The authors would like to thank colleagues who have informed and supported this work. We are grateful to our external reviewers Theresa Marteau, Steven Cummins, Hazel Cheeseman and Caroline Cerny. We would also like to thank Health Foundation colleagues Hugh Alderwick, Jo Bibby, Katherine Merrifield, Gwen Nightingale, Adam Tinson, Sean Agass and Jennifer Dixon.

Errors or omissions remain the responsibility of the authors alone.

When referencing this publication please use the following URL: https://doi.org/10.37829/HF-2022-P10.

• The UK’s health looks increasingly frayed and unequal. Even prior to the pandemic, people were living more years in poor health, gains in life expectancy had stalled, and inequalities were widening. This has a costly impact on individuals, communities, public services, and the economy.
• Smoking, poor diet, physical inactivity and harmful alcohol use are leading risk factors driving the UK’s high burden of preventable ill health and premature mortality. All are socioeconomically patterned and contribute significantly to widening health inequalities.
• This report summarises recent trends for each of these risk factors and reviews national-level policies introduced or proposed by government in England between 2016 and 2021 to address them. Based on our review, we assess the government’s recent policy position and point towards policy priorities for the future.
• There are stark warning signs that government needs to shift its approach to improve health. Rates of childhood obesity have risen sharply in recent years and inequalities have widened. Smoking remains stubbornly high among those living in more deprived areas. Alcohol-related hospital admissions and deaths have increased and rates of harmful drinking have gone up. Physical activity levels also remain low and appear to have declined during the pandemic.
• Population-level interventions that impact everyone and rely on non-conscious processes are most likely to be both effective and equitable in tackling major risk factors for ill health. Yet recent government policies implemented in England have largely focused on providing information and services designed to change individual behaviour.
• As well as relying heavily on policies that promote individual behaviour change, our review shows that the strength of the government’s approach has been uneven for the leading risk factors, and decision making across departments has been disjointed. Action to tackle harmful alcohol use in England has been particularly weak.
• To reduce exposure to risk factors and tackle inequalities, government will need to deploy multiple policy approaches that address the complex system of influences shaping people’s behaviour.
• Population-level interventions that are less reliant on individual agency and aim to alter the environments in which people live should form the backbone of strategies to address smoking, alcohol use, poor diet and physical inactivity. These interventions need to be implemented alongside individual-level policies supporting those most in need. The strong role played by corporations in shaping environments and influencing individual behaviour must also be recognised and addressed in a consistent way through government policy.
• Some of the biggest immediate gains could be made by adopting price-based policies, taxes and regulations already proposed in previous government documents. Examples include minimum unit pricing for alcohol (already introduced in Scotland and Wales); a sugar and salt reformulation tax; and raising the age of sale for tobacco from 18 to 21.
• The costs of government inaction on the leading risk factors driving ill health are clear. As the country recovers from the COVID-19 pandemic and seeks to build greater resilience against future shocks, now is the time to act.

Why government needs to act

A healthy population is an asset for any nation, supporting positive social and economic outcomes for individuals and society.,,, Across a number of measures, however, the UK’s health looks increasingly frayed and unequal., In the decade prior to the pandemic, improvements in life expectancy were lower than in most European and other high-income countries. People are living more years in poor health and inequalities in how long those in the most and least deprived parts of the country can expect to remain in good health are widening., Those living in the north of England, Scotland, and the South Wales Valleys have particularly low average healthy life expectancy compared to other parts of the country, with a gap of almost 20 years between women living in the richest and poorest areas.

International data show that relative to comparable European countries, the UK also has a higher prevalence of largely preventable, non-communicable conditions including some types of cancer, diabetes, COPD, asthma and obesity.,, This is costly for individuals and the economy. More than a third of those aged 25–64 in areas of England with the lowest healthy life expectancy are economically inactive due to long-term sickness or disability.

