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.

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.,,,

Diagram adapted from: Adams J, Mytton O, White M, Monsivais P. Why Are Some Population Interventions for Diet and Obesity More Equitable and Effective Than Others? The Role of Individual Agency. PLoS Med 13(4); 2016 (https://doi.org/10.1371/journal.pmed.1001990).

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.

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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.,,,,

Source: Public Health England Outcomes Framework (based on the ONS, Annual Population Survey).

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.

Source: NHS Digital, National Child Measurement Programme. NHS Digital, Health Survey for England.

Source: NHS Digital, National Child Measurement Programme, Sport England, Active Lives Survey.

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.,

Source: OHID fingertips, local alcohol profiles.

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Policies proposed by government in England since 2016 to address smoking, diet, physical activity and harmful alcohol use are summarised in Tables 1–4. Only some of these policies have been implemented, and policies in each area are linked to a mix of specific and overarching government targets (Box 1). Wider government targets have also been set that necessitate action on these risk factors – including a commitment to extend healthy life expectancy by 5 years by 2035, while narrowing the gap between the richest and poorest.

Policies on targeted risk factors also interact with other national policy and political decisions that shape social, economic, and environmental factors influencing people’s ability to adopt healthy behaviours., This includes, for example, spending decisions relating to public health, social security and the NHS; funding for local government services, such as housing; and economic decisions relating to taxation and pricing.

Box 1: National targets for each leading risk factor

	Target	Government strategy	Responsible body
Smoking	Ambition to go ‘smoke-free’ by 2030, defined as a smoking prevalence of less than 5%	DHSC and Cabinet Office green paper: Advancing our health: prevention in the 2020s  (July 2019)	DHSC and Cabinet Office
	Reduce smoking prevalence among adults from 15.5% to 12% or less by the end of 2022	DH Tobacco Control Plan for England (July 2017)	DHSC; Public Health England (PHE) (now OHID); NHS England (NHSE); local systems (trusts/CCGs/LAs)
	Reduce the proportion of 15-year-olds who regularly smoke from 8% to 3% or less by the end of 2022	DH Tobacco Control Plan for England (July 2017)	DHSC; PHE (now OHID)
	Reduce inequalities in smoking prevalence between those in routine and manual occupations and the general population	DH Tobacco Control Plan for England (July 2017)	DHSC; PHE (now OHID); local systems: LAs/CCGs (now integrated care systems (ICSs))
	Reduce prevalence of smoking in pregnancy from 10.7% to 6% or less by the end of 2022	DH Tobacco Control Plan for England (July 2017)	DHSC; PHE (now OHID); NHSE; local health systems
Physical activity	Ensure all children and young people have access to at least 60 minutes of physical activity every day (30 minutes at school and 30 minutes outside school)	School Sport and Activity Action Plan (July 2019) Childhood obesity: a plan for action (2016)	Department for Education (DfE); Department for Digital, Culture, Media and Sport (DCMS); DHSC
Childhood obesity	Halve childhood obesity by 2030 and significantly reduce the gap in obesity between children from the most and least deprived areas by 2030	Tackling obesity: government strategy (July 2020) Childhood obesity: a plan for action, chapter 2 (June 2018)	DHSC
Harmful alcohol use	No national targets have been set to reduce harmful alcohol use

Smoking policy

Since the 1970s, the UK government has adopted a mix of population-level tax and regulatory policies alongside information campaigns and cessation services supporting individuals to quit smoking. Regarded as a global leader in tobacco control, the UK produced its first comprehensive tobacco strategy in 1998 and was one of the first countries to introduce smoke-free laws to protect people from secondhand smoke in public places and vehicles., Measures such as plain packaging and health warnings on packs have been introduced, and tobacco affordability has been reduced through escalating duty rates. Public support for government intervention to limit marketing and availability of tobacco is also high and has grown over time.,

While smoking rates have remained higher among those who are more disadvantaged, including those working in routine and manual occupations, overall smoking rates declined significantly since the government began to take action – from 46% in 1974 to 16% in 2019 (Figure 6).,

Source: ONS, Adult smoking habits, Health Foundation policy navigator and ASH: Key dates in the history of anti-tobacco campaigning and Timeline of tobacco tax increases in the UK.

Notes: Only results from 2000 are weighted, pre-2000 estimates are only available every 2 years.

The government’s most recent tobacco control plan for England (2017) did not extend this previous focus on national legislation and regulation, instead shifting towards individual-level interventions such as providing guidance to support smokers to quit. The plan set a range of targets designed to achieve the government’s vision of a ‘smoke-free generation’ in which adult smoking rates are 5% or lower. Specific targets were set for 2022 to reduce smoking prevalence among adults from 15.5% to 12% or less, and to reduce prevalence among people in routine and manual occupations, pregnant women, and 15-year-olds.

The interventions that support these targets are broad and focus on information provision – including promises to monitor trends, update national guidance and train health professionals to provide stop-smoking support. While there was a commitment to maintain high tobacco duty rates and make the prison estate in England smoke-free, no new tobacco regulations were introduced in the 2017 plan. Since publication of a 2018 delivery plan, which included some detail of progress against the 2017 tobacco control plan targets, little information tracking progress has been published.

A number of targeted individual-level policy interventions are also outlined in the NHS Long Term Plan (2019), focused on expanding access to stop-smoking services for inpatient populations, including pregnant women and people with mental ill health. While these initiatives have potential to provide valuable targeted support for these high-risk population groups, it is unclear whether funding will be adequate to meet demand. It is also not clear how service rollout will be prioritised across NHS trusts, particularly in the context of high ongoing NHS pressures and a growing elective care backlog.

