Nanny or steward? The role of government in public health

doi:10.1016/j.puhe.2006.10.009

Public Health

Volume 120, Issue 12, December 2006, Pages 1149-1155

https://doi.org/10.1016/j.puhe.2006.10.009 Get rights and content

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.

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.

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 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.

Section snippets

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

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%

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

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, 30, 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

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

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

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

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Mini-SymposiumNanny or steward? The role of government in public health

Summary

Introduction

Section snippets

Intervention or freedom: the nanny state debate

Taxation

Regulation to restrict access

Advertising bans

Proscribing behaviour

Education

Conclusions

J Health Econ

J Health Econ

Health, civilisation and the state. A history of public health from ancient to modern times

Drink and the Victorians. The temperance question in England 1815–1872

Drink and drugs

Smoking in British popular culture 1800–2000

Lives, liberty and seat belts in Britain: Lessons for the United States

International Journal of Health Services

Choosing health. Making healthier choices easier