Two news stories dominated the headlines this week – Cancer Research UK (CRUK) rolling out a new campaign linked with their findings that obesity is now the leading risk factor for four cancers and Conservative leadership candidate Boris Johnson calling for a review and potential roll-back of ‘sin taxes’, in particular those measures designed to alter consumer food environments. These intertwined stories exemplify the complexity of managing population health challenges, the role of robust and transparent evidence, and the importance of clear translation and messaging of both the challenges and the evidence to tackle them.
We know that price is a major determinant of consumption and there is strong evidence globally that fiscal and pricing policies are a ‘win-win’ for population health. But pricing policies are often underutilized, due to a number of reasons including political context, conflicts of interest, and public support. However, such policies have the dual benefit of generating tax revenue while reducing disease by dis-incentivising the consumption of unhealthy commodities, supporting healthy choices, and encouraging industries to reformulate their products to make them healthier.
Furthermore, maintaining or reducing healthcare costs without negatively impacting health outcomes requires that cost-effective prevention interventions are at the forefront of healthcare. Investment in prevention is key if the NHS is to be sustainable and a battery of preventive approaches is necessary – there is no ‘silver bullet’. The NHS 5 year Forward View stated as much.
An example of a strong fiscal policy for health is the UK’s long-standing tobacco tax. The UK has the highest pack price (20 cigarettes) of any EU country (£9.91), double the European average, contributing to the decrease in tobacco consumption over the last three decades. Evidence from microsimulation modeling shows that gains can still be made, for example, by increasing the tobacco duty escalator to 5% which is estimated to avoid 75,200 new cases of smoking-related disease by 2035, saving £49m in NHS costs and £192m in societal costs in a single year.
CRUK’s research showing the country’s rising obesity rates role in cancer risk and Boris’ call for a review of the impact of ‘sin taxes’ highlight the difficulty of picking through the evidence for adapting our ‘environments’ to support health and the translation of this evidence into real world decision making. The introduction of the UK’s Soft Drinks Industry Levy (SDIL) in 2018 marked a clear move by Government to shape food environments to address the wide-spread availability of drinks high in added sugar – excess sugar consumption is a leading risk factor for overweight and obesity across the population. The UK Health Forum’s* microsimulation model was used in 2016 to model the impact a 20% tax on sugary drinks would have on rates of overweight and obesity in the UK. It found that a 20% tax on sugary drinks could reduce obesity rates in the UK by 5% by 2025 or equal to 3.7 million fewer obese people. The stark number of 3.7 million is equivalent to the combined populations of Birmingham, Leeds, Sheffield, Manchester, Bristol and Leicester**. This reduction in the number of people who are obese would have a significant knock-on effect to the risk of developing cancer – beyond just the four cited by CRUK – across the population.
Boris’s argument that these types of fiscal policies on consumption commodities are regressive for those with lower incomes is not supported by the evidence, however. We know that both the risk factors for and non-communicable diseases (NCDs) themselves – heart disease, diabetes, cancer – tend to be more prevalent in the most deprived groups, with health inequalities estimated to cause over 700,000 deaths and 33 million cases of ill-health, accounting for 20% of total healthcare costs, and 1.4% of GDP once lost productivity is taken into account. Those in the lower income bracket tend to have more unhealthy behaviours and live in more polluted areas, so carry a disproportionately high disease burden. They have the most to benefit from fiscal policies such as the SDIL, especially in an NHS style system which is inherently equitable and serves as an ‘equalizer’ – moving resources from the rich to the poor and from the healthier to the sick.
Evidence for the impact of public health interventions to tackle risk factors often relies on statistical modelling methods – such as microsimulation – since randomized controlled trials are not always feasible or ethical, and frequently lack a commercial sponsor. Modelling is a crucial part of the decision-making process by providing evidence for the effectiveness of policy, as evident from the tobacco duty escalator and the SDIL. Any review of such policies and their economic and health impacts should include this methodology.
* The UK Health Forum modelling unit was subsequently acquired by HealthLumen in 2019.
** Calculated by Cancer Research UK using ONS Population Estimates for UK, England and Wales, Scotland and Northern Ireland, Mid-2014: http://www.ons.gov.uk/ons/publications/re