- Email: [email protected]
Nanny or steward? The role of government in public health
ARTICLE IN PRESS Public Health (2006) 120, 1149–1155
www.elsevierhealth.com/journals/pubh
Mini-Symposium
Nanny or steward? The role of government in public health Karen Jochelson The King’s Fund, London, WC1 0AN, UK Available online 25 October 2006
KEYWORDS Nanny state; Stewardship; Tobacco; Alcohol; Road safety; Government
Summary The past year has witnessed contentious debates about public health in England around smoking bans, alcohol licencing, food labelling and junk food advertising. Some people argue that any government intervention in these areas is ‘nanny statist’—an unnecessary intrusion into people’s lives and what they do, eat and drink. Others argue that only the state can alter the environment that shapes people’s decisions and behaviour. This paper suggests that there is a strong argument to be made for government intervention to safeguard public health. Legislation brings about changes that individuals on their own cannot, and sets new standards for the public good. Rather than condemning such activity as ‘nanny statist’, it might be more appropriate to view it as a form of ‘stewardship’. The paper draws on international evidence about alcohol use, smoking and road safety to show how taxation, advertising bans, regulations proscribing behaviour and education create a public health framework and shape individual choices towards healthier and safer behaviour. & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction The past year has seen contentious debates about public health in England around smoking bans, 24 hour licencing for alcohol, and junk food advertising. Critics of government policy have been quick to label proposed measures ‘nanny statist’ and an unnecessary intrusion into people’s personal lives. Government has been equally quick to distance itself from an old-style interventionist state. Corresponding author. Tel.:+44(0)20 7307 2663.
E-mail address: [email protected].
Dismissing government interventions as nanny statist precludes debate about options open to government and their likely impact on population health. This paper suggests that there is a strong argument to be made for government intervention to safeguard public health. Legislation brings about changes that individuals on their own cannot, and sets new standards for the public good. Rather than condemning such activity as ‘nanny statist’, it might be more appropriate to view it as a form of ‘stewardship’. This paper begins by examining the ‘nanny state’ debate in England, looking at examples from the past and today. It then looks at international
0033-3506/$ - see front matter & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2006.10.009
ARTICLE IN PRESS 1150 evidence about alcohol use, smoking and road safety, to show how taxation, regulation and education create a public health framework and shapes individual choices towards healthier and safer behaviour. It concludes with reflections on the impact of government intervention, and suggests that stewardship might be a more appropriate concept than ‘nanny’ as a way to envision a government’s role around protecting and promoting health.
Intervention or freedom: the nanny state debate The debate over the limits to state intervention and extent of individual freedom weaves through the history of public health. In the simplest terms, it divides between interventionists and libertarians. For interventionists, governments promote freedom for individuals by creating opportunities and levelling out inequities in society. For libertarians, minimal government is the best way to protect individual freedom, which is about not being interfered with by others. Regulations we now take completely for granted have sparked fierce controversy in their time. The first British Public Health Act, passed in 1848, gave local government powers over the water and sewage systems and was opposed for being ‘paternalist’ and ‘despotic’. For one newspaper ‘a little dirt and freedom’ was ‘more desirable than no dirt at all and slavery’.1 The Licensing Act, 1872, restricted pub-opening hours and prohibited children from drinking spirits in a pub. Many felt it better that ‘England should be free than ycompulsorily sober’. Temperance supporters replied that ‘drunken freedom’ was ‘not liberty’.2,3 The first reports linking smoking with lung cancer and recommending that people stop smoking were hugely controversial. Some newspapers defending smokers’ rights rejected tobacco tax and advertising bans as a ‘blow to freedom’, and health education as ‘propaganda’.4 The decision to make wearing seatbelts mandatory in 1983 was rejected by some MPs as ‘paternalism run rampant’; the act of a ‘nanny state’ restricting ‘freedom of choice’ for drivers; while others argued that it was ‘right for the state, with its knowledge and its power, to step in for the good of the community’.5,6 Few people would now dispute the public and individual benefits of access to clean water, a sewage system and clean air—these are infrastructural issues that individuals can do little on their
K. Jochelson own to create, but from which they benefit. Yet government action around smoking, alcohol use, exercise or eating habits is not viewed in a similar way, particularly in England. Since it came to power, the Labour government has been keen to distance itself from old-style biggovernment and avoid the nanny-statist label. It sees government as no longer ‘intrusive’ but ‘enabling’, and its role, as Prime Minister Blair explained in a recent speech, is ‘empowering the individual, not trying to make their choices for them’.7 Government rhetoric swings between supporting individual informed choice and state intervention. For example, Choosing Health, a public health white paper issued in 2004, outlines government’s role as providing information, so individuals can make ‘informed choices’, providing personalized services to support individuals motivated to make lifestyle changes, and encouraging corporate responsibility. It also recognizes a protective role in regulating activities that ‘unduly inconvenience or damage the health of others’. It believes this reflects a middle road between ‘a paternalistic state’ that ‘limit[s] individual choice, y and ban[s] y unhealthy behaviour’ and ‘stand[ing] back, leaving people’s health to whatever the hidden hand of the market and freedom of choice produces’.8 Blair’s recent speech gives more emphasis to the role of government ‘in setting standards’ through legislation as a way ‘to change a culture’.7 Libertarian critics responded to government proposals for smoke-free legislation, food labelling or life-style advice with rallying cries for individual freedom. They argued that lifestyle choices are a decision for individuals, not government, with one columnist describing advocates for state controls as ‘the forces of darkness: opposed to freedom, opposed to choice, and opposed to individual responsibility’.9 Forest, a tobacco industry-funded smokers’ rights group, argued that ‘it is up to individuals how they live their lives’ and the ‘right’ to smoke or ‘eat what you like’, was ‘as fundamental a freedom as the right to a free and private vote in elections’.10 Others dismissed advice about healthier lifestyles as ‘relentless interference’ and ‘propaganda’ turning Britons ‘into lifestyle automatons’.11,12 The debate over the nanny state and the limits to state intervention has been particularly fierce in England. This may reflect the gradual divergence in policies around health and health care in England, Scotland and Wales since devolution in 1998.13 For example, the Welsh Assembly which has focused on public health and preventing ill-health, voted for smoke-free public places in 2003, but did not then
ARTICLE IN PRESS Nanny or steward? The role of government in public health have the power to implement it. Scotland was the first to pass legislation for smoke-free public places in 2005, with widespread public, professional and political support.14 England finally passed similar legislation in 2006, but only after considerable debate revealing a lack of consensus within the two main political parties. The English government’s health policy rhetoric revolves around markets, competition, and individual choice and this may make it more difficult to justify interventions to improve or protect collective health or regulate decisions which appear to be individual ‘choices’ about lifestyle and health. Dismissing government intervention as nannystatist limits debate about the possible benefits of state intervention. Any government that wants to change the behaviour of companies or the public in response to a perceived health risk has a number of policy options open to it. It can introduce measures that encourage change in individuals, such as public information campaigns or a new health promotion service. It can introduce measures that promote change in populations, such as increasing or lowering taxation to encourage particular choices. Or it can introduce restrictive measures that ban or regulate activities or products such as advertising codes, or minimum food or air standards. The following sections draw on international and UK evidence about alcohol use, smoking and road safety to show how taxation, regulation and education create a public health framework and shape individual choices towards healthier and safer behaviour.
