Observations On the Contrary

Letter to an unknown health minister

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d6004 (Published 21 September 2011) Cite this as: BMJ 2011;343:d6004
  1. Tony Delamothe, deputy editor, BMJ
  1. tdelamothe{at}bmj.com

Legislation, regulation, and taxation are the best ways to change behaviour


Dear Minister

I imagine you in your suite at the Millennium UN Plaza Hotel, pondering how to justify your entourage’s trip to the United Nations summit on non-communicable diseases this week. You already knew that heart disease, lung disease, cancer, and diabetes together kill more than half the people in your country. The summit recognised that prevention must be the cornerstone of global and national responses to non-communicable diseases (BMJ 2011;343:d6034, doi:10.1136/bmj.d6034). So what have you decided to do about the risk factors targeted by the summit: tobacco use, unhealthy diet, lack of physical activity, and alcohol misuse?

I wasn’t at the summit, but the participants I’ve talked to were disappointed that food and alcohol companies got off so lightly. But don’t despair: so much was published in the run up to the summit that a consensus about future action is emerging.

But firstly I need to get a few apologies out of the way. I’m sorry that some Western countries with antismoking policies to protect their own citizenry lobbied against imposing fiscal penalties on tobacco elsewhere. And that they resisted recommendations from the G77 group of low and middle income countries to reduce the amount of saturated fats, sugar, and salt in processed food (BMJ 2011;343:d5328, doi:10.1136/bmj.d5328). You must have thought that these countries were more concerned to protect the financial health of some of their companies than the health of your population.

In fact, the focus of their lobbying is the best guide to what works to change behaviour. Legislation and taxation were so firmly resisted in the run up to the summit because they have the best chance of effecting change. In her article on the risk of industry derailing the summit, Deborah Cohen quoted an academic: “Note that effective evidence based measures on alcohol (controlling price, availability, and marketing) are being deleted, and industry favoured measures (partnership working, community actions, and health promotion) being substituted” (BMJ 2011;343:d5328, doi:10.1136/bmj.d5328). Or as an alcohol industry representative said before the summit, “We will do anything as long as it is voluntary” (BMJ 2011;343:d5336, doi:10.1136/bmj.d5336).

There’s an instructive tale from the United Kingdom about what does and doesn’t work to reduce smoking. Earlier this month the Financial Times reported how the tobacco industry’s main trade body is losing five of its seven employees. This followed “a year and a half of frustrated ambitions as the government resisted pressure to ease restrictions on smoking and tobacco advertising and marketing, including bans on cigarette adverts imposed between 2003 and 2005, the 2007 prohibition on smoking in public places and a forthcoming ban on cigarette vending machines” (http://on.ft.com/pbAeNY). Part of the reason for this, said the outgoing head of the trade body, was that the government coalition had been less willing than past conservative administrations to rely on industry self regulation.

Despite the UK government’s success at playing hardball with tobacco manufacturers, it is promoting “responsibility deals” with food manufacturers. Intended to help people make healthy choices, these favour partnerships over legislation but have been branded as “irresponsible” and “inadequate” by the Children’s Food Campaign in an early progress report (BMJ 2011;343:d5791, doi:10.1136/bmj.d5791). Many big food companies haven’t yet signed up to any health pledge; others have signed up to ones that are irrelevant to them.

The summit’s declaration does include the elimination of industrially produced trans fats from food, but tellingly this welcome outcome grew out of legislative change, not industry self regulation. Denmark paved the way by banning trans fats in 2003, and New York city’s ban in 2008 caught the US’s attention. The food industry had been arguing that it couldn’t be done (BMJ 2011;343:d5567, doi:10.1136/bmj.d5567).

So if you want to make a difference to the health of your people, be prepared to ignore the claims of companies trying to protect their business and of countries trying to protect their companies. Remember the warning of Margaret Chan, director general of the World Health Organization, that many of the threats to health nowadays “come from corporations that are big, rich, and powerful, driven by commercial interests” (http://bit.ly/pA18W9).

Expect to have to convince your colleagues in government about the importance of changing the law and regulating and taxing unhealthy products. The declaration acknowledges that taxes reduce tobacco consumption, so don’t let your trade minister get away with arguing that they don’t. And warn him or her of the dangers of sleepwalking into trade agreements that might come back to kick you both in the teeth. For example, Australia’s attempt to introduce the world’s toughest antismoking legislation may yet be thwarted by treaties it has signed over the years. The Scottish National Party may have won a landslide electoral victory with a manifesto promise to set a minimum price for a unit of alcohol, but its opponents are talking darkly of blocking this under European Union competition laws (BMJ 2011;343:d5869, doi:10.1136/bmj.d5869).

“Safe, affordable, effective and quality medicines” is what the summit’s declaration says that the drugs to treat non-communicable diseases should be. Yet New Zealand’s attempts to keep down the prices of prescription drugs there is being endangered by the Trans-Pacific Partnership trade agreement (BMJ 2011;342:d3933, doi:10.1136/bmj.d3933).

The summit declaration you’ve signed would have been much more onerous if the policies and targets agreed by countries like yours hadn’t been “systematically deleted, diluted, and downgraded,” as the four disease associations behind the summit complained to the UN secretary general last month (http://on.ft.com/puPO8N). But there’s nothing to stop you from acting on the evidence that has been amassed in the run up to the summit. Doing that would more than justify your trip.

Yours faithfully

Tony Delamothe, deputy editor, BMJ


Cite this as: BMJ 2011;343:d6004

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