The government’s prevention green paper – Advancing our health: prevention in the 2020s (2019) – appeared to pave the way for a greater level of ambition around population-level smoking policy, including fiscal and regulatory interventions. A ‘smoke-free by 2030’ target was set and the need for bold action recognised. DHSC also committed to consider a ‘polluter pays’ approach, whereby the government would legislate to make tobacco manufacturers contribute towards the cost of tobacco control. Over 2 years later, however, the government is yet to publish a response to the green paper and there is little detail on how it intends to achieve the target. In addition, the government’s updated tobacco control plan for England remains unpublished despite an original release date of July 2021.

Table 1: Summary of major policy initiatives on smoking (2016–2021)

Policy initiative	Date	Strategy	Responsible body	Lever	Degree of agency and targeting
‘Polluter pays’ levy on tobacco industry	2019	Advancing our health: prevention in the 2020s	DHSC and Cabinet Office	Regulation (fee)	Population-level; low agency
	Implemented? No.
All people admitted to hospital who smoke offered NHS-funded tobacco treatment services by 2023/24	2019	NHS Long Term Plan	NHSE; local health systems (ICSs)	Service provision	Individual-level; high agency
	Implemented? Underway.
Smoke-free pregnancy pathway for expectant mothers and their partners	2019	NHS Long Term Plan	NHSE; local health systems	Service provision	Individual-level; high agency; targeted at high-risk groups
	Implemented? Underway.
Smoking cessation offer for long-term users of specialist mental health services	2019	NHS Long Term Plan	NHSE; local health systems	Service provision	Individual-level; high agency; targeted at high-risk groups
	Implemented? Underway.
To achieve the targets set in the 2017 Tobacco Control Plan for England (see Box 1) a number of broad commitments were made, largely relating to funding and enforcement of existing policies. These included commitments to: update national guidance provide national monitoring and support for stop-smoking services continue funding mass media campaigns adopt measures to encourage e-cigarette use.

Policy to improve diet and address obesity

The government has introduced some policies aimed at rebalancing the food environment towards healthier options. Most notably, in 2018 the government introduced a levy on sugary drinks (the soft drinks industry levy). The levy has been successful in incentivising manufacturers to reformulate their products, leading to a fall in average sugar content in soft drinks of 29%, with high public support maintained.,,, The government’s 2020 obesity strategy also featured regulatory measures aimed at restricting marketing and advertising of unhealthy foods. This included restrictions on some products high in fat, salt or sugar (HFSS) being marketed on TV before 9pm and a ban on paid-for advertising online; restrictions on the promotion of some HFSS products in shops; and calorie labelling measures. All are set to come into force by the start of 2023.

Despite these steps forward – and the effectiveness of fiscal and regulatory measures introduced to tackle smoking – government action on obesity is still largely focused on changing individual behaviour. A recent review of UK government obesity strategies between 1992 and 2020 showed it has tended to favour policies that depend on individuals’ motivation and ability to engage with information and advice. Few fiscal or regulatory policies have been introduced aimed at directly shaping the choices available to individuals.

A central plank of the 2020 obesity strategy was a new ‘Better Health’ information campaign, based around an NHS 12-week weight loss plan app. As childhood obesity rates climbed through 2021, the government launched a series of pilots aimed at incentivising healthier eating and providing specialised weight management services. This included a ‘Health Incentives’ app rewarding participants for behaviours, such as eating more fruit and vegetables (piloted in Wolverhampton from early 2022), and the launch of 15 specialist NHS clinics for severely obese children.,

A number of recently proposed population-level policies to improve diets have also been cast aside, with a lack of follow-up and transparency after their announcement. Despite announcing a ban on the sale of energy drinks to those younger than 16 in the 2019 prevention green paper, the policy has not been implemented. Likewise, a commitment in 2018 to consider including sugary milk drinks within the SDIL has been abandoned, with the 2020 obesity strategy making no mention of either policy.

While a white paper responding to the 2021 National Food Strategy is yet to be published, early signs are not encouraging regarding government’s willingness to implement the fiscal and regulatory interventions recommended, such as a sugar and salt reformulation tax., The latest data also indicate that the government’s 2018 national childhood obesity target – to ‘halve childhood obesity and significantly reduce the gap in obesity between children from the most and least deprived areas by 2030’ – will be missed. In 2020, an inquiry by the House of Lords Select Committee on Food, Poverty, Health and the Environment concluded that a ‘unifying government ambition or strategy on food’ has been lacking, with a resulting lack of coordination and a dearth of coherent policies addressing interrelated issues such as poverty, food insecurity and poor health.

Table 2: Summary of policy initiatives on diet (2016–2021)