Taxation International studies show that increasing the price of alcohol generally leads to a decrease in consumption, with a positive follow-on effect for public health. In the UK alcohol consumption has increased as the price of alcohol relative to income has fallen and tax has fallen in real terms.15,16 Countries that increase the price of alcohol through tax find that consumption decreases. In 1992, the Northern Territory in Australia introduced a harm reduction levy on all drinks with over 3% alcohol. Over the four following years, per capita consumption decreased by 22% and alcohol related morbidity and mortality also declined.17 US studies have found that states with higher alcohol taxes have fewer deaths from liver cirrhosis, fewer motor vehicle fatalities, especially among young adults, and fewer homicides, rapes, robberies, assaults, motor vehicle thefts, domestic violence, and child abuse.18,19
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A similar pattern is evident when looking at tobacco use. Studies in low, middle and highincome countries show that taxation policy is a particularly effective way to reduce the demand for tobacco.20–22 For example, when Massachusetts imposed substantial tax increases on cigarettes in 1993, consumption fell by 4% compared to a 1% decrease in other states that had not introduced the tax.23 A UK study shows that as tobacco prices increased from the 1970s, consumption began to decline. However, when tax failed to keep up with inflation, as happened between 1977 and 1979, smoking increased by 10%.21,24 Price increases induce some smokers to quit and prevent others from becoming regular or persistent smokers.
Regulation to restrict access Completely banning access to alcohol or tobacco would be politically unacceptable, and most likely encourage illegal use. However, restricting access to alcohol and tobacco seems to reduce consumption rates, and brings wider social and health benefits. Certainly liberalizing licencing laws encourages increased consumption of alcohol. When Sweden allowed its liquor stores to open on Saturday, sales of alcohol increased, and so did rates of domestic violence and public drunkeness. As a result, the Saturday closure was reinstituted.25 When Scotland relaxed its licensing hours in 1976, alcohol consumption increased by 13%, but remained unchanged in the rest of the UK, where hours remained the same. However, when England and Wales relaxed their opening hours in 1988, only consumption by heavy drinkers appeared to increase.16 Legislation for smoke-free public places has been introduced in California (1995), New South Wales, Australia (2000), New York (2003), Ireland (2004) Scotland (2005) and England (2006). Compliance with such regulation depends on a widespread consensus among smokers and non-smokers about the ethics of public smoking, since regulations have to be enforced largely through peer pressure and social conformity, rather than financial or legal penalties.20 Research show that bans on smoking in public places reduce non-smokers’ exposure to tobacco smoke,26,27 and reduce consumption so encouraging smokers to quit. A review of 26 studies of smokefree workplaces in four countries concluded that totally smoke-free work places are twice as effective in reducing consumption and prevalence
ARTICLE IN PRESS 1152 as policies that restrict smoking to a few designated areas.28
Advertising bans Total advertising bans are associated with declining consumption of alcohol and tobacco which leads to declining morbidity and mortality from related illnesses. Reducing exposure to positive images of smoking and drinking changes attitudes to these behaviours. Research suggests that advertising shapes positive attitudes to drinking.29–31 A study that compared 17 countries over a 13-year period found that those with total bans on beer, wine and spirits advertising had lower alcohol consumption levels, lower mortality due to cirrhosis of the liver and fewer motor vehicle fatalities than countries that only banned spirit advertising or allowed advertising. A follow up study with data from 20 countries spanning a 26-year period, similarly found that banning alcohol advertising resulted in a decrease in consumption.32 Tobacco advertising bans also have a direct impact on consumption rates. A survey of advertising bans in 102 countries showed that partial bans have little or no effect, since tobacco companies switch to other media and to sponsorship, but comprehensive media bans reduce consumption.33 Norway, Finland and Iceland were among the first countries to ban tobacco advertising in the 1970s, and saw substantial reductions in smoking rates and tobacco consumption. In Iceland, smoking prevalence among 12–16 year olds, for example, dropped from 32% in 1974 to 13% in 1986, following a ban in 1971.21
Proscribing behaviour Smoking bans work through peer pressure, but wearing seatbelts and not driving when drunk depend on the state proscribing permitted behaviour and using surveillance and penalties to ensure compliance. For example, Britain was one of the first countries to require front seat belts to be fitted to cars in 1965. Adoption rates were low until it made front seatbelt use compulsory for drivers and front-seat passengers in 1983, rear seatbelt use mandatory for children in 1989, and rear seatbelt use for adults mandatory in 1991. This had an immediate impact on compliance. Between February 1982 and February 1983, seatbelt use
K. Jochelson jumped from 38% to 93% for drivers and front seat passengers. Between October 1990 and October 1991, rear-seat belt use jumped from 43% to 63%.34 Road safety organizations believe that since 1983, mandatory seatbelt use in Britain has prevented 50,000 deaths, 590,000 serious casualties and 1,590,000 minor injuries.35 The savings made as a result of these avoided deaths and injuries—in terms of medical and emergency care, lost economic ouput and loss of life and injury—is estimated at £163 billion.36 Studies comparing accident data in the year before and the year after the first seatbelt legislation found fatalities were down by between 23% and 32%; the number of patients brought to hospital declined by 15%; and those requiring admission to wards dropped by 25%.37,38 UK and international studies also show that introducing a blood-alcohol limit for drivers has an impact on fatalities and casualties. A US study based on data from 50 states found that fatalities declined by 14% between 1980 and 1997 when the legal blood alcohol concentration level dropped from 0.10% to 0.08%.39 Conversely, when the blood alcohol concentration limit was increased from 0.02% to 0.05% in Portugal, fatalities increased by 10%.40 The high compliance rates for seat belts and the blood-alcohol limit in the UK are a result of driver and passenger perceptions of the risk of getting caught and fear of the likely legal penalties. In 1992–1994, there were, on average, 120,000 fixed penalty notices, written cautions and court prosecutions for not wearing a seatbelt. By 2000, this had risen to over 200,000, even though the number of seatbelt wearers had risen in this period. This suggests that surveillance had increased.41 Similarly, since 1996, drivers involved in accidents in the UK have been breathalysed. If convicted of a drink-driving offence, drivers may lose their licence for minimum of a year. Even though the number of roadside screening tests increased from 450,000 in 1988 to 815,000 in 1998, the percentage of positive (and refused tests) has fallen from nearly 25% to 12%, indicating that fewer people are drinking and driving.42 A survey showed that respondents restricted their drinking for fear of being breathalysed, even though they realized their chances of being stopped were small, and their knowledge of the penalties was poor.43 Random or selective testing, though not permitted in the UK, has proven effective in Australia, New Zealand, the US and some European countries in reducing fatalities. On average, random testing resulted in an 18% decrease in alcohol-related
ARTICLE IN PRESS Nanny or steward? The role of government in public health crashes and a 22% decrease in fatal crashes, while selective breath testing resulted in a 20% reduction in crashes and a 23% reduction in fatal crashes.44
Education Health awareness programmes aim to change individuals’ knowledge and attitudes about risks related to health, in the hope this will affect behaviour. The evidence is equivocal about their effect. Studies of mass media alcohol campaigns show that they are cost effective, because they reach a high percentage of their target audience, but they have only some impact on knowledge and attitudes and little impact on behaviour.16 Evaluations of school-based information and normative programmes show they have, at best, short-lived, modest effects, and do not delay the onset of drinking nor sustain reduced drinking, and do not prevent alcohol misuse.16,29 Evaluations of anti-smoking education campaigns also show that awareness of the health risks of smoking does not equate with a change in behaviour.4 However, smokers exposed to mass media campaigns are still more likely to quit than those who are not.45,46 A review of international evidence showed that anti-smoking programmes for teenagers at best delay the onset of smoking, but are unlikely to prevent it.46,47 The evidence on road safety education campaigns suggests, that alone they are relatively ineffective in changing behaviour. From 1975 to 1982, the UK government ran annual education campaigns to encourage drivers and passengers to wear seatbelts, with little success and compliance levels only increased when wearing a seatbelt became mandatory.48,49 However, campaigns are a useful complement to legislation. When drinkdriving education campaigns ceased for a few years in the 1970s, the proportion of road fatalities involving alcohol rose from 15% in 1967 to 35% in 1975. Since 1977 drink driving education campaigns have run every year and by 1999 just 4% of people involved in road accidents failed the breath test.50 This suggests that education can be effective if it is not stand alone, but part of a wider health promotion campaign with clear behavioural goals. Social marketing tries to change social or health behaviours by better understanding consumers’ existing needs, beliefs and feelings and segmenting the market and targeting campaigns accordingly. Campaigns aim to increase knowledge, but also set specific behavioural goals. For example, a social
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marketing campaign aimed at pregnant women from low-income groups who smoked, showed that more women quit than in primary care trusts that did not run the campaign.51 Attitudes and behaviours change slowly. Education programmes are ineffective on their own, but as part of a comprehensive control policies including high taxation, advertising bans, and restricted access to alcohol or tobacco, or mandatory behaviour with penalties and surveillance, it is likely that they can help shape positive attitudes to healthier or safer behaviour.
