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.