Policy initiative	Date	Strategy	Responsible body	Lever	Degree of agency and targeting
Sugar and salt reformulation tax A number of other recommendations were made in the NFS, outlined more fully in Table 2 (Appendix)	2021	National Food Strategy (NFS)	Commissioned by Department for Environment, Food and Rural Affairs	Taxation	Population-level; low agency
	Implemented? Government has promised to respond formally with a white paper within 6 months of the NFS’s publication.
Ban on high fat, sugar and salt (HFSS) products being shown on TV before 9pm	2020	Tackling Obesity: government strategy	DHSC	Regulation (marketing)	Population-level, low agency
	Implemented? Due to be implemented from the beginning of 2023. Does not cover all media where advertising could be time restricted such as cinema and radio.
Total online advertising restriction for HFSS products	2020	Tackling Obesity: government strategy	DHSC	Regulation (marketing)	Population-level, low agency
	Implemented? Due to implemented from the beginning of 2023. Does not cover brand advertising, owned content or advertising by small and medium-sized businesses.
Restrictions on promotion of unhealthy food and drinks in retail outlets and online	2020	Tackling Obesity: government strategy	DHSC	Regulation (marketing)	Population-level, low agency
	Implemented? Due to be introduced from October 2022.
Calorie labelling in large out-of-home sector businesses	2020 2018	Tackling Obesity: government strategy; Childhood obesity: a plan for action, chapter 2	DHSC	Regulation (information provision)	Population-level, high agency
	Implemented? Yes, regulations come into force from April 2022 (for large businesses with 250+ employees).
Front-of-pack nutrition labelling reforms (consultation)	2020	Tackling Obesity: government strategy	DHSC	Regulation (provision of information/warnings)	Population-level, high agency
	Implemented? No consultation response published.
‘Better Health’ campaign	2020	Tackling Obesity: government strategy	DHSC PHE (now OHID)	Information provision (mass media campaign)	Population-level, high agency
	Implemented? Yes.
Expansion of diabetes prevention programme	2020 2019	Tackling Obesity: government strategy; NHS Long Term Plan	NHS England (NHSE)	Service provision; information	Individual-level, high agency, targeted at high-risk groups
	Implemented? Yes.
National Infant Feeding Survey: reinstatement	2019	Advancing our health: prevention in the 2020s	DHSC and Cabinet Office	Information	Population-level, low agency
	Implemented? No.
Restricting sales of energy drinks to children younger than 16	2019	Advancing our health: prevention in the 2020s; Childhood obesity: a plan for action, chapter 2	DHSC and Cabinet Office	Regulation	Population-level, low agency
	Implemented? No.
Primary care weight management services: Increasing access	2020 2019	Tackling Obesity: government strategy; NHS Long Term Plan	NHS England (NHSE); PHE (now OHID); local health systems	Service provision	Individual-level, high agency; targeted at high-risk groups
	Implemented? Underway.
Adding milk drinks to the soft drinks industry levy (SDIL)	2018	Childhood obesity: a plan for action, chapter 2	DHSC	Taxation	Population-level, low agency
	Implemented? No.
Voluntary sugar reduction programme: Taking out 20% of sugar in products	2016	Childhood obesity: a plan for action	PHE (now OHID)	Voluntary programme	Population-level, low agency
	Implemented? Yes.
Soft drinks industry levy (SDIL)	2016	Sugar reduction: the evidence for action; Budget 2016	Public Health England (PHE); HM Treasury	Taxation	Population-level, low agency
	Implemented? Yes.

Physical activity policy

The primary approach taken to improve physical activity has been information provision. DHSC publishes guidelines about the amount and type of physical activity people should undertake. The 2019 prevention green paper updated these guidelines for adults, alongside launching a physical activity campaign to support those living with health conditions to be more active. The government’s 2016 ‘plan for action’ on childhood obesity set a target that all children and young people should have access to at least 60 minutes of physical activity every day. This was reiterated in a Department for Education and DHSC school sport and activity action plan published in 2019. Little information has been published on progress against this target, and robust data are lacking to monitor and evaluate progress.

Beyond the role of DHSC, responsibility for increasing physical activity is split across a number of government departments: the Department for Culture, Media and Sport has overarching responsibility for sport, but physical activity is also covered by the Department for Education and the Department for Transport. As part of the Department for Culture, Media and Sport’s Sporting Future strategy (2015), Sport England announced £100m of funding for 12 local delivery pilots in 2017 to test new ways of encouraging communities, particularly those facing persistent inequalities, to increase their levels of physical activity. These pilots, which ran until September 2020 and were centred around a system-wide, place-based approach, do not appear to have been funded longer term or rolled out more widely.

The Department for Transport has also published a number of recent strategies designed to encourage active travel by improving cycling and walking infrastructure. This includes an investment strategy (2017) and a white paper setting out a ‘bold vision for cycling and walking’ (2020)., As part of this vision, £2bn of new funding to improve cycling and walking infrastructure was announced, as well as plans to incentivise GPs to prescribe cycling in places with poor health and low physical activity rates. In October 2021, the Net Zero strategy reiterated a target for half of all journeys in towns and cities to be cycled or walked by 2030. It is questionable whether the £2bn of new funding allotted to reach these targets is at the scale required to support a long-term shift towards active travel. Greater Manchester’s 1,800 mile cycling and walking network, for example, is estimated to cost £1.5bn on its own.,

Little has been published by government on the impact of its physical activity campaigns or GP prescribing initiatives. A recent inquiry conducted by the House of Lords National Plan for Sport and Recreation Committee found that government strategies relating to physical activity have been siloed, with cross-government work not happening at the scale required and fragmented delivery and funding systems. There has also been a focus on short-term projects and pilots, an approach that may hamper more meaningful long-term changes in activity levels.

Table 3: Summary of policy initiatives on physical activity (2016–2021)

Policy initiative	Date	Strategy	Responsible body	Lever	Degree of agency and targeting
New commissioning body and inspectorate: Active Travel England	2020	Gear Change: A bold vision for cycling and walking	Department for Transport	Regulation	Population-level, low agency
	Implemented? Yes, launched in January 2022.
Incentivising GPs to prescribe cycling and building cycle facilities in towns with poor health	2020	Gear Change: A bold vision for cycling and walking	Department for Transport Primary care networks (PCNs)	Service provision and regulation (subsidy)	Individual-level, high agency
	Implemented? Not clear.
Supporting cycling and walking infrastructure – £2bn investment	2020	Gear Change: A bold vision for cycling and walking	Department for Transport	Funding and regulation	Population-level, low agency
	Implemented? Yes, funding confirmed up to 2025.
‘Moving Healthcare Professionals’ national programme	2019 2017	Advancing our health: prevention in the 2020s; Moving Healthcare Professionals	PHE (now OHID) and Sport England	Information (mass media/campaign)	Individual-level, high agency
	Implemented? Yes.
Physical activity campaign for people with health conditions	2019	Advancing our health: prevention in the 2020s	DHSC and Sport England	Information (mass media/campaign)	Individual-level, high agency
	Implemented? Not clear.
Local pilots testing new ways of delivering sustainable increases in activity levels	2017	Sporting Future: Second Annual Report	DCMS; Sport England	Funding	Mixture of tailored interventions
	Implemented? Yes, £100m allocated over 4 years for 12 local delivery pilots (since Jan 2018).