Conclusions Almost every government intervention in the public health arena has been criticized by commentators of the time as a sign of tyranny, nanny statism, or the end of individual freedom. Yet the evidence discussed above illustrates the considerable individual and public health benefits of once-contested interventions—results, which arguably mitigate the small limitations on individual freedom and choice. The findings show the positive impact of education, taxation, and restrictive legislation on shaping individual’s choices for healthier behaviour, and ultimately on better health. At the outset of this paper, I suggested that ‘stewardship’ might be a more appropriate term than ‘nanny statism’ to understand the justification for and impact of the range of interventions that governments use to shape behaviour. Stewardship implies government has a responsibility for protecting national health, and to serving in the public interest and for the public good.52 For the World Health Organization, stewardship is ‘the very essence of good government’ and means that governments are ‘ultimately responsible’ for ‘their citizens’ wellbeing’.53 Public health measures which set new social standards to promote the public good and bring about changes that individuals on their own cannot, fall easily into the stewardship framework. Legislation on air quality or smoke-free public places, for example, set minimum standards that protect health and are beyond the power of individuals to choose. Stewardship also implies that a government protects its citizens against harm from others. Few would quibble with government regulations protecting vulnerable individuals, such as children from dangerous substances, or protecting a society against polluting industries. Similarly, laws against drunk driving, speed limits or smoking in public places help protect us from the potentially dangerous actions of
ARTICLE IN PRESS 1154 others by defining what is acceptable and ensuring compliance through penalties, surveillance and social pressure. Stewardship is more controversial when it comes to protecting individuals from harming themselves. However, we try to protect individuals wanting to commit suicide, from acting on their desire, knowing that they might feel differently about their lives in future. Are smoking, drinking and eating unhealthily any different? Governments cannot ban these activities, nor can it compel people to do things they do not wish to. But the case studies suggest they can encourage better choices through regulation, taxation, advertising codes and informational campaigns. These may restrict individual choices a little, but they also make it easier for individuals to make healthier choices if they wish. Some political theorists argue that such government intervention is not inconsistent with individual freedom. Sunstein and Thaler, for example, suggest that public policy eliminates obviously bad choices and encourages more positive ones to promote individual and general well-being.54 Goodin believes that where people have a conscious desire to do something they cannot bring themselves to do, public policy can enable them to recognize and act on their desire.55 Certainly, many smokers want to quit and many overweight people would like to be thinner. If government interventions make it easier for individuals to act on these desires, then it is difficult to argue that it undermines their liberty. Libertarians may well dismiss stewardship as mere semantics. But this restricts opportunities for political debate about the benefits of and limits to state intervention. It also fails to acknowledge that the debate itself is part of the process of changing attitudes and creating consensus about where to draw the line. Prime Minister Blair speaks of his ‘own personal journey of change’ over the smoke-free legislation, noting that ‘a few years back’ he ‘would have hesitated long and hard’ over the issue, but now he believed in the ‘need to be tougher, more active in setting standards and enforcing them’.7 What is clear from the case studies is that governments can act as stewards and create frameworks which encourage individuals to make healthier decisions.
References 1. Porter D. Health, civilisation and the state. A history of public health from ancient to modern times. London: Routledge; 1999. p. 120.
K. Jochelson 2. Harrison B. Drink and the Victorians. The temperance question in England 1815–1872. London: Faber and Faber; 1971. 3. Rose L. Drink and drugs. London: Batsford Academic and Educational; 1984. 4. Hilton M. Smoking in British popular culture 1800–2000. Manchester: Manchester University Press; 2000. 5. Leichter H. Lives, liberty and seat belts in Britain: Lessons for the United States. International Journal of Health Services 1986;16(2):213–26. 6. Official Report, House of Commons, Sixth Series. Parliamentary Debates: Commons, vol. 28. 1981-1982. p. 633–4, 640. 7. Blair T. Our Nation’s Future. Speech on Healthy Living. 26 July 2006. Available from: /http://www.number-10.gov.uk/ output/Page9921.aspS. 8. Department of Health. Choosing health. Making healthier choices easier. London: The Stationary Office; 2004. 9. Pollard S. Smoking bans are offensive. But they work, The Independent. October 2003. 10. Taylor K, Fraser S. Eat unhealthily in the name of democracy. Scotland on Sunday. August 2002. 11. Starr S. Exercise in futility, 30 April 2004 [accessed on 5 September 2005]. Available from: /www.spikedonline.com/Printable/0000000CA508.htmS. 12. Bristow J. A really bad habit, 12 March 2004. [accessed 5 September 2005] Available from: /http://www. spiked-online.com/Printable?0000000CA473.htmS 13. Greer SL. Territorial politics and health policy. UK health policy in comparative perspective. Manchester and New York: Manchester University Press; 2004. 14. Ash Scotland and Cancer Research UK. The Unwelcome Guest: How Scotland invited the tobacco industry to smoke outside. Ash Scotland, 2005. 15. Department of Health and National Statistics. Statistics on Alcohol: England. Bulletin 2004/15, 2004 16. Raistrick D, Hodgson R, Ritson B. Tackling alcohol together. The evidence base for a UK alcohol policy. London: Free Association Books; 1999. 17. Crosbie D, et al. Alcohol, taxation reform and public health in Australia. A submission to the Federal Parliamentary Enquiry into substance abuse in Australian Communities; 2000. Available from: /www.aph.gov.au/house/committee/ fca/subabuse/sub123.pdfS. 18. Edwards G, Anderson P, Babo TF, Casswell S, Ferrence R, Giesbrecht N, et al. Retail price influences on alcohol consumption, and taxation of alcohol as a prevention strategy. In Alcohol policy and the public good. Oxford: Oxford University Press; 1994. 19. Chaloupka F, Grossman H, Saffer H, National Institute of Alcohol Abuse and Alcohol. The effects of price on alcohol consumption and alcohol-related problems. 2002. Available from: /www.niaaa.nih.govS. 20. Jha P, Chaloupka F. The economics of global tobacco control. BMJ 2000;321:358–61. 21. Melihan-Cheinin P, Hirsch A. Effects of smoke-free environments, advertising bans and price increases. In: Boliger CT, Fagestroem KP, editors. The tobacco epidemic. Basel: Kargar; 1997. p. 230–46. 22. World Bank. Economics of tobacco control. Myths and facts. 2001. Available from: www.worldbank.org/tobacco/ faq.asp;. 23. Biener L, Harris JE, Hamilton W. Impact of the Massachusetts tobacco control programme: population based trend analysis. BMJ 2000;321(7257):351–4.