Smoking, poor diet, physical inactivity, and harmful alcohol use are leading risk factors driving this high burden of preventable ill health and premature mortality., All are socioeconomically patterned and have multiple, interrelated causes. People’s ability to adopt healthy behaviours is strongly shaped by the circumstances in which they live. That includes the education and support they receive in their early years, the resources they have to buy healthy food, the shops in their local communities, and whether there are green spaces and safe streets to be physically active in. There are also strong commercial factors at play, including the relative expense and availability of healthy and unhealthy foods, alcohol, and tobacco, and the ways in which they are advertised and promoted. These ‘wider determinants of health’ therefore act in both direct and indirect ways, through complex causal systems, to influence how populations and individuals are exposed to different risk factors.,

COVID-19 has exposed the consequences of government and wider society failing to act ambitiously enough to address the nation’s poor health., Our obesity rates – the highest in Europe – left the UK particularly vulnerable to poor outcomes from the virus and contributed to high death rates. Likewise, people with type 2 diabetes and hypertension (conditions linked to poor diet, obesity, and physical inactivity) are significantly more likely to die from COVID-19. For people younger than 65, the COVID-19 mortality rate was almost four times higher in the most deprived areas of England than in the least deprived during the first two waves of the pandemic, partly due to a higher burden of preventable poor health.

Government interventions to address the leading risk factors

Government has signalled its intention to act to reduce inequalities and improve health. It has promised to ‘level up’ the country and committed to extend healthy life expectancy by 5 years by 2035, while narrowing the gap between the richest and poorest., It has also set ambitious targets for some risk factors, including to go ‘smoke-free’ by 2030 and halve childhood obesity while reducing inequalities., Based on current trajectories, these targets will be missed.,,

With a new Office for Health Promotion and Disparities (OHID) and a ‘health disparities’ white paper expected from the Department of Health and Social Care (DHSC) in 2022, there is an opportunity for more cross-government action on health. This must address the breadth of factors that affect people’s exposure to ill health. There are signs the public would support a shift in approach. Recent Health Foundation/Ipsos MORI polling – conducted between 25 November and 1 December 2021 – found only 1 in 5 (18%) people in England agree that the government has the right policies in place to improve public health, while nearly half (46%) disagree. The polling also suggests strong public support for government action to address health inequalities, with the majority agreeing it is important that the government addresses health differences by income (75%), geographical area (72%), education level (69%) and ethnicity (65%).

A population-level approach

Public health interventions can be viewed along two continuums (Figure 1). Along one, population-level approaches and those targeting individuals lie at the two extremes. The other captures the level of personal resources or ‘agency’ needed for individuals to benefit from interventions. Examples of higher agency, individual-level interventions include educational classes, apps that provide people with rewards and advice to incentivise healthy eating,, and counselling services. Examples of low-agency, population-level interventions include minimum unit pricing for alcohol, regulations to restrict marketing and advertising of unhealthy food, and taxes aimed at encouraging reformulation of unhealthy products.

While important as part of a multi-component approach, interventions that rely on high levels of individual agency will have limited impact in isolation. Unless carefully targeted and tailored to those most in need of support, they can also widen inequalities. This is because more affluent individuals are more likely to have the necessary personal resources – or agency – required to benefit. For example, following referral to an exercise or healthy eating class, a person will have to identify that they have a problem, see a health professional, get a referral, travel to the class, understand and be able to act on the advice provided, and sustain a change in their behaviour over the long term. With potential for attrition at each step, this will be far easier for those who have more time, money and fewer competing stresses in their lives. By contrast, population-level interventions that rely on non-conscious processes and impact everyone – such as fiscal measures, reformulation, and marketing restrictions – are generally more likely to be both effective and equitable.,,,

It is not, however, a simple case of either/or. To reduce exposure to risk factors driving ill health and tackle inequalities, the government will still need to deploy multiple policy approaches designed to address the complex system of influences that shape behaviours. The focus needs to be on population-level policies including taxation, regulation, and public spending, which should be implemented alongside individual-level interventions to support those most in need. To be effective, policies that directly target a particular risk factor must be underpinned by wider structural interventions designed to improve the circumstances in which people live – reducing factors such as poverty and poor housing, and making it easier for people to adopt healthy behaviours.

This report explores national government policy approaches directly targeting smoking, unhealthy diets, physical inactivity and harmful alcohol use. We begin by providing an overview of recent trends in these risk factors, then summarise recent key targets and policies put forward for each by the UK government in England. We analyse national level policies introduced or proposed by government between 2016 and 2021, including policy aims, approaches, and other factors (see Appendix 1 for more details). Based on this review, we assess the government’s current policy position and point towards priorities for the future.

