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Head To Head

Are nanny states healthier states?

BMJ 2016; 355 doi: (Published 07 December 2016) Cite this as: BMJ 2016;355:i6341
  1. Simon Capewell, professor of public health and policy1,
  2. Richard Lilford, professor of public health2
  1. 1Department of Public Health and Policy, University of Liverpool, UK
  2. 2Warwick Medical School, University of Warwick, Coventry CV4 7AL
  1. Correspondence to: S Capewell capewell{at}, R Lilford r.j.lilford{at}

State regulation is necessary for safety, says Simon Capewell, but Richard Lilford argues that restricting adults’ choice can undermine such aims

Yes—Simon Capewell

The term “nanny state” is often used pejoratively but it can also describe a safe and healthy environment for our children and families, as invoked by the use of “nanny” to describe a grandmother or professional carer.

To fulfil our potential, we each depend on Maslow’s “pyramid of needs”: esteem, love, affection, and belonging to a group. These in turn depend on a foundation of physical safety, shelter, health, food, water, and sleep.1 In rich countries, we take these health determinants for granted—for example, with clean drinking water, drains, unpolluted air, car seatbelts, safe planes, immunisations, and smoke-free environments.2 However, in countries without such regulation and legislation, these crucial determinants of health are not guaranteed, and the strong are then free to exploit the weak.

Voluntary pledges, responsibility deals, and the effectiveness hierarchy

Public health legislators can choose “upstream” or “downstream” approaches. Downstream interventions include advice or education for individuals, “nudge,” voluntary pledges, and “responsibility deals.” These approaches are generally ineffective, weak,3 4 or inequitable.5

Conversely, upstream interventions such as regulation, taxation, or mandatory reformulation represent much more powerful structural actions that make the environment safer and healthier. This “effectiveness hierarchy” is evidenced by public health successes in controlling tobacco, alcohol, and harmful dietary nutrients such as salt, sugar, and fats.6 For instance, use of industrial trans fats in food products has only been modestly decreased in the UK by downstream advice, education, and labelling. In Denmark, however, upstream measures underpinned by legislation have effectively eliminated this food toxin.7

The nanny state generally enjoys (sometimes muted) support from scientists, the public, and democratic politicians. Hence the many effective public health interventions supported …

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