ARTICLE IN PRESS Nanny or steward? The role of government in public health 24. Townsend J, Roderick P, Cooper J. Cigarette smoking by socioeconomic group, sex, and age: effects of price, income and health publicity. BMJ 1994;309:923–7. 25. Olsson O, Wikstrom P. Effects of the experimental Saturday closing of liquor retail stores in Sweden. Contemporary Drug Problems 1982;1(3):325–54. 26. Eisner MD, Smith AK, Blanc PO. Bartenders’ respiratory health after establishment of smokefree areas and taverns. J Am Med Assoc 1998;280(22):1909–14. 27. Farrelly MC, Nonnemaker JM, Chou R, Hyland A, Peterson KK, Bauer UE. Changes in hospitality workers exposure to secondhand smoke following the implementation of New York’s smoke-free law. Tob Control 2005;14:236–41. 28. Fichtenberg CM, Glantz SA. Effect of smoke-free workplaces on smoking behaviour: systematic review. Bri Med J 2002;325(7357):188–94. 29. Babor T, Caetano R, Casswell C, Edwards G. Alcohol. No Ordinary Commodity. Research and public policy. Oxford: Oxford University Press; 2003. 30. Casswell S, Zhang J-F. Impact of liking for advertising and brand allegiance on drinking and alcohol-related aggression: a longitudinal study. Addiction 1998;93(8):1209–17. 31. Casswell S, Pledger M, Pratap S. Trajectories of drinking from 18 to 26 years: identification and prediction. Addiction 2002;97:1427–37. 32. Saffer H. Alcohol advertising bans and alcohol abuse: an international perspective. J Health Econ 1991;10:65–79. 33. Saffer H, Chaloupka F. The effect of tobacco advertising bans on tobacco consumption. J Health Econ 2000; 19:1117–37. 34. Department for Transport. Road safety statistics: Great Britain car and van seat belt wearing —percentage rates. Think! Road Safety website. 2004. [accessed 5 September 2005]. Available from: /www.thinkroadsafety.gov.uk/statistics/belt0410.htmS. 35. Department for Transport (2001). Seatbelt facts—Laws passed and lives saved: 20 facts for the 20th anniversary of compulsory seatbelt wearing. Think! Seatbelts website. 2001. [Accessed on 5 September 2005] Available from: /www.thinkseatbelts.comS. 36. Department for Transport. November, 2003. Highways Economics Note No.1 2002. Available from: /http:// www.dft.gov.uk/stellent/groups/dft_rdsafety/documents/ page/dft_rdsafety_026183.hcsS. 37. Hobbs CA. The effectiveness of seat belts in reducing injuries to car occupants. TRRL Laboratory Report 811. Transport and Road Research Laboratory: Crowthorne; 1978. 38. Rutherford WH, et al. The medical effects of seat belt legislation in the United Kingdom. Department of Health and Social Security. Research Report No 13. London: HMSO; 1985. 39. Grube J. Preventing alcohol-related problems: alcohol policy challenges. Transportation research circular in putting research into action: a symposium on the implementation
40. 41.
42.
43.
44.
45.
46.
47.
48. 49.
50.
51.
52. 53.
54.
55.
1155
of research-based impaired driving counter measures, Washington DC, USA: Transportation Research Board; 2004 Available from: www.trb.org. Eurocare. Drinking and Driving in Europe: a Eurocare report to the European Union. Brussels: Eurocare; 2003. Department for Transport. Attitudes to road safety, 2003. /http://www.dft.gov.uk/stellent/groups/dft_transstats/ documents/page/dft_transstats_028383.hcspS. Clayton AB, Tunbridge RJ. Drinking and Driving in Great Britain—the end of the decline? Paper prepared for presentation at T2000, the 15th international conference on alcohol, drugs and traffic safety, Stockholm, Sweden, 2000. Lennox R, Quimby A. Survey of drink driving behaviour, knowledge and attitudes, Transport and Road Research Laboratory; Road Safety Division: 1990. Waller S, Naidoo B, Thom B. Prevention and reduction of alcohol misuse. Evidence briefing. London: Health Development Agency; 2002. Naidoo B, et al. Smoking and public health: a review of reviews of interventions to increase smoking cessation, reduce smoking initiation and prevent further uptake of smoking Health Development Agency Evidence Briefing. London: Health Development Agency; 2004. Health Development Agency. Smoking interventions for children and young people. Health Development Agency Briefing No. 6. 2004. Grey A, Owen L, Bolling K. A breath of fresh air. Tackling smoking through the media. London: Health Development Agency; 2000. Mackay M. Seat belt legislation in Britain. J Trauma 1987; 27(7):759–62. McCarthy M. The benefit of seat belt legislation in the United Kingdom. J Epidemiol Commun Health 1989;43: 218–22. Royal Society for the Prevention of Accidents. Drinking and Driving Policy Paper. 2002. Available from: /www.rospa.com/roadsafety/info/drink_drive.pdfS. National Social Marketing Centre (National Consumer Council 2006). It’s Our Health! Realising the potential of effective social marketing. Summary. Available from: /http://www. nsms.org.uk/images/CoreFiles/NCCSUMMARYItsOurHealthJune 2006.pdfS. Saltman RB, Ferroussier-Davis O. The concept of stewardship in health policy. Bull WHO 2000;78(6):732–9. World Health Organisation. The world health report. Health systems: improving performance. Geneva: World Health Organisation; 2000. Sunstein CS, Thaler RH. Libertarian paternalism is not an oxymoron [working paper]. AEI-Brookings 2003; 1:02–3. Goodin R. In defense of the nanny state. In: Etzioni A, editor. Rights and the common good. The communitarian perspective. New York: St Martins Press; 1995. p. 123–38.