The risk factors driving ill health often overlap and share many common determinants and health impacts. This section outlines key trends and health impacts for each risk factor individually. We describe the socioeconomic inequalities that exist for each, focusing on differences by level of deprivation. Other inequalities relating to ethnicity, gender and age also exist but are not covered in this report.

Smoking

Smoking is the leading cause of preventable ill health and death in England, and a significant contributor to inequalities in life expectancy. It puts people at high risk of developing cancer, cardiovascular and respiratory diseases,, and was responsible for nearly 75,000 deaths and more than 500,000 hospital admissions in England in 2019.

Smoking prevalence in England has almost halved from 27% to 16% over the past two decades. However, socioeconomic inequalities remain high (Figure 2). In 2019, 17% of adults in the most deprived areas smoked, compared with 9% in the least deprived. The difference is also stark for smoking during pregnancy. Nearly twice as many women smoked at time of delivery in the most deprived local authorities compared with the least deprived. Smokers working in routine and manual occupations try to quit as often as more affluent individuals, but are less likely to succeed.

It remains unclear how smoking habits changed during the pandemic, with inconsistent findings from surveys and official statistics on smoking not comparable with previous years due to changes in data collection methodology.,,,,

Diet

Diet is a key determinant of people’s health, with an estimated 60,000 deaths in England attributable to poor diets in 2019. As well as causing overweight and obesity, diets that are low in nutritious wholefoods and high in sugar and ultra-processed foods (UPFs) are independently associated with a range of health impacts. This includes increased risk of some cancers, hypertension, heart disease, poor oral health and premature death.,,

Fruit and vegetable consumption has been consistently low over the past decade, particularly among those living in the most deprived areas., In 2018, fewer than 3 in 10 adults in England ate the recommended five portions a day. The UK population consumes more highly processed food than any other European country,,, and consumption of free (added) sugars exceeds government guidelines, with those aged 11–18 years in 2016–2019 consuming more than double the recommended limit. The pandemic has had mixed effects on eating habits, with increases in cooking from scratch and eating healthier meals reported, but also in snacking. It has increased food poverty and insecurity, with 2.5 million people using food banks in 2020/21 – a 33% annual increase.

Physical activity

Physical activity can help to prevent and manage overweight and obesity, and protect against a range of noncommunicable diseases including cardiovascular disease and diabetes., It also has positive effects on mental health and can support social inclusion. In 2019, an estimated 10,000 deaths were attributable to low physical activity. Although the relative impact on morbidity and mortality is lower for physical activity than poor diet, increased physical activity provides additional benefits, including prevention of falls and fractures.,

The UK population is around 20% less active than in the 1960s and will be 35% less active by 2030 if trends continue. Activity fell in adults and children during the pandemic. Between May 2020 and May 2021, 61% of adults aged 16 years and older were physically active compared with 63% between May 2018 and May 2019. The percentage of physically active children fell from 47% in 2018/19 to 45% in 2020/21.

Obesity

Poor diet and physical inactivity are leading risk factors for overweight and obesity, which significantly increase the risk of developing conditions including type 2 diabetes, some cancers, cardiovascular and liver disease, dementia and mental health conditions. Obesity can also impact day-to-day living as a result of breathing difficulties, tiredness and joint pain. In 2018/19, there were 876,000 obesity-related hospital admissions.

Rates of overweight and obesity among adults and children have increased over the past 20 years in England (Figure 3). There are also significant – and widening – socioeconomic inequalities, particularly for obesity rates in children (Figure 4). A sharp increase in rates of childhood overweight and obesity has been seen during the pandemic: in the space of a year, rates rose from 35% to 41% in 10–11-year-olds, and from 23% to 28% in 4–5-year-olds.

Alcohol use

Alcohol consumption can negatively impact nearly every organ in the body, causing liver disease, heart disease, cancer, and mental health problems. It was the main reason for 320,000 hospital admissions in 2019/20, with 6,984 alcohol-specific deaths in England in 2020, a 20% increase on the previous year., Harmful alcohol use also has a significant social impact, increasing the risk of accidents, violence, child neglect and antisocial behaviour.

