Should smokers be forced to apply for an annual licence to purchase cigarettes? And what about one hour’s exercise every lunch hour for all employees during the working day? When Professor Julian le Grand raised the issue of how far the state should try to prevent individuals from leading unhealthy lifestyles, we asked three public health specialists for their views

The consequences of inaction are unthinkable

Iain Crombie, professor of Public Health at the University of Dundee

It seems self-evident that adults should be responsible for their own health. This is consistent with the ethical principle of autonomy. An individual has the right to think, decide, and act freely and independently. Government intervention is seen as an infringement of individual liberty. The individual has to be able to choose to take risks, otherwise we have a society controlled by the health police.

There is another perspective, however. The ethical principle, justice, proposes fairness, equity and impartiality in dealing with individuals. It leads to the view that everyone should have the opportunity to attain their full potential for health. This is why the constitution of the World Health Organization states that governments have a duty to ensure that their citizens enjoy the highest standards of health. G overnments must act to prevent or minimize the impact of serious avoidable risk.

The UK government has repeatedly taken such actions. The reduction in accidents at work resulted from a series of laws passed in the 19 th and 20 th centuries to improve safety at work. The Clean Air Acts in the 1950s were a government response to deaths from air pollution. Similarly, road traffic legislation covering speed limits, drink driving, wearing of seat belts and MOTs was motivated by government concern about accident rates. Food hygiene standards are currently high because government passed and continues to enforce food safety laws. Together these government interventions have led to major improvements in health.

More recently, action has been taken on smoking with bans on marketing and on smoking in public places and a substantial investment in smoking cessation services. Now there are proposals to require cigarette packets to carry shocking images of diseases caused by smoking.

Should there be equivalent direct action for other major public health problems, such as obesity and alcohol? For example, junk foods are engineered to appeal to human taste (high sugar, fat and salt) and they are cheap, widely available and heavily marketed. Humans are programmed to indulge in times of plenty to cope in periods of shortage; it is not surprising that they indulge when food is continuously plentiful. Alcohol consumption is also determined by price, marketing and availability (opening hours and outlet density). Obesity leads to increased morbidity and increased NHS costs for which we all have to pay. Alcohol misuse also causes substantial morbidity and leads to social disruption and crime.

The argument for government action is convincing. The current problems pose a serious but avoidable threat to health. There is good evidence that the broader social and physical environment in which people live has a powerful influence on the choices they make. Only government action can change the environment. Finally there is the practical issue of the cost. Modelling studies show that the NHS would be unable to sustain the health care costs for the disease burden posed by obesity. The consequences of inaction by government are unthinkable.

Is nanny so bad?

Current government health policy places too much emphasis on individual choice and on restricting the role of government to providing advice and information to aid making healthy choices. All the evidence shows it doesn’t work, says David J Hunter

Left to themselves, people do not choose to live healthy lives. That is the stark conclusion of a new report on public health from the Nuffield Council on Bioethics. The state must therefore intervene to control or shape behaviour,

It is not so much a case of the ‘nanny state’ meddling in people’s lives, as a dose of desirable libertarian paternalism intended to help people do what they cannot, or will not, do for themselves. In any event, leaving everything to individual choice is too simplistic especially when many individuals suffer ill health or adopt unhealthy behaviours for reasons beyond their control.

Sadly, government is out of fashion and viewed as inept and bureaucratic. Few trust it. Government has largely brought such a fate upon itself by preaching the unbridled virtues of markets, competition and individual choice. The public realm has been privatised with notions of citizenship and collective action receiving less attention.

But health is not just another commodity to be purchased by individuals. The ‘diseases of comfort’ - smoking, obesity, lack of physical exercise, alcohol misuse, mental ill health - together with growing health inequality, are complex problems that demand complex solutions involving a range of stakeholders, including government, at different levels of society. The government chief scientist’s recent Foresight report on obesity concluded that the obesity epidemic cannot be prevented by individual action alone and demands a societal approach; that tackling obesity requires far greater change than anything tried so far, and at multiple levels – personal, family, community, national; and that preventing obesity is a societal challenge similar to climate change and requires partnership between government, science, business and civil society.