www.elsevierhealth.com/journals/pubh
Mini-Symposium
Nanny or steward? The role of government in public health Karen Jochelson The King’s Fund, London, WC1 0AN, UK Available online 25 October 2006
KEYWORDS Nanny state; Stewardship; Tobacco; Alcohol; Road safety; Government
Summary The past year has witnessed contentious debates about public health in England around smoking bans, alcohol licencing, food labelling and junk food advertising. Some people argue that any government intervention in these areas is ‘nanny statist’—an unnecessary intrusion into people’s lives and what they do, eat and drink. Others argue that only the state can alter the environment that shapes people’s decisions and behaviour. This paper suggests that there is a strong argument to be made for government intervention to safeguard public health. Legislation brings about changes that individuals on their own cannot, and sets new standards for the public good. Rather than condemning such activity as ‘nanny statist’, it might be more appropriate to view it as a form of ‘stewardship’. The paper draws on international evidence about alcohol use, smoking and road safety to show how taxation, advertising bans, regulations proscribing behaviour and education create a public health framework and shape individual choices towards healthier and safer behaviour. & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction The past year has seen contentious debates about public health in England around smoking bans, 24 hour licencing for alcohol, and junk food advertising. Critics of government policy have been quick to label proposed measures ‘nanny statist’ and an unnecessary intrusion into people’s personal lives. Government has been equally quick to distance itself from an old-style interventionist state. Corresponding author. Tel.:+44(0)20 7307 2663.
E-mail address: [email protected].
Dismissing government interventions as nanny statist precludes debate about options open to government and their likely impact on population health. This paper suggests that there is a strong argument to be made for government intervention to safeguard public health. Legislation brings about changes that individuals on their own cannot, and sets new standards for the public good. Rather than condemning such activity as ‘nanny statist’, it might be more appropriate to view it as a form of ‘stewardship’. This paper begins by examining the ‘nanny state’ debate in England, looking at examples from the past and today. It then looks at international
0033-3506/$ - see front matter & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2006.10.009
ARTICLE IN PRESS 1150 evidence about alcohol use, smoking and road safety, to show how taxation, regulation and education create a public health framework and shapes individual choices towards healthier and safer behaviour. It concludes with reflections on the impact of government intervention, and suggests that stewardship might be a more appropriate concept than ‘nanny’ as a way to envision a government’s role around protecting and promoting health.
Intervention or freedom: the nanny state debate The debate over the limits to state intervention and extent of individual freedom weaves through the history of public health. In the simplest terms, it divides between interventionists and libertarians. For interventionists, governments promote freedom for individuals by creating opportunities and levelling out inequities in society. For libertarians, minimal government is the best way to protect individual freedom, which is about not being interfered with by others. Regulations we now take completely for granted have sparked fierce controversy in their time. The first British Public Health Act, passed in 1848, gave local government powers over the water and sewage systems and was opposed for being ‘paternalist’ and ‘despotic’. For one newspaper ‘a little dirt and freedom’ was ‘more desirable than no dirt at all and slavery’.1 The Licensing Act, 1872, restricted pub-opening hours and prohibited children from drinking spirits in a pub. Many felt it better that ‘England should be free than ycompulsorily sober’. Temperance supporters replied that ‘drunken freedom’ was ‘not liberty’.2,3 The first reports linking smoking with lung cancer and recommending that people stop smoking were hugely controversial. Some newspapers defending smokers’ rights rejected tobacco tax and advertising bans as a ‘blow to freedom’, and health education as ‘propaganda’.4 The decision to make wearing seatbelts mandatory in 1983 was rejected by some MPs as ‘paternalism run rampant’; the act of a ‘nanny state’ restricting ‘freedom of choice’ for drivers; while others argued that it was ‘right for the state, with its knowledge and its power, to step in for the good of the community’.5,6 Few people would now dispute the public and individual benefits of access to clean water, a sewage system and clean air—these are infrastructural issues that individuals can do little on their
K. Jochelson own to create, but from which they benefit. Yet government action around smoking, alcohol use, exercise or eating habits is not viewed in a similar way, particularly in England. Since it came to power, the Labour government has been keen to distance itself from old-style biggovernment and avoid the nanny-statist label. It sees government as no longer ‘intrusive’ but ‘enabling’, and its role, as Prime Minister Blair explained in a recent speech, is ‘empowering the individual, not trying to make their choices for them’.7 Government rhetoric swings between supporting individual informed choice and state intervention. For example, Choosing Health, a public health white paper issued in 2004, outlines government’s role as providing information, so individuals can make ‘informed choices’, providing personalized services to support individuals motivated to make lifestyle changes, and encouraging corporate responsibility. It also recognizes a protective role in regulating activities that ‘unduly inconvenience or damage the health of others’. It believes this reflects a middle road between ‘a paternalistic state’ that ‘limit[s] individual choice, y and ban[s] y unhealthy behaviour’ and ‘stand[ing] back, leaving people’s health to whatever the hidden hand of the market and freedom of choice produces’.8 Blair’s recent speech gives more emphasis to the role of government ‘in setting standards’ through legislation as a way ‘to change a culture’.7 Libertarian critics responded to government proposals for smoke-free legislation, food labelling or life-style advice with rallying cries for individual freedom. They argued that lifestyle choices are a decision for individuals, not government, with one columnist describing advocates for state controls as ‘the forces of darkness: opposed to freedom, opposed to choice, and opposed to individual responsibility’.9 Forest, a tobacco industry-funded smokers’ rights group, argued that ‘it is up to individuals how they live their lives’ and the ‘right’ to smoke or ‘eat what you like’, was ‘as fundamental a freedom as the right to a free and private vote in elections’.10 Others dismissed advice about healthier lifestyles as ‘relentless interference’ and ‘propaganda’ turning Britons ‘into lifestyle automatons’.11,12 The debate over the nanny state and the limits to state intervention has been particularly fierce in England. This may reflect the gradual divergence in policies around health and health care in England, Scotland and Wales since devolution in 1998.13 For example, the Welsh Assembly which has focused on public health and preventing ill-health, voted for smoke-free public places in 2003, but did not then
ARTICLE IN PRESS Nanny or steward? The role of government in public health have the power to implement it. Scotland was the first to pass legislation for smoke-free public places in 2005, with widespread public, professional and political support.14 England finally passed similar legislation in 2006, but only after considerable debate revealing a lack of consensus within the two main political parties. The English government’s health policy rhetoric revolves around markets, competition, and individual choice and this may make it more difficult to justify interventions to improve or protect collective health or regulate decisions which appear to be individual ‘choices’ about lifestyle and health. Dismissing government intervention as nannystatist limits debate about the possible benefits of state intervention. Any government that wants to change the behaviour of companies or the public in response to a perceived health risk has a number of policy options open to it. It can introduce measures that encourage change in individuals, such as public information campaigns or a new health promotion service. It can introduce measures that promote change in populations, such as increasing or lowering taxation to encourage particular choices. Or it can introduce restrictive measures that ban or regulate activities or products such as advertising codes, or minimum food or air standards. The following sections draw on international and UK evidence about alcohol use, smoking and road safety to show how taxation, regulation and education create a public health framework and shape individual choices towards healthier and safer behaviour.
