available at: http://www.astho.org/Policy-and-Position-Statements/A-Transformed-Health-System-in-the-21st-Century-Position-Statement/. Accessed Nov. 10, 2011.
  16. Raphael, D. Introduction. In D Raphael (Ed.), Social Determinants of Health: Canadian Perspectives. Toronto: Canadian Scholar's Press. 2004.
  17. Office of Minority Health. National Stakeholder Plan to Achieve Health Equity. Available at http://minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=1&lvlid=34. Accessed on 5/18/11.
  18. U.S. Department of Health and Human Services, Office of Minority Health. National Partnership for Action to End Health Disparities. The National Plan for Action Draft as of February 17, 2010. Chapter 1: Introduction. http://www.minorityhealth.hhs.gov/npa/templates/browse.aspx?&lvl=2&lvlid=34. Accessed on January 14, 2015.
  19. Gallup, Inc. and Healthways, Inc. Gallup-Healthways Well-Being Index. 2013.  Accessed at http://www.gallup.com/poll/162344/poor-health-tied-big-losses-job-types.aspx.
  20. Ward BW, Schiller JS, Goodman RA. Multiple chronic conditions among US adults: a 2012 update. Prev Chronic Dis. 2014;11:130389. DOI: http://dx.doi.org/10.5888/pcd11.130389.
  21. Leigh JP [2011]. Economic Burden of Occupational Injury and Illness in the United States. Millbank Quarterly 89(4):728-772
  22. Academy of General Dentistry. Position Paper on Increasing Access to and Use of Oral Health Care Services. Available at http://www.agd.org/files/newsletter/7025accesstocarewhitepaper7-31-08.pdf. Accessed 11/10/2011. 
  23. Baicker K, Cutler D, Song Z. Workplace wellness can generate savings. Health Aff (Millwood) 2010; 29(2):304–11
  24. Anderko L, Canova D, DeSantis C, Howard J, Goetzel R, Millard F, et al. Healthier workforce for a healthier economy. Washington (DC): Georgetown University; 2012. http://nhs.georgetown.edu/docs/TheVitalityGroup.pdf. Accessed January 13, 2015.
  25. Jordan, N., Grissom, G., Alonzo, G., Dietzen, L., Sangsland, S. (2007). Economic benefit of chemical dependency treatment to employers. Journal of Substance Abuse Treatment, 34, 311-319
  26. Dilley, Julia A., et al., “Program, Policy and Price Interventions for Tobacco Control: Quantifying the Return on Investment of a State Tobacco Control Program,” American Journal of Public Health, Published online ahead of print December 15, 2011. See also, Washington State Department of Health, Tobacco Prevention and Control Program, News release, “Thousands of lives saved due to tobacco prevention and control program,” November 17, 2010, http://www.doh.wa.gov/Publicat/2010_news/10-183.htm
  27. Holford TR, Meza R, Warner KE, et al. Tobacco Control and the Reduction in Smoking-Related Premature Deaths in the United States, 1964-2012. JAMA. 2014;311(2):164-171. doi:10.1001/jama.2013.285112.
  28. Bureau of Labor Statistics. The Employment Situation: December 2008. Washington, DC: US Department of Labor; 2009
  29. Baicker K, Cutler D, Song Z. Workplace wellness programs can generate savings. Health Affairs. 2010;29:1–8.
  30. CDC. National Prevention Strategy: America’s Plan for Better Health and Wellness. 2014. http://www.cdc.gov/Features/PreventionStrategy/. Accessed January 14, 2015.