Tag Archives: public health

Should we just give up trying to tackle obesity and smoking through behavioural change?

Studies of behavioural interventions (trying to make people lead more healthy lives) consistently show small effect sizes. An effective smoking intervention would improve quit rates by four per cent1 and a successful weight loss intervention would do well to produce a sustained weight loss of more than five per cent of body weight.2

The really big gains in public health have come not from behavioural change, but from public legislation. Take a few examples:

  1. Forcing tobacco companies to advertise the harms of tobacco.
  2. Raising taxes on alcohol and tobacco.
  3. Seatbelt legislation.

Governments are now considering legislation, regulation or fiscal policies to reduce excessive calorie/sugar consumption. But can we really rely entirely on these measures – should we withdraw funding for research into improved behavioural interventions? I don’t think so for two principal reasons:

  1. There are limits to what can be achieved by public legislation. A classical example was prohibition in America in the 1930s. In the end, it did far more social harm than good. There are limits to how far we can get by coercive means. Very high taxes on tobacco can actually increase consumption by fostering a lucrative black market.3 History repeats itself. Sooner or later, we’re going to have to rely on individual motivation to provide health gains that cannot be achieved by government action alone.4
  2. Many interventions, although of modest effect, can still be highly cost effective. It might be true that a behaviour change can achieve only a four per cent reduction in smoking but the interventions are often relatively inexpensive, and the health effects of a four per cent reduction are impressive when compared to many clinical treatments. In short, we should not be deflected from doing what we can to promote behaviour change on the grounds that the effect sizes are of small magnitude – they are often worth having, i.e. highly cost effective5.

Of course, all this leaves open the important question of how best to achieve behaviour change. There are a large number of psychological and social theories, such as the ‘stages of change’ model6. Incidentally, these theories do not exist in competing or water tight compartments. Many have similar or overlapping elements. One of the theories receiving a lot of current attention is so-called ‘nudge’ theory7,8. I am a very strong supporter of this theory, from both philosophical and psychological points of view, as follows:

  1. Philosophically, this theory makes a lot of sense. It is not illiberal (unlike very high taxation or prohibitions) and recognises human autonomy. In short, it is not coercive. However, it does seek to help people promote their own long-term aims, and overcome short-term impulses. In other words, it seeks to support people when they try to maximise their long-term objectives but succumb to short-term gratification. This philosophical idea is predicated on the notion that there really is a difference between these two things – long-term objectives and short-term gains and that a person can freely choose to place limits on their future options.
  2. This is where modern psychological theory comes in. Traditionally, psychologists have held the view that the acid test of a person’s preferences is their expressed behaviour. If you really want to know what a person thinks about something then their behaviour is the most reliable test – a tenet of behaviourism. However, this does not conform with modern neurophysiology. For instance, it has been found that there are two circuits, one governing desire and the other governing gratification. These are only weakly linked9.

It thus seems both philosophically and psychologically entirely cogent to argue that people have two different kinds of motivation which may be in conflict – their long-term aims and desire for short-term gratification. In short, simply yielding to temptation is not tantamount to expressing an ‘overriding’ or ‘genuine’ preference. No, the brain is modular and can quite easily hold two contradictory beliefs at the same time. In fact, Homer anticipated all this, with the story of Odysseus, who had himself lashed to the mast so that he would not be able to destroy his boat in a desperate lunge to requite his desire for the sirens.

My own University of Birmingham is planning to collaborate with Professor Nick Chater’s group of behavioural psychology, at the Warwick Business School, in taking these ideas forward. We are forging links with the local authorities, both here in Birmingham and in Coventry, so that we can add to the scientific basis for behaviour change.


1. Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction.2004;99(1):29-38

2. LaFaive MD, Nesbit T. Higher Cigarette Taxes Create Lucrative, Dangerous Black Market. http://www.mackinac.org/18128 (accessed 26 April 2013).

3. Anderson JW, Konz EC, Frederich RC, Wood CL. Long-term weight-loss maintenance: a meta-analysis of US studies. The American Journal of Clinical Nutrition.2001;74(5):579-584

4. Teixeira PJ, Silva MN, Mata J, Palmeira AL, Markland D. Motivation, self-determination, and long-term weight control. Int J Behav Nutr Phys Act .2012;9(22):1-13

5. Bader P, Boisclair D, Ferrence R. Effects of Tobacco Taxation and Pricing on Smoking Behavior in High Risk Populations: A Knowledge Synthesis. Int. J. Environ. Res. Public Health.2011;(8):4118-4139

6. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology. 1983;51(3):390-395.

7. Thaler R, Sunstein C. Nudge: Improving Decisions About Health, Wealth and Happiness. 1st ed. London. Penguin Books; 2009

8. Nick Chater. Lessons in Nudge Marketing: Wy nudges work… and why they don’t. http://portal.sliderocket.com/ACXHL/Nudge-Marketing-Event-07-07-2011 (accessed 26 April 2013).

9. Bauer M. How to Avoid the Temptations of Immediate Gratification. http://www.scientificamerican.com/article.cfm?id=how-to-avoid-the-temptations-of-immediate-gratification (accessed 23 April 2013).


