Shove and nudge: the Tobacco Control Plan and the Responsibility Deal

The civil servants inside the Department of Health's public health team are clearly working overtime. Not content with travelling around the country consulting on plans for the largest shake-up in the organisation of public health in decades, this month has also seen the launch of the Tobacco Control Plan and the first sighting of the much anticipated Responsibility Deal.

These strategies are important in themselves, but also in what they reveal of the government's emerging thinking on public health as a whole. We've had an early indication in Healthy Lives, Healthy People, which navigated tricky territory between individual responsibility and state action, pointing to both the role of wider determinants of health and the responsibility of the individual in explicitly recognising the need for 'nudge and shove' (albeit with a clear preference for the former). The creation of both Public Health England, and devolution of significant power and budgets to local authorities, means it remains unclear where the responsibility lies.

These tensions are evident in both the Tobacco Control Plan and the Responsibility Deal. The headlines on the former have been about regulation: rather than following a softly, softly approach, the government will build on its predecessor's ban on smoking in public places by outlawing tobacco displays, vending machines and possibly advertising on packaging. However the overall narrative of the plan is clearly about more local responsibility. This is consistent with wider government philosophy and is likely to lead to welcome innovation, but also to a widening diversity of experience and possible health inequalities. Tobacco is critical to health inequalities, since smoking rates have become less equal over time and are now the leading cause of inequality in health between rich and poor. The former government's explicit targets on smoking for poorer groups, and the regulation and performance management that went alongside them, did make substantial headway and the targets were met. These levers, and the National Support Team that helped deliver them, have been swept away. Whether a switch to incentives, more local freedom and government 'encouragement' from the centre in the context of national 'ambitions' will be as effective is critical to whether the health of the poorest really will start to improve faster than that of the richest.

The Responsibility Deal, which excludes the tobacco industry, reflects the government's preference for working voluntarily with industry first, before turning to regulation. It makes some important steps forward in areas such as workplace health, salt, and out-of-home calorie labelling in big chains such as McDonald's, Pizza Hut and Harvester Restaurants. It has also engaged the big supermarkets and the Association of Convenience Stores, more important in disadvantaged areas where the big chains are less present. However, Diabetes UK and the British Heart Foundation are right to press for more measurement and evaluation to find out if actions are followed up and how they actually impact behaviour and health.

The long-awaited alcohol strategy will be the next test for government. How will it balance the interests of those who consume with little or no harm to their health, and the social costs of disturbance, crime, violence and family breakdown associated with excessive consumption? Alcohol Concern and others are clearly worried that the government will not go far enough – reflected in their high-profile withdrawal from the Responsibility Deal. The government will need to prove that its approach to alcohol is firmly rooted in evidence-based solutions, from nudging industry and supporting individuals, evidence-based regulation and broader economic and social policy responses.

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Comments

#383 Gabrielle Sulich

I agree wholeheartedly with the need for evidence based solutions, especially when you think about the sheer cost; Where is the evidence to say that giving responsibility to local authorities will work?

#421 Mark Gamsu

Thanks David - a thoughtful response - my twopenn'orth on the tobacco control plan - shame that there is not a specific inequalities dimension to the 3 'ambitions' that are set out - they all seem to relate to the population as a whole. Maybe I have missed a bit of detail here? Approximately 20% of the actions are about implementing or continuing with Labour Government policy - which is not a bad thing - much of this was championed by PH leaders. There is a strong focus on the role of local areas - local authorities in particular - with words being used like 'encourage' and 'support' I suppose the question will be materially what do these words mean - particularly given the cuts to key local authority services such as trading standards. There are a range of tentative actions such as 'review' and 'research' which seems partly a desire to check out the impact of new territory such as the internet and also to test confidence in initiatives such as smokefree legislation. The most confident sections seem to relate to national marketing and guidance production - and the final 2 chapters on information/intelligence and protecting tobacco control from vested interests have no key actions - maybe the author(s) got tired or the minister was less keen on this - draw your own conclusions. Final comments - feels like a rather conservative and tentative document - largely describing what is - did not get a feeling for a new relationship with citizens or the voluntary sector - where is the Big Society here? - similarly there was minimal mention of primary care and its contribution - maybe this is because the current service delivery models are more or less fine?

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