Taxation International studies show that increasing the price of alcohol generally leads to a decrease in consumption, with a positive follow-on effect for public health. In the UK alcohol consumption has increased as the price of alcohol relative to income has fallen and tax has fallen in real terms.15,16 Countries that increase the price of alcohol through tax find that consumption decreases. In 1992, the Northern Territory in Australia introduced a harm reduction levy on all drinks with over 3% alcohol. Over the four following years, per capita consumption decreased by 22% and alcohol related morbidity and mortality also declined.17 US studies have found that states with higher alcohol taxes have fewer deaths from liver cirrhosis, fewer motor vehicle fatalities, especially among young adults, and fewer homicides, rapes, robberies, assaults, motor vehicle thefts, domestic violence, and child abuse.18,19
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A similar pattern is evident when looking at tobacco use. Studies in low, middle and highincome countries show that taxation policy is a particularly effective way to reduce the demand for tobacco.20–22 For example, when Massachusetts imposed substantial tax increases on cigarettes in 1993, consumption fell by 4% compared to a 1% decrease in other states that had not introduced the tax.23 A UK study shows that as tobacco prices increased from the 1970s, consumption began to decline. However, when tax failed to keep up with inflation, as happened between 1977 and 1979, smoking increased by 10%.21,24 Price increases induce some smokers to quit and prevent others from becoming regular or persistent smokers.
Regulation to restrict access Completely banning access to alcohol or tobacco would be politically unacceptable, and most likely encourage illegal use. However, restricting access to alcohol and tobacco seems to reduce consumption rates, and brings wider social and health benefits. Certainly liberalizing licencing laws encourages increased consumption of alcohol. When Sweden allowed its liquor stores to open on Saturday, sales of alcohol increased, and so did rates of domestic violence and public drunkeness. As a result, the Saturday closure was reinstituted.25 When Scotland relaxed its licensing hours in 1976, alcohol consumption increased by 13%, but remained unchanged in the rest of the UK, where hours remained the same. However, when England and Wales relaxed their opening hours in 1988, only consumption by heavy drinkers appeared to increase.16 Legislation for smoke-free public places has been introduced in California (1995), New South Wales, Australia (2000), New York (2003), Ireland (2004) Scotland (2005) and England (2006). Compliance with such regulation depends on a widespread consensus among smokers and non-smokers about the ethics of public smoking, since regulations have to be enforced largely through peer pressure and social conformity, rather than financial or legal penalties.20 Research show that bans on smoking in public places reduce non-smokers’ exposure to tobacco smoke,26,27 and reduce consumption so encouraging smokers to quit. A review of 26 studies of smokefree workplaces in four countries concluded that totally smoke-free work places are twice as effective in reducing consumption and prevalence
ARTICLE IN PRESS 1152 as policies that restrict smoking to a few designated areas.28
Advertising bans Total advertising bans are associated with declining consumption of alcohol and tobacco which leads to declining morbidity and mortality from related illnesses. Reducing exposure to positive images of smoking and drinking changes attitudes to these behaviours. Research suggests that advertising shapes positive attitudes to drinking.29–31 A study that compared 17 countries over a 13-year period found that those with total bans on beer, wine and spirits advertising had lower alcohol consumption levels, lower mortality due to cirrhosis of the liver and fewer motor vehicle fatalities than countries that only banned spirit advertising or allowed advertising. A follow up study with data from 20 countries spanning a 26-year period, similarly found that banning alcohol advertising resulted in a decrease in consumption.32 Tobacco advertising bans also have a direct impact on consumption rates. A survey of advertising bans in 102 countries showed that partial bans have little or no effect, since tobacco companies switch to other media and to sponsorship, but comprehensive media bans reduce consumption.33 Norway, Finland and Iceland were among the first countries to ban tobacco advertising in the 1970s, and saw substantial reductions in smoking rates and tobacco consumption. In Iceland, smoking prevalence among 12–16 year olds, for example, dropped from 32% in 1974 to 13% in 1986, following a ban in 1971.21
Proscribing behaviour Smoking bans work through peer pressure, but wearing seatbelts and not driving when drunk depend on the state proscribing permitted behaviour and using surveillance and penalties to ensure compliance. For example, Britain was one of the first countries to require front seat belts to be fitted to cars in 1965. Adoption rates were low until it made front seatbelt use compulsory for drivers and front-seat passengers in 1983, rear seatbelt use mandatory for children in 1989, and rear seatbelt use for adults mandatory in 1991. This had an immediate impact on compliance. Between February 1982 and February 1983, seatbelt use
K. Jochelson jumped from 38% to 93% for drivers and front seat passengers. Between October 1990 and October 1991, rear-seat belt use jumped from 43% to 63%.34 Road safety organizations believe that since 1983, mandatory seatbelt use in Britain has prevented 50,000 deaths, 590,000 serious casualties and 1,590,000 minor injuries.35 The savings made as a result of these avoided deaths and injuries—in terms of medical and emergency care, lost economic ouput and loss of life and injury—is estimated at £163 billion.36 Studies comparing accident data in the year before and the year after the first seatbelt legislation found fatalities were down by between 23% and 32%; the number of patients brought to hospital declined by 15%; and those requiring admission to wards dropped by 25%.37,38 UK and international studies also show that introducing a blood-alcohol limit for drivers has an impact on fatalities and casualties. A US study based on data from 50 states found that fatalities declined by 14% between 1980 and 1997 when the legal blood alcohol concentration level dropped from 0.10% to 0.08%.39 Conversely, when the blood alcohol concentration limit was increased from 0.02% to 0.05% in Portugal, fatalities increased by 10%.40 The high compliance rates for seat belts and the blood-alcohol limit in the UK are a result of driver and passenger perceptions of the risk of getting caught and fear of the likely legal penalties. In 1992–1994, there were, on average, 120,000 fixed penalty notices, written cautions and court prosecutions for not wearing a seatbelt. By 2000, this had risen to over 200,000, even though the number of seatbelt wearers had risen in this period. This suggests that surveillance had increased.41 Similarly, since 1996, drivers involved in accidents in the UK have been breathalysed. If convicted of a drink-driving offence, drivers may lose their licence for minimum of a year. Even though the number of roadside screening tests increased from 450,000 in 1988 to 815,000 in 1998, the percentage of positive (and refused tests) has fallen from nearly 25% to 12%, indicating that fewer people are drinking and driving.42 A survey showed that respondents restricted their drinking for fear of being breathalysed, even though they realized their chances of being stopped were small, and their knowledge of the penalties was poor.43 Random or selective testing, though not permitted in the UK, has proven effective in Australia, New Zealand, the US and some European countries in reducing fatalities. On average, random testing resulted in an 18% decrease in alcohol-related
ARTICLE IN PRESS Nanny or steward? The role of government in public health crashes and a 22% decrease in fatal crashes, while selective breath testing resulted in a 20% reduction in crashes and a 23% reduction in fatal crashes.44
Education Health awareness programmes aim to change individuals’ knowledge and attitudes about risks related to health, in the hope this will affect behaviour. The evidence is equivocal about their effect. Studies of mass media alcohol campaigns show that they are cost effective, because they reach a high percentage of their target audience, but they have only some impact on knowledge and attitudes and little impact on behaviour.16 Evaluations of school-based information and normative programmes show they have, at best, short-lived, modest effects, and do not delay the onset of drinking nor sustain reduced drinking, and do not prevent alcohol misuse.16,29 Evaluations of anti-smoking education campaigns also show that awareness of the health risks of smoking does not equate with a change in behaviour.4 However, smokers exposed to mass media campaigns are still more likely to quit than those who are not.45,46 A review of international evidence showed that anti-smoking programmes for teenagers at best delay the onset of smoking, but are unlikely to prevent it.46,47 The evidence on road safety education campaigns suggests, that alone they are relatively ineffective in changing behaviour. From 1975 to 1982, the UK government ran annual education campaigns to encourage drivers and passengers to wear seatbelts, with little success and compliance levels only increased when wearing a seatbelt became mandatory.48,49 However, campaigns are a useful complement to legislation. When drinkdriving education campaigns ceased for a few years in the 1970s, the proportion of road fatalities involving alcohol rose from 15% in 1967 to 35% in 1975. Since 1977 drink driving education campaigns have run every year and by 1999 just 4% of people involved in road accidents failed the breath test.50 This suggests that education can be effective if it is not stand alone, but part of a wider health promotion campaign with clear behavioural goals. Social marketing tries to change social or health behaviours by better understanding consumers’ existing needs, beliefs and feelings and segmenting the market and targeting campaigns accordingly. Campaigns aim to increase knowledge, but also set specific behavioural goals. For example, a social
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marketing campaign aimed at pregnant women from low-income groups who smoked, showed that more women quit than in primary care trusts that did not run the campaign.51 Attitudes and behaviours change slowly. Education programmes are ineffective on their own, but as part of a comprehensive control policies including high taxation, advertising bans, and restricted access to alcohol or tobacco, or mandatory behaviour with penalties and surveillance, it is likely that they can help shape positive attitudes to healthier or safer behaviour.
