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Opportunity knocks

The public health debate has picked up pace resulting in the publication of the Public Health White Paper. But has the government taken the right stance on smoking and obesity?

The public health debate has picked up pace in the UK recently, resulting in the publication of the Public Health White Paper in November 2004. But has the government taken the right stance on smoking and obesity?

When the White Paper was launched in the House of Commons, Dr John Reid referred to the fact that a child born in Kensington lives seven years longer than a child born in Manchester. Does the blueprint live up to expectations in tackling such inequalities, and will fundamental change be delivered in our lifetimes? To what extent did the government bow to pressure from lobby groups on issues such as banning smoking in public places?

Before launching the White Paper, it was clear that the government wanted people to make healthy choices rather than implementing a 'nanny state' approach. In his speech to IPPR and Demos a month before publication, the Prime Minister referred to striking a balance between advancing public health, and not interfering unduly in lifestyle choices. Choosing Health: making healthier choices easier is clear in its preferred approach: enabling people to make informed choices about health and lifestyle, with little space for compulsion and banning.

However, I believe the government has missed a trick. For whilst individuals should make their own choices, the government does have the right to implement decisions, when there is evidence of danger to others from unhealthy behaviour. The White Paper was a top three issue discussed on the fringes of the party conferences last Autumn.

Smoking controversy

The key issue that disappointed health experts and pressure groups was failing to introduce an outright ban on smoking in public places. The single biggest contributor to health inequalities, coalitions of experts had been presenting the overwhelming case in support of the ban. Positive evidence from smoking bans in New York, Ireland and Norway did little to influence the government - neither did the overwhelming public support of a ban. This was surprising, given that this government has let the focus groups and comment pages dictate its approach to policy issues.

Even though many of the broadsheets backed the ban, Ministers were running scared of the Sun leader writers and drinkers at working men's clubs. So they opted to ban smoking in public places except pubs and bars where food isn't served, and private members' clubs. Having visited Dublin and New York post ban, the success is down to blanket bans, with no exceptions. By permitting smoking in certain premises, pub proprieters may well close down their kitchens to evade the ban.

Just a week before the publication of the White Paper, smoking was banned in all public places in Scotland. It's ironic that Dr Reid's constituents in Hamilton will benefit from the ban, but workers in Carlisle's pubs and bars will continue to be exposed to second-hand smoke.

With the aim of reducing the number of smokers by two million in five years, the government has set a major target that will require a step-change in support and advice available to smokers. The White Paper promises additional investment in NHS Stop Smoking services and the government has pledged to introduce the EU's additional warnings and graphic images on tobacco products. But the government missed a major opportunity of not enforcing an outright ban.

Obesity threat

With obesity, The White Paper recognises that it is increasing in adults and children, and poses a serious threat to our health. Acknowledging that obesity is a public health issue marks a significant change in approach, where previous governments saw obesity as solely a matter of individual responsibility. This position has sparked considerable political and public debate over how the responsibility for obesity should be attributed between government, schools, parents, food manufacturers and consumers.

While the Tories have labelled the proposals as a return to the 'nanny state', the Health Secretary argues otherwise. He maintains that, while the public must be allowed to make their own choices on their health, it is the government's role to ensure that individuals have the necessary information to allow them to make an informed choice.

So by encouraging people to make healthy food choices, obesity should be prevented through these tactics. The government has asked the Food Standards Agency to develop clearer labelling on processed food, while OFCOM have been charged with developing guidelines on how and when food is advertised to children.

Instead of forcing legislation, the White Paper offers the industry the opportunity to work with the government and develop guidelines on these areas. A voluntary approach is clearly preferred by the government, as it persuades the food industry to voluntarily lower salt, fat and sugar content of products.

Under a code for processed foods, fat, sugar and salt content will need to be clearly indicated. However, the government will have a hard job finding a consensus between industry and consumer groups.

Besides this, the White Paper also focuses on increasing the role of the NHS and health professionals in decreasing obesity, and sets out structural developments for the future. A commitment to providing a £1bn investment in school sport and physical education will go a long way to meeting the Public Service Agreement to halt childhood obesity by 2010.

We finally have a government that has recognised that tomorrow's health problems can be prevented today, and that we have a collective responsibility to tackle health inequalities. On reflection, the White Paper could have been a springboard for action and a blueprint for change.

However, on the issues of smoking and obesity, the government lost its nerve and buckled to the media and voter's resentment. Any serious health practitioner would ban smoking in public places immediately, and insist on more than a voluntary approach to reducing and labelling fat, salt and sugar content.

Later this month, Dr John Reid and his colleagues are scheduled to meet before the Health Select Committee (HSC), in a one-off session on the White Paper. I'm sure HSC members will relish asking the Secretary of State why they failed to capitalise on a new era in public health. They will want to know why they missed the best opportunity yet to take decisive action to meet our public health goals and tackle health inequalities.

The Author
John Lehal is associate director for Edelman's Health Policy and Public Affairs Practice.

2nd September 2008

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