Intended for healthcare professionals


Levelling up prevention in primary care

BMJ 2022; 378 doi: (Published 26 September 2022) Cite this as: BMJ 2022;378:o2324
  1. Laura Heath, GP, Wellcome Trust doctoral fellow,
  2. Brian Nicholson, GP, academic clinical lecturer,
  3. Paul Aveyard, GP, professor of behavioural medicine
  1. Nuffield Department of Primary Care Health Sciences, University of Oxford
  1. Follow Laura Heath on Twitter @laurahheath

Much of what we do in primary care is prevention. We diagnose and manage hypertension, reduce cholesterol, optimise diabetes care, and initiate anticoagulation in atrial fibrillation. All of these are preventative interventions in patients who are largely asymptomatic. By embracing these preventative activities, we endorse them as a worthwhile use of clinician time.

Preventative treatment of diabetes and hypertension rarely extends to treating the underlying cause, however, and behavioural risk factors in people without “comorbidity” to prevent the onset of disease are even less likely to be tackled. Half of all smokers will die prematurely, 52% of cancer deaths are attributable to smoking,1 and obesity can reduce life expectancy by 10 years.2 While good progress was made in reducing smoking prevalence in the past few decades, prevalence has stalled at around 15%,3 and the prevalence of excess weight rose during the pandemic with two thirds of UK adults now overweight or obese.4

Despite this, clinicians tend to deliver advice to change behaviour rather than offer treatment or support for smoking cessation and obesity.56 Patients typically share the same goal as their GP in wanting to stop smoking or lose weight and many are trying to achieve this, but what they lack—and what they have a right to expect from their GP—is often the offer of treatment to help them reach their goal. People do not lower their blood pressure if they are advised to do so, we need to treat tobacco addiction and obesity with at least the same dedication as these other examples of preventative care.

Some GPs report that smoking and obesity are public health problems and not within the clinician remit. Yes, much more needs to be done on a population level to reduce the risk of development of obesity or of tobacco addiction,7 and the recent government U turn on TV advertising on junk food and ban on “buy one get one free” deals for foods high in fat, salt, or sugar was disappointing. But this does not remove our clinical responsibility to the patient in front of us, especially when there are effective and cost saving treatments available.89 Smoking and excess weight are often the most significant health risks a person faces and not tackling them is a disservice to our patients, regardless of what we are directly incentivised to do.

Some believe that tackling behavioural risk factors—and excess weight, in particular—could be stigmatising, disrupt the doctor-patient relationship, or shifts society’s burden to the individual to solve. This prevents action. Studies have shown, however, that discussing weight sensitively with the offer of support is usually welcomed.10 Ironically, if clinicians do not engage with treatment and support, it passes the buck back to the individual completely to “go it alone.”

We asked clinicians in a focus group study to explain why their management of hypertension was more frequent and routine than their management of obesity. The hesitant response was that hypertension can be treated by a pill. As clinicians, we need to reflect on the unconscious biases that dictate what medicine we do and do not practise. These biases towards particular risk factors can result in outsourcing, devaluing, and underfunding key preventative care interventions because behavioural risk factors do not fit a traditional biomedical physician model.

Prevention is particularly important today as we await the government’s health disparities white paper. Tobacco addiction and obesity are increasingly related to poverty. The prevalence of overweight and obesity is 17 and 8 percentage points higher in the most deprived compared with the least deprived areas for women and men respectively.11 Similarly, 17% of adults in the most deprived areas smoke compared with 9% in the least deprived.12 As clinicians, we should not wait for the eradication of poverty to act. It is time for smoking cessation and obesity services to be reprioritised, not outsourced and underfunded. They should be levelled up and fully integrated in a personalised, holistic primary care system.


  • I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: LH is funded by the Wellcome Trust. BDN is funded by the National Institute for Health Research and Cancer Research UK. PA is funded by NIHR Biomedical Research Centre, Oxford, and NIHR Applied Research Collaboration, Oxford and Thames Valley and is an NIHR senior investigator. PA is an investigator in two publicly funded (National Institute for Health Research) trials in which the weight loss intervention was donated by Nestlé Health Sciences and Oviva to the University of Oxford outside the submitted work. PA is an investigator on a trial part funded by Cambridge Weight Plan. None of these associations led to payments to PA personally. The views expressed are those of the author(s) and not necessarily those of the University of Oxford, NHS, NIHR, CRUK, Wellcome, or the Department of Health.