Conclusions Almost every government intervention in the public health arena has been criticized by commentators of the time as a sign of tyranny, nanny statism, or the end of individual freedom. Yet the evidence discussed above illustrates the considerable individual and public health benefits of once-contested interventions—results, which arguably mitigate the small limitations on individual freedom and choice. The findings show the positive impact of education, taxation, and restrictive legislation on shaping individual’s choices for healthier behaviour, and ultimately on better health. At the outset of this paper, I suggested that ‘stewardship’ might be a more appropriate term than ‘nanny statism’ to understand the justification for and impact of the range of interventions that governments use to shape behaviour. Stewardship implies government has a responsibility for protecting national health, and to serving in the public interest and for the public good.52 For the World Health Organization, stewardship is ‘the very essence of good government’ and means that governments are ‘ultimately responsible’ for ‘their citizens’ wellbeing’.53 Public health measures which set new social standards to promote the public good and bring about changes that individuals on their own cannot, fall easily into the stewardship framework. Legislation on air quality or smoke-free public places, for example, set minimum standards that protect health and are beyond the power of individuals to choose. Stewardship also implies that a government protects its citizens against harm from others. Few would quibble with government regulations protecting vulnerable individuals, such as children from dangerous substances, or protecting a society against polluting industries. Similarly, laws against drunk driving, speed limits or smoking in public places help protect us from the potentially dangerous actions of
ARTICLE IN PRESS 1154 others by defining what is acceptable and ensuring compliance through penalties, surveillance and social pressure. Stewardship is more controversial when it comes to protecting individuals from harming themselves. However, we try to protect individuals wanting to commit suicide, from acting on their desire, knowing that they might feel differently about their lives in future. Are smoking, drinking and eating unhealthily any different? Governments cannot ban these activities, nor can it compel people to do things they do not wish to. But the case studies suggest they can encourage better choices through regulation, taxation, advertising codes and informational campaigns. These may restrict individual choices a little, but they also make it easier for individuals to make healthier choices if they wish. Some political theorists argue that such government intervention is not inconsistent with individual freedom. Sunstein and Thaler, for example, suggest that public policy eliminates obviously bad choices and encourages more positive ones to promote individual and general well-being.54 Goodin believes that where people have a conscious desire to do something they cannot bring themselves to do, public policy can enable them to recognize and act on their desire.55 Certainly, many smokers want to quit and many overweight people would like to be thinner. If government interventions make it easier for individuals to act on these desires, then it is difficult to argue that it undermines their liberty. Libertarians may well dismiss stewardship as mere semantics. But this restricts opportunities for political debate about the benefits of and limits to state intervention. It also fails to acknowledge that the debate itself is part of the process of changing attitudes and creating consensus about where to draw the line. Prime Minister Blair speaks of his ‘own personal journey of change’ over the smoke-free legislation, noting that ‘a few years back’ he ‘would have hesitated long and hard’ over the issue, but now he believed in the ‘need to be tougher, more active in setting standards and enforcing them’.7 What is clear from the case studies is that governments can act as stewards and create frameworks which encourage individuals to make healthier decisions.
References 1. Porter D. Health, civilisation and the state. A history of public health from ancient to modern times. London: Routledge; 1999. p. 120.
K. Jochelson 2. Harrison B. Drink and the Victorians. The temperance question in England 1815–1872. London: Faber and Faber; 1971. 3. Rose L. Drink and drugs. London: Batsford Academic and Educational; 1984. 4. Hilton M. Smoking in British popular culture 1800–2000. Manchester: Manchester University Press; 2000. 5. Leichter H. Lives, liberty and seat belts in Britain: Lessons for the United States. International Journal of Health Services 1986;16(2):213–26. 6. Official Report, House of Commons, Sixth Series. Parliamentary Debates: Commons, vol. 28. 1981-1982. p. 633–4, 640. 7. Blair T. Our Nation’s Future. Speech on Healthy Living. 26 July 2006. Available from: /http://www.number-10.gov.uk/ output/Page9921.aspS. 8. Department of Health. Choosing health. Making healthier choices easier. London: The Stationary Office; 2004. 9. Pollard S. Smoking bans are offensive. But they work, The Independent. October 2003. 10. Taylor K, Fraser S. Eat unhealthily in the name of democracy. Scotland on Sunday. August 2002. 11. Starr S. Exercise in futility, 30 April 2004 [accessed on 5 September 2005]. Available from: /www.spikedonline.com/Printable/0000000CA508.htmS. 12. Bristow J. A really bad habit, 12 March 2004. [accessed 5 September 2005] Available from: /http://www. spiked-online.com/Printable?0000000CA473.htmS 13. Greer SL. Territorial politics and health policy. UK health policy in comparative perspective. Manchester and New York: Manchester University Press; 2004. 14. Ash Scotland and Cancer Research UK. The Unwelcome Guest: How Scotland invited the tobacco industry to smoke outside. Ash Scotland, 2005. 15. Department of Health and National Statistics. Statistics on Alcohol: England. Bulletin 2004/15, 2004 16. Raistrick D, Hodgson R, Ritson B. Tackling alcohol together. The evidence base for a UK alcohol policy. London: Free Association Books; 1999. 17. Crosbie D, et al. Alcohol, taxation reform and public health in Australia. A submission to the Federal Parliamentary Enquiry into substance abuse in Australian Communities; 2000. Available from: /www.aph.gov.au/house/committee/ fca/subabuse/sub123.pdfS. 18. Edwards G, Anderson P, Babo TF, Casswell S, Ferrence R, Giesbrecht N, et al. Retail price influences on alcohol consumption, and taxation of alcohol as a prevention strategy. In Alcohol policy and the public good. Oxford: Oxford University Press; 1994. 19. Chaloupka F, Grossman H, Saffer H, National Institute of Alcohol Abuse and Alcohol. The effects of price on alcohol consumption and alcohol-related problems. 2002. Available from: /www.niaaa.nih.govS. 20. Jha P, Chaloupka F. The economics of global tobacco control. BMJ 2000;321:358–61. 21. Melihan-Cheinin P, Hirsch A. Effects of smoke-free environments, advertising bans and price increases. In: Boliger CT, Fagestroem KP, editors. The tobacco epidemic. Basel: Kargar; 1997. p. 230–46. 22. World Bank. Economics of tobacco control. Myths and facts. 2001. Available from: www.worldbank.org/tobacco/ faq.asp;. 23. Biener L, Harris JE, Hamilton W. Impact of the Massachusetts tobacco control programme: population based trend analysis. BMJ 2000;321(7257):351–4.