Policy to address harmful alcohol use

No government strategy to address alcohol harm has been published since 2012. That strategy had promised a ‘radical change in approach’ and outlined a number of population-level, low agency interventions to ‘turn the tide against irresponsible drinking’. This included minimum unit pricing for alcohol, banning multi-buy alcohol promotions in shops, and regulating to ensure public health is considered as an objective by local authorities when making alcohol licensing decisions.

Soon after its publication, the government backtracked on all such policies. A decade on these have not been adopted, despite mounting evidence on the effectiveness of measures such as minimum unit pricing following its introduction in Scotland (2018) and Wales (2020)., Although government announced plans for a new alcohol strategy in May 2018, this was not produced. And instead of introducing measures to tackle harmful drinking in its 2019 prevention green paper, government chose to work with industry to promote low alcohol products. Alcohol does not feature as a priority as part of government’s prevention agenda, with no national targets set. No policies have been introduced in the previous 5 years other than a commitment to set up alcohol care teams in hospitals with high rates of alcohol-related admissions, and to launch ‘sobriety tags’ detecting whether offenders have broken drinking bans.,

Alcohol continues to be widely marketed – including online, on TV, in public spaces and as part of event sponsorships. This ignores evidence showing marketing directly influences alcohol consumption. While the Scottish government is planning to consult on measures to restrict alcohol marketing, no such measures are under consideration in England. Besides a recent commitment to consult on calorie labelling for alcoholic drinks and mandatory labelling of the Chief Medical Officer’s low-risk drinking guidelines, there has been a striking lack of action for something that is responsible for over 350,000 hospital admissions a year.

Table 4: Summary of policy initiatives on alcohol (2012–2021)

No national strategy to address harmful alcohol use has been produced since 2012.

Policy initiative	Date	Strategy	Responsible body	Lever	Degree of agency and targeting
Calorie labelling on alcoholic drinks	2020	Tackling obesity: government strategy	DHSC	Regulation (for provision of information)	Population-level, high agency
	Implemented? Consultation promised.
Alcohol-free descriptor threshold increases	2019	Advancing our health: prevention in the 2020s	DHSC	Regulation	Population-level, low agency
	Implemented? Unclear.
Working with industry to increase availability of alcohol-free and low-alcohol products	2019	Advancing our health: prevention in the 2020s	DHSC	Voluntary programme	Population-level, low agency
	Implemented? Unclear.
Alcohol Care Teams (ACTs)	2019	NHS Long Term Plan	NHSE	Service provision	Individual-level, high agency
	Implemented? Underway/extent of rollout unclear.
Minimum unit pricing for alcohol	2012	The Government’s Alcohol Strategy	Home Office	Regulation (pricing)	Population-level, low agency
	Implemented? No.
Ban on multi-buy promotions for alcohol in shops	2012	The Government’s Alcohol Strategy	Home Office	Regulation (marketing)	Population-level, medium agency
	Implemented? No.
Health as a local alcohol licensing objective	2012	The Government’s Alcohol Strategy	Home Office	Regulation	Population-level, low agency
	Implemented? No.

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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.

Table of UK government policies proposed or committed to in England for smoking, diet, physical activity and alcohol (2016–2021)