Current government health policy places too much emphasis on individual choice, and on restricting the role of government to providing advice and information to aid making healthy choices. All the evidence shows it doesn’t work. A rebalancing of policy is called for which gives a greater emphasis to an ecological approach to public health. There is a hard nosed economic dimension to this argument. Unless we control demand on health care services, and prevent people ending up in hospital, we will quickly find that we cannot afford publicly funded health services.

The smoking ban in public places is a powerful example of effective government leadership, even if there was initial reluctance in England. Similar leadership is urgently needed in respect of other public health challenges. There are limits to markets and to viewing individuals as consumers exercising unfettered choice which may be damaging to their health and that of others. The public health community’s voice, hitherto somewhat muted, needs to be heard as an advocate for action.

David J Hunter is professor of Health Policy and Management in the Wolfson Research Institute at Durham University and Chair of the UK Public Health Association

Striking a balance

Cries of “nanny statism” are not new to this government or even to modern politics. Almost every government intervention in the public health arena over the past several centuries has been derided by critics of the time as a sign of tyranny, nanny statism or the end of individual freedom, says Dr Karen Jochelson

Things we take for granted were once at the heart of heated debates. Sewerage systems and clean water are the product of public health measures once condemned by newspapers as infringements on personal freedom. One would be shocked to see a landlord happily selling a child double gins but it is something Victorian anti-booze campaigners had to fight long and hard to outlaw. And it would be a pretty fundamentalist libertarian who still opposed our once controversial, now widely accepted and adhered to, seat belt laws.

In the simplest of terms governments can enact restrictive or enabling measures. But how to strike a balance?

Education programmes raise awareness but cannot be relied upon to translate into behaviour change. Tax-led price rises on unhealthy products or behaviours do affect change but have a disproportionate impact on the incomes of poorer households. Regulation is effective especially when supported with penalties for non-compliance. But while strict rules are suitable and enforceable for behaviours such as wearing a seat belt, the behaviours that cause obesity or sexual transmitted infections would be far more difficult to police.

In a 2005 paper, The King’s Fund suggested the term ‘stewardship’ as a better description of a government’s role in the public health context. It implies government has a responsibility for protecting national health and to serve in the public interest and for the public good. It suggests a protective function, where individuals are protected from harm by others and sometimes from themselves. But that still doesn’t provide a clear cut answer as to what government interventions are tolerable to its citizens. W hen polled, people are predictably strongly in favour of legislation controlling the potentially dangerous behaviour of others but view their own behaviour as benign!

Restrictive measures are the most effective but they are only acceptable to the public after a sustained campaign of information from pressure groups about an issue. The temperance movement had existed for more than 50 years, gradually changing attitudes to alcohol and public drunkenness, before legislation supporting their aims was enacted. Public opinion needs to evolve before the relatively blunt tool of legislation can be successfully introduced. There may be the odd groan when they are increased on Budget day but financial disincentives are generally accepted these days as appropriate on cigarettes and alcohol – but what would be the reaction to plans to charge obese passengers more for seats on aeroplanes?

It will be the public debate itself, over what constitutes acceptable intervention and what is intolerable government intrusion, which will serve as the process of changing attitudes and creating consensus about where governments should draw the line.

Dr Karen Jochelson is Fellow in Public Health at the King’s Fund

In 2008 the King’s Fund is undertaking a programme of work looking at the specific role of NHS organisations in changing public health behaviour in terms of how much they can achieve and where their efforts should best be focused. The ‘Kicking Bad Habits: How Can the NHS Help?’ project aims to bring together expert academics, practitioners, managers and researchers from the public, voluntary and private sectors to crystallise what effective, affordable action might be practically taken by the NHS to improve public health outcomes. It will look at what motivates change, interventions for low socio-economic groups and the role of financial incentives, among other things