ARTICLE IN PRESS Nanny or steward? The role of government in public health 24. Townsend J, Roderick P, Cooper J. Cigarette smoking by socioeconomic group, sex, and age: effects of price, income and health publicity. BMJ 1994;309:923–7. 25. Olsson O, Wikstrom P. Effects of the experimental Saturday closing of liquor retail stores in Sweden. Contemporary Drug Problems 1982;1(3):325–54. 26. Eisner MD, Smith AK, Blanc PO. Bartenders’ respiratory health after establishment of smokefree areas and taverns. J Am Med Assoc 1998;280(22):1909–14. 27. Farrelly MC, Nonnemaker JM, Chou R, Hyland A, Peterson KK, Bauer UE. Changes in hospitality workers exposure to secondhand smoke following the implementation of New York’s smoke-free law. Tob Control 2005;14:236–41. 28. Fichtenberg CM, Glantz SA. Effect of smoke-free workplaces on smoking behaviour: systematic review. Bri Med J 2002;325(7357):188–94. 29. Babor T, Caetano R, Casswell C, Edwards G. Alcohol. No Ordinary Commodity. Research and public policy. Oxford: Oxford University Press; 2003. 30. Casswell S, Zhang J-F. Impact of liking for advertising and brand allegiance on drinking and alcohol-related aggression: a longitudinal study. Addiction 1998;93(8):1209–17. 31. Casswell S, Pledger M, Pratap S. Trajectories of drinking from 18 to 26 years: identification and prediction. Addiction 2002;97:1427–37. 32. Saffer H. Alcohol advertising bans and alcohol abuse: an international perspective. J Health Econ 1991;10:65–79. 33. Saffer H, Chaloupka F. The effect of tobacco advertising bans on tobacco consumption. J Health Econ 2000; 19:1117–37. 34. Department for Transport. Road safety statistics: Great Britain car and van seat belt wearing —percentage rates. Think! Road Safety website. 2004. [accessed 5 September 2005]. Available from: /www.thinkroadsafety.gov.uk/statistics/belt0410.htmS. 35. Department for Transport (2001). Seatbelt facts—Laws passed and lives saved: 20 facts for the 20th anniversary of compulsory seatbelt wearing. Think! Seatbelts website. 2001. [Accessed on 5 September 2005] Available from: /www.thinkseatbelts.comS. 36. Department for Transport. November, 2003. Highways Economics Note No.1 2002. Available from: /http:// www.dft.gov.uk/stellent/groups/dft_rdsafety/documents/ page/dft_rdsafety_026183.hcsS. 37. Hobbs CA. The effectiveness of seat belts in reducing injuries to car occupants. TRRL Laboratory Report 811. Transport and Road Research Laboratory: Crowthorne; 1978. 38. Rutherford WH, et al. The medical effects of seat belt legislation in the United Kingdom. Department of Health and Social Security. Research Report No 13. London: HMSO; 1985. 39. Grube J. Preventing alcohol-related problems: alcohol policy challenges. Transportation research circular in putting research into action: a symposium on the implementation
40. 41.
42.
43.
44.
45.
46.
47.
48. 49.
50.
51.
52. 53.
54.
55.
1155
of research-based impaired driving counter measures, Washington DC, USA: Transportation Research Board; 2004 Available from: www.trb.org. Eurocare. Drinking and Driving in Europe: a Eurocare report to the European Union. Brussels: Eurocare; 2003. Department for Transport. Attitudes to road safety, 2003. /http://www.dft.gov.uk/stellent/groups/dft_transstats/ documents/page/dft_transstats_028383.hcspS. Clayton AB, Tunbridge RJ. Drinking and Driving in Great Britain—the end of the decline? Paper prepared for presentation at T2000, the 15th international conference on alcohol, drugs and traffic safety, Stockholm, Sweden, 2000. Lennox R, Quimby A. Survey of drink driving behaviour, knowledge and attitudes, Transport and Road Research Laboratory; Road Safety Division: 1990. Waller S, Naidoo B, Thom B. Prevention and reduction of alcohol misuse. Evidence briefing. London: Health Development Agency; 2002. Naidoo B, et al. Smoking and public health: a review of reviews of interventions to increase smoking cessation, reduce smoking initiation and prevent further uptake of smoking Health Development Agency Evidence Briefing. London: Health Development Agency; 2004. Health Development Agency. Smoking interventions for children and young people. Health Development Agency Briefing No. 6. 2004. Grey A, Owen L, Bolling K. A breath of fresh air. Tackling smoking through the media. London: Health Development Agency; 2000. Mackay M. Seat belt legislation in Britain. J Trauma 1987; 27(7):759–62. McCarthy M. The benefit of seat belt legislation in the United Kingdom. J Epidemiol Commun Health 1989;43: 218–22. Royal Society for the Prevention of Accidents. Drinking and Driving Policy Paper. 2002. Available from: /www.rospa.com/roadsafety/info/drink_drive.pdfS. National Social Marketing Centre (National Consumer Council 2006). It’s Our Health! Realising the potential of effective social marketing. Summary. Available from: /http://www. nsms.org.uk/images/CoreFiles/NCCSUMMARYItsOurHealthJune 2006.pdfS. Saltman RB, Ferroussier-Davis O. The concept of stewardship in health policy. Bull WHO 2000;78(6):732–9. World Health Organisation. The world health report. Health systems: improving performance. Geneva: World Health Organisation; 2000. Sunstein CS, Thaler RH. Libertarian paternalism is not an oxymoron [working paper]. AEI-Brookings 2003; 1:02–3. Goodin R. In defense of the nanny state. In: Etzioni A, editor. Rights and the common good. The communitarian perspective. New York: St Martins Press; 1995. p. 123–38.