While the number of adults drinking more than the recommended 14 units per week had been falling in England, this trend has reversed over the past few years. Surveys and polling have consistently shown adults reported drinking more during the pandemic than in previous years. Although the highest fifth of earners are the most likely to drink over the recommended amount, alcohol-attributable hospital admissions and deaths are significantly higher for adults living in the most deprived areas (Figure 5)., Possible explanations include the presence of multiple risk factors, more high-risk drinking behaviours such as binge drinking, and poorer access to alcohol treatment and support in more deprived areas.,

Smoking, alcohol use, poor diet and physical inactivity drive a significant burden of morbidity and mortality in England. This burden falls unequally across the population, perpetuating health inequalities. Government progress in tackling these risk factors has been too slow in recent years, with key national targets for smoking and childhood obesity set to be missed.

An uneven approach

Our review shows that government policies implemented over the past 5 to 10 years have relied heavily on promoting individual behaviour change. Some population-level fiscal and regulatory policy measures have been proposed by government over the past decade, including minimum unit pricing for alcohol, banning sales of energy drinks to children younger than 16, and adopting a ‘polluter pays’ levy for tobacco companies. But many have been abandoned or not moved beyond consultation stage, even where there is strong evidence of their effectiveness. A significant number of implemented policies have instead focused on providing information and rolling out coaching schemes that depend on people investing considerable personal resources. This is despite strong evidence showing such interventions will have less of an impact on health, particularly among people who are more socioeconomically disadvantaged and may be less able to draw on the social, material and time assets required to benefit.

This drift towards policies focused on individual behaviour change may have occurred because they are deemed more politically acceptable and easier to implement than those addressing population-level drivers. It is simpler to provide information and services to individuals than it is to design and deliver policies aimed at altering the environmental conditions and commercial influences shaping people’s behaviour. While there are signs that public opinion has shifted due to the pandemic, political, ideological, commercial and cultural factors have historically acted as barriers to the adoption of population-level policies in England. Public, media and political discourse about health and risk factors for ill health have been dominated by notions of personal responsibility, individual choice and the primacy of free markets, alongside an aversion towards policies deemed to be ‘nannying’.,,

The strength of the government’s approach has also been uneven across risk factors. Action to tackle harmful alcohol use in England has been particularly weak. Government effectively intervened to protect public health by escalating tobacco duty, but has avoided similar action for alcohol, with the alcohol industry lobbying successfully against the introduction of policies to modify prices and marketing.,,, A TV watershed and online ban are set to be introduced by the start of 2023 for some products high in fat, salt or sugar, but alcohol products are not included in these restrictions.

In relation to both alcohol and food policy, governments have tended to avoid more deterrence-based, interventionist approaches. Instead, they have often trusted those responsible for producing harmful products to help improve public health voluntarily – regardless of possible conflicts of interest, such as the food industry’s profits from increased sales of ultra-processed food. The Public Health Responsibility Deal – a public–private partnership launched by the government in 2011 that relied on voluntary action by commercial organisations – is an example of this approach. As with other such agreements based on industry self-regulation, the responsibility deal has proven to be largely ineffective.

The strong influence of corporations over the policymaking process is likely to be a key factor underlying this uneven approach. Unlike for tobacco control, no WHO Framework Convention exists to set limits on the alcohol or food industry’s influence. This is despite manufacturers of harmful food and drink exhibiting similar strategies to the tobacco industry to undermine government action. A number of studies have demonstrated how the alcohol industry employs sophisticated tactics to promote mixed messages and misinformation about alcohol harms that negatively impact consumer understanding., There is also evidence showing parts of the food industry engage in activities to prevent or delay effective policies for dietary change. These practices have presented barriers to the implementation of evidence-based policies, impeding government progress and allowing messages about unhealthy food and drink to be dominated by large corporations. A 2014 investigation into the consultation on minimum unit pricing for alcohol, for example, uncovered records of industry meetings with government officials that led to the policy’s abandonment.

