Lindsey Davies: Q&A - Royal College of Physicians

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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