Policy initiative	Date	Summary	Strategy	Responsible body	Intended impact	Lever; targeting; degree of agency
Smoking
‘Polluter pays’ policy	2019	Commitment to consider placing a ‘polluter pays’ levy on tobacco companies, with funds used to support groups most in need and crack down on the illicit tobacco market.	Advancing our health: prevention in the 2020s (July 2019)	DHSC and Cabinet Office	Intended to support raising of revenues to fund smoking cessation efforts.	Lever: Regulation (fee) Population-level; low agency
	Implemented? No further details on the policy have been published by the government.
All people admitted to hospital who smoke offered NHS-funded tobacco treatment services by 2023/24	2019	Pledge to ensure that by 2023/24, all people admitted to hospital who smoke are offered NHS-funded tobacco treatment services – across both physical and mental health services.	NHS Long Term Plan (January 2019)	NHSE; local health systems (Integrated Care Systems – ICSs)	Aimed at ensuring the NHS helps deliver a ‘smoke-free generation’. Designed to guide local development and delivery.	Lever: service provision Individual-level; high agency; targeted at high-risk groups
	Implemented? ‘Early implementer sites’ for inpatient tobacco treatment services are due to be in place from 2020/21 and services rolled out up to 2024.
Smoke-free pregnancy pathway for expectant mothers and their partners	2019	Commitment to adapt the Ottawa Model for Smoking Cessation for expectant mothers and their partners, with a new ‘smoke-free pregnancy pathway’ established incorporating focused sessions and treatments.	NHS Long Term Plan (January 2019)	NHSE; local health systems	Aimed at ensuring the NHS helps deliver a ‘smoke-free generation’. Designed to guide local development and delivery.	Lever: Service provision Individual-level; high agency; targeted at high-risk groups
	Implemented? Implementer sites for ‘smoke-free pregnancy’ services are supposed to be place from 2020/21 and then rolled out further from 2021/22.
Smoking cessation offer for long-term users of mental health services	2019	Promise to introduce a new universal smoking cessation offer for long-term users of specialist mental health and learning disability services.	NHS Long Term Plan (January 2019)	NHS England (NHSE); local health systems	Aimed at ensuring the NHS helps deliver a ‘smoke-free generation’. Designed to guide local development and delivery.	Lever: Service provision Individual-level; high agency
	Implemented? In November 2020, NHSE/I indicated early implementer sites to test and refine outpatient tobacco treatment services would be in place from 2022/23 and then rolled out further from 2023/24.
Diet
Sugar and salt reformulation tax	2021	Recommendation for a sugar and salt reformulation tax, with revenue used to provide fresh fruit and vegetables to low-income families. Designed to build on and replace the Soft Drinks Industry Levy (SDIL).	National Food Strategy	Commissioned by Defra	Aiming to help break the ‘junk food cycle’ and reduce pressure on the NHS. Designed to incentivise manufacturers to reduce sugar and salt in their products.	Lever: Taxation Population-level; low agency
	Implemented? Government has promised to respond formally with a white paper within 6 months of the NFS’s publication.
Mandatory reporting for large food companies on sales of food and drink	2021	Proposal to require food companies with 250+ employees to publish annual reports on food and drink sales numbers. Data by company would be publicly available and form part of the Food Standards Agency’s annual report to parliament on the state of the food system.	National Food Strategy	Commissioned by Defra	Aimed at enabling better scrutiny of business activity and maintaining public pressure on companies to support healthy eating.	Lever: Regulation Population-level; high agency
	Implemented? Government has promised to respond formally with a white paper within 6 months of the NFS’s publication.
‘Eat and Learn’ initiative for schools	2021	Recommendation for an ‘Eat and Learn’ schools initiative, with measures including reinstatement of food A level; more rigorous inspection for school cookery and nutrition lessons in schools; and doubling funding for the School Fruit and Vegetable Scheme.	National Food Strategy	Commissioned by Defra	Proposed to ensure food education is taken more seriously and ensure everyone has the culinary skills and knowledge needed to eat well.	Levers: Information and funding Population-level; medium agency
	Implemented? Government has promised to respond formally with a white paper within 6 months of the NFS’s publication. In February 2022 government committed to invest up to £5m to launch a ‘school cooking revolution’, including development of new curriculum content and bursaries for teacher training and leadership.
Extend eligibility for free school meals	2021	Recommendation to increase the earnings threshold for free school meals to £20,000 before benefits, ensuring 82% of children in households with very low food security would be eligible for free school meals and 70% of those with low food security.	National Food Strategy	Commissioned by Defra	Aimed at addressing current situation whereby children older than Key Stage 1 must live in a household with an annual income of <£7,400 before benefits to qualify for free school meals.	Lever: Regulation and funding (subsidy) Population-level; medium agency; targeted at higher risk groups
	Implemented? Government has promised to respond formally with a white paper within 6 months of the NFS’s publication.
Funding the Holiday Activities and Food programme	2021	Recommendation for government to fund the Holiday Activities and Food programme for at least the next three years or until the next Spending Review (rather than end of 2021 as planned). Proposed that children in households on qualifying benefits earning less than £20,000 should also be allowed access.	National Food Strategy	Commissioned by Defra	Aimed at ensuring the poorest children get at least one freshly cooked meal a day as well as social contact, exercise and enrichment activities, during the school holidays.	Lever: Regulation (subsidy) and service provision Individual-level; medium agency
	Implemented? Government has promised to respond formally with a white paper within 6 months of the NFS’s publication.
Expansion of Healthy Start scheme	2021	Recommendation for proceeds from a sugar and salt reformulation tax to be used to expand eligibility for Healthy Start vouchers. Proposed raising the earnings threshold to £20,000 per year (pre-benefits) and extending the age limit to cover children younger than five.	National Food Strategy	Commissioned by Defra	Aimed at ensuring more low-income pregnant women and their children can access healthy foods. (Through means-tested vouchers redeemable for specific healthy foods.) Designed to expand eligibility.	Lever: Fiscal (subsidy) Individual-level; medium agency
	Implemented? Government has promised to respond formally with a white paper within 6 months of the NFS’s publication.