There are some signs that businesses are starting to recognise the need to consider their impacts on health. Investors are increasingly interested in encouraging corporations to support positive health outcomes. One example is the recent health-related shareholder resolution filed at the supermarket Tesco, which agreed to boost sales of healthier food and drinks in response to investor pressure coordinated by ShareAction. There have been subsequent ripple effects across the retail industry, with a further shareholder resolution on health recently filed at Unilever.

Alongside the role of commercial interests, recent analyses have highlighted inadequate political leadership and governance, as well as a perceived lack of public demand for policy action, as further reasons underlying the government’s failure to consistently implement evidence-based policies.,

Disjointed policymaking

Disjointed policymaking is evident across all risk factors. Policy decisions have been taken that undermine many of the government’s own health improvement targets. This includes cutting the public health grant to local authorities by 24% in real terms between 2015/16 and 2021/22. Spending on stop-smoking and tobacco control services fell by a third over this time. During the same period, spending on mass media anti-smoking campaigns in England declined by 90% and the number of adult smokers trying to quit in the previous year fell by a quarter. Local government expenditure on resources that support people to be active – including parks, recreation and leisure centres – has also declined over the past decade.,

This comes against a backdrop of broader cuts to local public services that are key to ensuring people can live healthy lives, including housing and provision of early years services. The 2021 Spending Review settlement increases health spending, but it is weighted towards acute NHS services and does not reverse cuts to the public health grant or do enough to address rising poverty., Although the recently published levelling up white paper reiterates an ambitious commitment to reduce gaps in healthy life expectancy over the next decade, it does not come with sufficient funding to ensure action on the root causes of ill health.

Government has recently introduced policies to restrict promotion of unhealthy food and drink, including a ban on online advertising of some products high in fat, salt or sugar from 2023, yet other political decisions have the potential to undermine these. The post-Brexit trade deal with Australia, for example, failed to protect nutritional quality or prioritise health. With no requirement for health to be considered in trade negotiations, and food companies playing an influential role in World Trade Organization negotiations, there is potential for further obstruction of measures to protect health. Future free trade agreements could be struck that increase imports of unhealthy foods and impact on their pricing, availability and promotion. More generally, food marketing continues to be heavily skewed towards the least healthy options such as processed confectionery and ready meals., Unhealthy food and drink are low cost, and fast-food outlets are disproportionately clustered in low-income towns and areas., Spend on advertising these foods by big food companies is nearly 30 times what government spends on promoting healthy eating. ,,

In relation to physical activity and alcohol, economic policy decisions have often undercut efforts to protect public health. The alcohol duty escalator was abolished in 2013, and the Treasury has repeatedly frozen or cut duty for alcoholic drinks. Modelling suggests that changes in alcohol duty since 2012 have led to increased consumption, greater alcohol-related ill health, premature mortality, higher rates of alcohol-related crime and increased workplace absence than if the alcohol duty escalator had remained in place until 2015 as originally planned. Past announcements made by the Treasury have also contradicted public health messages on cigarettes and alcohol., Similarly, the freeze to fuel duty and exemptions from vehicle excise duty over the past decade have lowered the cost of driving and undermined government aims to increase active travel.

These examples of disjointed policymaking are symptomatic of wider government weaknesses in planning effectively for the long term and aligning policies across departments. Such shortcomings can be especially pronounced when addressing complex policy issues such as obesity that have multiple causes and require coordinated cross-government responses. Successive reviews have identified barriers to joined-up, long-term policymaking in the UK – including the lack of a clear national strategy at the centre of UK government; practical and organisational factors that encourage siloed working in Whitehall; and Treasury objectives and accounting that are narrowly focused and short term.,,,,

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We analysed national-level policies that have been proposed or committed to by the UK government in England that explicitly set out to address smoking, poor diet, physical inactivity and harmful alcohol use. We examined the headline policies included in key government strategy documents and government-commissioned reviews published between 2016 and 2021 (except for alcohol, where we went back to 2012 due to the lack of government strategies published since). We summarised information on policy aims, approach, agencies involved in implementation, and other factors. We also tracked whether policies had been implemented or not.

Our focus was on strategies that have principally aimed to improve health. As a result, our review provides an overview of government’s policy positions related to the prevention of smoking, poor diet, physical inactivity and harmful alcohol use, but does not provide an exhaustive account of all policies related to these risk factors across all government departments.