Lindsey Davies: Q&A - Royal College of Physicians

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Feature Image©Shutterstock Nudging, as opposed to nannying, is a key part of the coalition government’s approach to public health. ‘It is simply not possible to promote healthier lifestyles through Whitehall diktat and nannying about the way people should live’, says Andrew Lansley, secretary of state for health, in his foreword to the public health strategy for England. 1 So nannying, roughly translated as regulation and legislation, is out; and nudging, or changing people’s habits without regulation, is in. The new favoured method of changing people’s habits is to use behavioural insights, derived from behavioural science and economics, and in particular from the US book, Nudge, by Thaler and Sunstein. 2 A Behavioural Insights Team (commonly known as the ‘nudge unit’) has been set up in the Cabinet Office to drive forward this approach. In ‘Applying behavioural insight to health’ 3 the nudge unit sets out a range of existing and proposed interventions in public health. Most of them involve partnership with the private or voluntary sector, and are designed to be tried out and devolved to local communities for them to implement. We asked three experts in public health to comment on the specific interventions proposed in three main areas – obesity, smoking and alcohol – and to give their views on the unit’s overall approach. Reducing obesity Several of the nudge unit’s proposals to encourage more physical activity involve using new technology, such as Nike iPhone apps that can track your run and show your speed, incentives for children to walk to school using swipe card technology, and ‘active’ video gaming such as Nintendo Wii which involves some body movement. Professor Peter Kopelman, RCP special adviser on obesity, is not impressed by these ideas: ‘We’re looking at a spiralling obesity prevalence in people on low incomes so whatever we advocate has to be affordable – these are luxuries those people can’t afford’. Another proposal is to work with the food industry to get restaurants and fast food chains to provide calorie information about their meals, so that ‘people can be empowered to make a healthier choice’. ‘Where is the evidence for this I’m not aware of any,’ says Kopelman. ‘Also, that approach could encourage food faddism, because you’d be affecting not only overweight people but also people who are super conscious of their weight.’ ‘The causes of obesity are embedded in an extremely complex biological system, set within an equally complex societal framework’, he says, and therefore a collection of disparate unconnected measures are unlikely to address a problem of that scale. ‘This type of policy is only as good as the electoral term of the government supporting it, whereas effective public health strategy has to go Putting the nudge in motion The government wants to use behavioural insights to promote healthier lifestyles and reduce health inequalities, but how effective is ‘nudging’ Commentary asks three experts in public health for their thoughts on nudging people in the right direction 16 Commentary n June 2011 n www.rcplondon.ac.uk
Feature Comment Write to us... Respond to any of the articles featured or share your views on RCP matters. Email us at: letters.commentary@rcplondon.ac.uk right across government, go across politics and be sustainable over the long term.’ As proposed in the Foresight report, 4 he believes that an agreed strategy – involving the health sector, education, transport, town and country planning, industry and the voluntary sector – implemented using focused initiatives and legislation, is the only way to address the escalating health problems caused by obesity. Reducing alcohol misuse The nudge unit’s intervention on alcohol uses the concept that people are strongly influenced by what others do (norms). Students, though, overestimate the amount of binge-drinking their fellow students indulge in, so ‘social norming’ aims to correct that misperception by using posters and publicity to point out the reality, and therefore reduce the pressure to drink. In autumn 2011 the charity Drinkaware and the Welsh Assembly Government will use the social norming approach in a one-year trial in five Welsh universities, backed up by guidance for the universities on appropriate alcohol policies, the provision of support services and so on. In response to this, Professor Sir Ian Gilmore, RCP special adviser on alcohol, says that any new approaches that prove to be effective in tackling alcohol misuse are welcome. However, ‘there is a tendency’, he says, ‘for theories to come into vogue and go out again’ and it could be a mistake to predicate a large part of government policy on one such theory. The drink industry, of course, already uses very powerful nudges, in the form of advertising, discounted pricing and special offers, to encourage people to drink. ‘We also heard recently that Heineken is going to be the beer of the 2012 Olympic Games, so from now on a beer is going to be associated with sports and great sporting prowess. Is that nudge If so, I’d say it’s nudging people in the wrong direction.’ To counterbalance unhealthy nudges that are already in the environment, thanks largely to industry, we may need something stronger than behavioural nudges for individuals. ‘The ‘We also heard recently that Heineken is going to be the beer of the 2012 Olympic Games, so from now on a beer is going to be associated with sports ... Is that nudge If so, I’d say it’s nudging people in the wrong direction’ Sir Ian Gilmore most effective way of changing the environment often requires legislation – something this government is not prepared to do,’ says Professor Gilmore. Reducing harm from smoking The new proposed smoking cessation trial will be a collaboration between the unit, the Department of Health and Boots UK. It will use the behavioural ideas of commitment – ‘known to be a powerful force in behaviour change’, particularly when involving loved ones – and incentives (possibly in the form of Boots reward card points) to help smokers quit the habit. Although the detail of the intervention is not yet clear, Professor John Britton, chair of the RCP Tobacco Advisory Group, has strong reservations about it: ‘If this is a “Quit and win” type of approach, it has been tried and tested and shown not to work’. Andrew Lansley says in his public health strategy that he intends to cut the proportion of adults who smoke in England from 21.2% to 18.5% or less by the end of 2015, roughly a 0.5% cut per year. Britton says that initiatives to help individuals stop smoking, like the Boots trial, have a minimal impact on smoking prevalence in the whole population. ‘If you want a lot of people to give up smoking, you have to drive that centrally by measures that touch all smokers, such as media campaigns, taking tobacco out of sight in shops, and enforcing plain packaging.’ ‘Evidence from states in the USA shows that if you want to achieve a yearly 0.5% fall in the number of smokers, you have to do everything – keep raising prices, keep investing in public awareness campaigns, bring in new legislation, provide cessation services – and you have to keep coming up with new ideas because each of them has an impact on prevalence.’ A unanimous view All our experts agreed in principle that ideas from behavioural science may provide useful additional tools for improving public health, but many of the interventions proposed by the nudge unit have little or no evidence base. A rounded comprehensive approach, they said, is the only way to tackle these major public health issues of our time. n References 1 Department of Health. Healthy lives, healthy people: our strategy for public health in England. London: DH, 2010. 2 Thaler RH, Sunstein CR. Nudge: improving decisions about health, wealth, and happiness. Yale: Yale University Press, 2008. 3 Cabinet Office Behavioural Insights Team. Applying behavioural insight to health. London: Cabinet Office Behavioural Insights Team, 2010. 4 Foresight. Tackling obesities: future choices – project report. London: Stationery Office, 2007. With thanks to Professor John Britton, chair, RCP Tobacco Advisory Group; professor of epidemiology, University of Nottingham Professor Sir Ian Gilmore, chair, Alcohol Health Alliance UK; past president, RCP; liver specialist, Royal Liverpool Hospital Professor Peter Kopelman, principal, St George’s, University of London; science adviser, Office of Science and Innovations Foresight Obesity Project. Joanna Reid, RCP managing editor www.rcplondon.ac.uk n June 2011 n Commentary 17
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Lindsey Davies: Q&A - Royal College of Physicians

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