‘Community Eatwell’ programme, supporting those on low incomes to improve their diets.	2021	Recommendation for a programme to be trialled enabling GPs to prescribe fruit and vegetables, food education and social support to patients suffering from poor diet or food insecurity. Proposed inviting PCNs to design pilot programmes tailored to local needs, with funds invested in local healthy food infrastructure and facilities.	National Food Strategy	Commissioned by Defra Primary care networks (PCNs)	Aimed at improving the diet and health of participants, while ‘reducing the cost of medication’.	Levers: Regulation (subsidy) and service provision Individual-level; medium agency
	Implemented? Government has promised to respond formally with a white paper within 6 months of the NFS’s publication. In February 2022 government confirmed it would trial a Community Eatwell programme by running a 3-year pilot, building on successful models from around the world.
Ban on high fat, sugar and salt (HFSS) products being shown on TV before 9pm	2020 2019	Announcement of a ban on some HFSS products shown on TV and online before 9pm, to be applied to all TV channels regardless of audience size.	Tackling Obesity: government strategy	DHSC	With evidence showing advertising can shape children’s food choices and lead to short and longer term increases in the amount of food they eat, the ban is intended to limit the amount of advertising children see on television for HFSS products.	Lever: Regulation (marketing) Population-level; low-agency
	Implemented? Legislation to restrict advertising of HFSS products on TV before 9pm was introduced as part of the Health and Care Bill 2021–22. Subject to parliamentary approval, the policy is due to be implemented from the beginning of 2023. It does not cover all media where advertising could be time-restricted such as cinema and radio.
Online advertising restriction for HFSS products high in fat, sugar and salt	2020	Commitment to consult on how to introduce advertising restrictions online for foods high in fat, sugar and salt.	Tackling Obesity: government strategy	DHSC	Aimed at limiting children’s exposure to advertising for unhealthy food and drink online (where children consume an increasing amount of media) to help reduce consumption of HFSS products.	Lever: Regulation (marketing) Population-level; low agency
	Implemented? The government published a consultation in June 2021 and has confirmed it would introduce the ban by the end of 2022. Subject to parliamentary approval, it is now due to be implemented from the beginning of 2023. It does not cover brand advertising, owned content or advertising by small and medium sized businesses.
Restrictions on promotion of unhealthy food and drinks in retail outlets and online	2020	Announcement of a ban on promotions of HFSS products by location and price. Location restrictions will be applied to store entrances, aisle ends and checkouts and their online equivalents. Volume price restrictions prohibit retailers from offering promotions such as ‘buy-one-get-one-free’ or ‘three-for-two’ offers on HFSS products.	Tackling Obesity: government strategy	DHSC	Aimed at supporting shoppers to purchase healthier options and shifting the balance of promotions towards healthier options, as well as maximising availability of healthier products on promotion.	Lever: Regulation (marketing) Population-level; low agency
	Implemented? A consultation ran from 12 January to 6 April 2019. The new promotion regulations are supposed to be introduced from October 2022. The regulations only cover medium and large outlets (50+ employees) and do not cover the out-of-home sector.
Calorie labelling in large out-of-home sector businesses	2020 2018	Following an earlier (2018) consultation, government committed to require large out-of-home sector businesses (restaurants, cafes and takeaways with 250+ employees) to provide calorie labels on food. Smaller businesses will also be encouraged to voluntarily provide calorie information and government promised to consider extending the requirement to include them in future.	Tackling Obesity: government strategy; Childhood obesity: a plan for action, chapter 2	DHSC	Aimed at providing people with clear information about the calorie content of food and drink (often higher in the out-of-home sector). Focused on enabling people to make informed decisions, to support a healthier weight.	Lever: Regulation (information provision) Population-level; high agency
	Implemented? A consultation subsequently ran from September–December 2018. The government introduced legislation for out-of-home sector calorie labelling during summer 2021. The regulations come into force from April 2022. Implementation guidance for the policy was published in September 2021.
Front-of-pack nutrition labelling	2020 2019 2016 & 2018	Commitment to consult on how to improve the UK’s voluntary front of pack nutrition labelling scheme to reflect latest dietary guidance and international good practice. Previously committed to in chapters 1 and chapter 2 of the childhood obesity plan (2016 and 2018) and in the 2019 prevention green paper.	Tackling Obesity: government strategy	DHSC	Aimed at ensuring labelling of products in stores and cafes is helpful and easy to understand; supporting people to make informed and healthier food and drink choices.	Lever: Regulation (provision of information/warnings) Population-level; high agency
	Implemented? A consultation ran from July to November 2020. No government response to the consultation has been published. The consultation did not indicate an intention to make labels mandatory.
‘Better Health’ campaign	2020	Announcement of a new campaign based around a 12-week NHS weight loss app for people with obesity. Includes guides offering healthy eating, diet and exercise advice and weekly charts recording calories, exercise and fruit and vegetable intake. Targeted in particular at 40+ men, more socioeconomically disadvantaged groups, people from minority ethnic backgrounds and those with long-term health conditions.	Tackling Obesity: government strategy	DHSC PHE (now OHID)	Aimed at reaching millions of people who need to lose weight, encouraging them to eat better and move more to prevent or delay onset of serious diseases.	Lever: Information provision (mass media campaign) Population-level; high agency
	Implemented? The government implemented three ‘Better Health’ adult obesity campaign advertising bursts during 2020 and 2021. PHE’s evaluation of the impact of the 12-week weight loss app found most users did not complete it but among those who did, weight loss was relatively high compared with outcomes reported elsewhere.
Expansion of diabetes prevention programme	2020 2019	Commitment to fund a doubling of the number of people accessing support through the NHS diabetes prevention programme (DPP) over the next 5 years. DPP incorporates direct coaching, peer support sessions and education on lifestyle choices. In 2020 the government committed to accelerate expansion of the DPP even further to ensure tens of thousands more people are able to access services.	Tackling Obesity: government strategy; NHS Long Term Plan	NHS England (NHSE)	Intended to identify people at high risk of developing type 2 diabetes, to help them maintain a healthy weight and prevent or delay onset of the disease.	Lever: Service provision and information Individual level; high agency