NHS reorganisation – rearranging deckchairs or game changers

When Tony Blair’s Labour Government came to power in 1997, the health service was reorganised. Lots of people changed jobs but the changes were superficial and (as it turned out) mostly ephemeral. The Labour Government certainly left one great monument to health – the National Institute for Health and Clinical Excellence (NICE). When the Coalition Government came in, they rearranged the furniture with a vengeance and, it might fairly be said, without permission from the owners. We are now settling down to do the same work in our new chairs, but what about a legacy from this reorganisation? Has the Coalition Government left behind something enduring, controversial, bold, and potentially game changing? In my opinion, insufficient attention has been paid to a radical and exciting change which, when all the dust has settled, may stand as a signature for the Coalition Government’s reforms. Unlike the creation of NICE, reaction to this policy has been somewhat muted. Could the transfer of responsibility for preventive public health from the health service to local authorities turn out to be a master stroke?

A century ago, public health was largely about the containment and prevention of infectious diseases. Massive gains were achieved through public works, such as provision of water-born sewerage. Health services played a direct role by increasing vaccination. Of course, legislation continues to have a role in public health, for example making people to wear seatbelts or pay more for their cigarettes. Health professionals continue to have a role in prevention, largely by encouraging their patients to adopt healthier behaviour, an idea embodied in the ‘Making Every Contact Count’ (MECC)1 doctrine. But these factors aside, primary prevention really turns on services and policies carried out largely under the jurisdiction of local governments. Education, especially education in the early years is arguably the biggest determinant of health,2 since much of the social, psychological and even neurological substrate for further responsible citizenship is laid down in the first three years of life. Right ‘up there’ with education, we must mention crime prevention – indeed the underlying conditions for poor educational and social achievement and for criminal behaviour are one and the same (or at least largely overlapping)3. Child Support policy is also crucial, both for accident prevention and for encouraging exercise. Lastly, local authorities are responsible for social services, a service which has potential large impacts on education (as mentioned above) and directly on health.

All of these services – education, crime prevention, transport and social services – have effects that lie outside health and in all cases the main intended effect is not a health-related one (unless health is given a very wide definition, but when a word is made to mean everything, it starts to mean nothing, and so I am using health in the colloquial sense). It could, of course, be very cogently argued that policy can be adequately guided to take health considerations into account, and give them their due weight, without bringing part of the public health function into the local government. Moreover, it must be conceded that there is, as yet, no evidence that the policy will work. I know of no international comparisons that provide empirical support for the policy.

It could be argued that a minimal condition for this radical shift in policy should be demonstrable deficiency in the existing system – we should not repair something that ‘ain’t broke’. However, there is plenty of headroom for improvement. Britain incarcerates more of its citizens than most European countries; in 2009, it had the second highest prison rate in Western Europe behind Spain. We seem to have a particularly large proportion of homes with a single unemployed parent which perpetuate themselves to generate a vicious cycle of deprivation.

Of course, the origins of crime and poverty lie deep, and it is far from clear that inculcating public health physicians to local authorities will significantly ameliorate the problem – why should it?

Well, I think I can make an argument as to why the policy has a chance of success. So I’ll start with an ‘Enlightenment’ premise that, insofar as policy can be successful, this can only be achieved by policies which maximise the probability of achieving desired objectives. This in turn can only be achieved by generating, collecting and using evidence about what works. And it just so happens that, at this moment in history, expertise in generating, assembling and analysing evidence is resident mainly within health. This is somewhat ironic because the evidence-based movement – based on synthesising evidence from multiple sources – started in education4. Nevertheless, when I recently attended the Campbell Colloquium (where evidence concerning crime, education, social services, transport and microeconomics is assembled each year) I found that over half the presentations were given by health professionals.

I have the privilege of directing a large National Institute of Health Research funded centre, a network known as a CLAHRC (Collaborations for Leadership in Applied Health Research and Care). For many years now I have been working with local authorities (most notably Sandwell through John Middleton and Worcester through Richard Harling). Our aim has been to collaborate with policy makers and thereby integrating evidence from the international literature, with the particular circumstances prevailing at a local level – a melding of knowledge, sometimes referred to as knowledge management. Collaboration at the heart of local government offers a powerful voice within the local authority and a chance to promote evidence-based policy. My colleagues and I in the CLAHRC will seek to capitalise on this new policy, both for knowledge management purposes and also to design studies to generate new knowledge. I enclose a short synopsis (a CLAHRC BITE) to give an example of the kind of collaborative work that we now propose to carry out with local authorities.

Use of knowledge management to design a service delivery intervention and the research agenda BITE

[1] Health Committee – The Government’s Alcohol Strategy Written evidence from the NHS Confederation (GAS 64). Available from http://www.publications.parliament.uk/pa/cm201213/cmselect/cmhealth/132/132vw60.htm (accessed on 22 January 2013).

[2] Hallam A. The Effectiveness of Interventions to Address Health Inequalities in the Early Years: A Review of Relevant Literature. Scottish Government. 2008. Available at: http://www.scotland.gov.uk/Resource/Doc/231209/0063075.pdf (Accessed 24 January 2013)

[3] Middleton J. Crime is a public health problem. Medicine, Conflict and Survival. 1998; 14(1): 24-28

[4] Glass, N. Sure Start: The Development of an Early Intervention Programme for Young Children in the United Kingdom. Children and Society. 1999; 13: 257-264