	Implemented? The number of people offered support via the diabetes prevention programme annually has more than doubled since publication of the NHS LTP. Variation between areas is considerable, however, and not all offers of support translate into access. Emerging evidence indicates fairly positive results from the programme so far.
Restricting sales of energy drinks to children under 16	2019	The introduction of a ban on sale of energy drinks to under 16s was confirmed in 2019, following a previous commitment in 2018 and a consultation that had shown overwhelming public support for the policy.	Advancing our health: prevention in the 2020s; Childhood obesity: a plan for action, chapter 2	DHSC and Cabinet Office	Aimed at reducing consumption among children of energy drinks, which contain more calories and sugar than regular soft drinks on average.	Lever: Regulation Population-level; low agency
	Implemented? The policy appears to have been abandoned. No government response has been published following release of the prevention green paper. There was no mention of the policy in the 2020 government obesity strategy.
Primary care weight management services: Increasing access	2020 2019	Building on a previous NHS LTP commitment, in 2020 government committed to expand access to NHS and local authority weight management services centred around ‘behavioural and lifestyle’ coaching. All PCNs have been promised the opportunity for staff to become ‘healthy weight coaches’ and promised incentives to introduce weight management referral pathways in local health care systems.	Tackling Obesity: government strategy; NHS Long Term Plan	NHS England (NHSE); PHE (now OHID); local health systems	Aimed at ensuring more people get access to specialist support to help them lose weight via primary care.	Lever: Service provision Individual-level; high agency
	Implemented? In March 2021 the government announced £100m of funding for councils and the NHS to expand access to weight management services. An enhanced service specification was published by NHSE in June 2021, setting out what PCNs are expected to do in relation to weight management services.
Adding milk drinks to the soft drinks industry levy (SDIL)	2018	Commitment to consider including sugary milk drinks in the SDIL if insufficient progress on reduction has been made.	Childhood obesity: a plan for action, chapter 2	DHSC	Aimed at closing loopholes within the current SDIL, ensuring that government continues to drive progress on sugar reduction via manufacturer reformulation.	Lever: Taxation Population-level; low agency
	Implemented? The policy appears to have been abandoned. No expansions to the SDIL have been announced.
Voluntary sugar reduction programme: taking out 20% of sugar in products	2016	Introduction of a voluntary sugar reduction programme challenging all sectors of the food and drinks industry to reduce overall sugar across products that contribute to children’s sugar intakes – by at least 20% by 2020, including a 5% reduction in year 1.	Childhood obesity: a plan for action	PHE (now OHID)	Designed to reduce sugar content in the products children eat most to improve their diets without the need for individual behaviour change.	Lever: Voluntary programme Population-level; low agency
	Implemented? Yes. However, to date the programme has not been successful, leading to just a 3% reduction overall in sugar according to PHE’s progress report. Sugar sales also increased overall (by 2.6%). A final report on the programme is yet to be published.
Soft drinks industry levy (SDIL)	2016	Introduction of a Soft Drinks Industry Levy (SDIL) to reduce the amount of sugar in soft drinks, with three tiers of taxation depending on a drink’s sugar content. Between 2017/18 and 2020, revenue was used to double the value of the Primary PE and Sport Premium.	Sugar reduction: the evidence for action; Budget 2016	Public Health England (PHE); HM Treasury	Designed to change manufacturer behaviour; encouraging reformulation of products to ensure lower sugar content. Aimed at helping to encourage healthier diets and address obesity.	Lever: Taxation Population-level; low agency
	Implemented? Yes – implemented April 2018. Evidence suggests the SDIL has been effective in leading to industry reformulation of products. By February 2019, only 15% of soft drinks were liable for the levy, compared to 52% before its announcement in 2015. This equates to a fall in average sugar content in soft drinks of 29%.
Physical activity
New commissioning body and inspectorate: Active Travel England	2020	Commitment to create a new commissioning body and inspectorate, ‘Active Travel England’, to be led by a new national cycling and walking commissioner. The new body would hold the cycling budget, approve funding applications, inspect schemes, and provide training and good practice on active travel. Government promised Active Travel England would begin inspecting and publish annual reports from 2021.	Gear Change: A bold vision for cycling and walking (July 2020)	Department for Transport (DfT)	Designed to support active and sustainable travel (walking and cycling). Aimed at performing a similar role to Ofsted by raising standards and challenging failure, and influencing funding allocations for local transport schemes.	Lever: Regulation Population-level; low agency
	Implemented? Yes. Active Travel England was launched in January 2022.
Incentivising GPs to prescribe cycling and building cycle facilities in towns with poor health	2020	Commitment to work closely with the NHS to incentivise GPs to prescribe cycling. Several pilot sites were promised in places with poor health and low physical activity rates, with personalised care to be delivered via social prescribing in PCNs and GPs incentivised to prescribe cycling wherever appropriate. A stock of cycles would be available to lend, with training, access to cycling groups and peer support.	Gear Change: A bold vision for cycling and walking	Department for Transport (DfT) PCNs	Designed to incentivise behaviour change and encourage more cycling in towns where people have poorer health.	Lever: Service provision and regulation (subsidy) Individual level, high agency
	Implemented? It is unclear whether funding has been provided to PCNs to support social prescribing of cycling or whether pilots have been rolled out yet in areas of poor health. No information is publicly available to enable tracking of progress.
Supporting cycling and walking infrastructure	2020	Announcement of £2bn in government funding to improve cycling and walking infrastructure, amounting to a ‘sixfold increase in dedicated cycling and walking funding’. Accompanying statutory guidance was published directing councils to reallocate road space for significantly increased numbers of cyclists and pedestrians.	Gear Change: A bold vision for cycling and walking	Department for Transport (DfT)	Designed to help encourage more people to choose alternatives to public transport when they need to travel, ‘making healthier habits easier’.	Lever: Funding and regulation Population-level; low agency
	Implemented? At the Spending Review in October 2021 the government committed to the promised £2bn investment in walking and cycling – up to 2025. No updated Cycling and Walking Investment Strategy has yet been published.
‘Moving Healthcare Professionals’ national programme	2019	Launch of the second phase of a national programme supporting healthcare professionals to promote physical activity among their patients. Includes peer-led training courses and pilots testing how to embed conversations about physical activity into clinical practice.	Advancing our health: prevention in the 2020s; Moving Healthcare Professionals (Sport England)	PHE (now OHID) and Sport England	Focused on helping those with health conditions to keep symptoms under control and prevent additional conditions from developing.	Lever: Information Individual-level; high agency
	Implemented? Yes, although extent of roll-out and impact unclear.
Physical activity campaign for people with health conditions	2019	Commitment to launch a new physical activity campaign later in 2019 seeking to empower and inspire those living with health conditions to be more active.	Advancing our health: prevention in the 2020s	DHSC Sport England	Aimed at providing information to empower and inspire those living with health conditions to be more active.	Lever: Information (mass media) Individual level; high agency
	Implemented? It is unclear whether the physical activity campaign proposed in the prevention green paper was rolled out.
Local pilots testing new ways of delivering sustainable increases in activity levels	2017	Launch of 12 local delivery pilots testing new ways of delivering sustainable increases in activity levels. Includes activity such as creating new housing and infrastructure to lower congestion and shift travel patterns, and building physical activity into NHS care plans for older adults.	Sporting Future: Second Annual Report	DCMS; Sport England	Aimed at tackling challenges within specific areas and communities. Focused on bringing together stakeholders to tackle inactivity and reach under-represented groups.	Lever: Funding Population-level; low agency targeted in certain areas
	Implemented? Yes, £100m allocated over 4 years for 12 local delivery pilots (since January 2018 – ran until September 2020).
Harmful alcohol use
Calorie labelling on alcoholic drinks	2020	Announcement of a consultation to consider making companies provide calorie labelling on alcohol.	Tackling Obesity: government strategy	DHSC	Designed to ensure consumers are aware how many calories alcoholic drinks contain. Aimed at tackling the significant additional consumption of calories that occurs through drinking.	Lever: Regulation (for provision of information) Population-level, high agency
	Implemented? In November 2021 the government confirmed it will consult on the introduction of mandatory calorie labelling on pre-packed alcohol and alcohol sold in shops. The consultation will also seek views on mandatory provision of the UK CMO’s low-risk drinking guidelines and a drink-drive warning.
Alcohol-free descriptor threshold increases	2019	Commitment to ‘review the evidence’ on increasing the alcohol-free descriptor threshold from 0.05% abv up to 0.5% abv, in line with some other countries in Europe.	Advancing our health: prevention in the 2020s	DHSC	Aimed at supporting further industry innovation and encouraging people to move towards alcohol-free products. Designed to help nudge the general drinking population towards lower strength alternatives.	Lever: Regulation Population-level, low agency
	Implemented? No further information has been published setting out the government’s next steps on alcohol-free descriptor threshold increases.
Increasing availability of alcohol-free and low-alcohol products	2019	Proposal for government to work with industry to deliver a significant increase in availability of alcohol-free and low-alcohol products by 2025.	Advancing our health: prevention in the 2020s	DHSC	Designed to make alcohol-free and low-alcohol products more widely available, to help nudge the drinking population towards lower strength alternatives.	Lever: Voluntary programme Population-level; low agency
	Implemented? No further information has been published about the government’s progress in implementing the policy.
Alcohol care teams (ACTs)	2019	Commitment to ensure hospitals with the highest rate of alcohol dependence-related admissions are supported to establish alcohol care teams. ACTs will be delivered in the 25% worst affected hospitals.	NHS Long Term Plan	NHSE Trusts, local health systems	ACTs are aimed at preventing up to 50,000 alcohol-related hospital admissions over 5 years. Focused on reducing A&E attendances.	Lever: Service provision Individual-level; high agency
	Implemented? Activity to roll out ACTs was suspended in April 2020, with funding for the first round of early implementor sites pushed back to October 2020. Few data are available tracking establishment of ACTs or recording impact.
Minimum unit pricing (MUP) for alcohol	2012	Announcement of an intention to introduce MUP for alcohol in England, making it illegal for shops to sell alcohol for less than a certain defined price per unit.	The Government’s Alcohol Strategy	Home Office	An MUP for alcohol would be aimed at tackling the availability of cheap alcohol and ending its irresponsible promotion and discounting. It is designed to reduce demand for alcohol and thereby reduce harm.	Lever: Regulation (pricing) Population-level; low agency
	Implemented? No. Implemented in Scotland and Wales, but not in England.
Ban on multi-buy promotions for alcohol in shops	2012	Commitment to consult on a ban on multi-buy promotions in the off-trade (shops), which would mean multiple bottles or cans could not be sold cheaper than the multiple of one bottle or can.	The Government’s Alcohol Strategy	Home Office	Aimed at putting an end to any alcohol promotion or sale that offers customers a discount for buying multiple products in stores. Designed to restrict advertising that encourages and incentivises customers to buy larger quantities than they want.	Lever: Regulation (marketing) Population-level; medium agency
	Implemented? No ban on multi-buy promotions for alcohol in shops has been introduced. In July 2013 the government stated it believed evidence for its effectiveness in reducing hazardous and harmful consumption ‘remains inconclusive’.
Health as a local alcohol licensing objective	2012	Promise to consult on a requirement for local authorities to consider health as an objective when making alcohol licensing decisions. Public health would be considered alongside prevention of crime and disorder, public nuisance, public safety and protection of children from harm.	The Government’s Alcohol Strategy	Home Office	Aimed at controlling density of premises selling alcohol to reduce health and crime-related harms from alcohol. Focused on contributing to wellbeing in deprived communities in particular.	Lever: Regulation Population-level; low agency
	Implemented? Health has not been incorporated as a local alcohol licensing objective. In July 2013 the government confirmed the policy would not be adopted due to insufficient ‘local processes and data collection’ to support its implementation.