Can policymakers nudge people towards healthier choices?
Apr 25, 2011 No Comments
It is the early days of the new parliament and you are having a think in your pod. After a long hard campaign, when you’ve been subsisting mainly on cups of tea and biscuits and meals grabbed on the trail, you decide it is time to take life on. You stride purposefully towards the stairs when you bump into one of your new colleagues waiting by the lift. You strike up a conversation and before you know it, you are carrying the conversation on in the lift and being gently lowered towards the garden lobby. You make a mental note to take the stairs on the way back up and amble towards the cafeteria. At the entrance you are greeted by a table with today’s menu choices plated up for perusal. You’d been planning on going straight to the salad bar but the haggis, neeps and tatties catches your attention first and can’t be ignored. The MSP in front of you in the queue has helpfully handed you a tray and as you head to the till you notice there is just enough room for one of the freshly baked cakes, temptingly positioned an arm’s length away from the counter. On the way back to the office after your hearty lunch you are swayed by the aromas from the in-house coffee bar. Your freshly purchased latte will round lunch off nicely, you think, as you press the button on the lift to take you back to work.
Whether we realise it or not a myriad of subtle factors influence our choices, for better or for worse, on a daily basis. Unhealthy behaviours, such as smoking, poor diet and a lack of physical activity have fuelled an increase in so-called lifestyle illnesses, presenting a significant challenge for policymakers.
It is perhaps not surprising then that a book about behaviour economics, which outlined how people might be ‘nudged’ to make better choices without forcing certain outcomes upon them, became the holiday reading of choice for politicos a few summers ago. It captured the imagination of a British policy elite hungry for solutions and led to a report reviewing the implications of behavioural theory for policymaking by the Cabinet Office and Institute for Government, and the creation of a behavioural insights team, know as ‘the nudge unit’, at Westminster.
The influential MINDSPACE report outlined just why this should pique policymakers’ interest.
“For policy-makers facing policy challenges such as crime, obesity or environmental sustainability, behavioural approaches offer a potential powerful new set of tools. Applying these tools can lead to low cost, low pain ways of ‘nudging’ citizens – or ourselves – into new ways of acting by going with the grain of how we think and act. This is an important idea at any time, but is especially relevant in a period of fiscal constraint.”
The report, which sets out a user-friendly framework for policymakers, hoped to stimulate debate about applying behavioural theory more widely across the public sector.
“There are lots of different ways of changing behaviour and government will always use traditional methods like regulation and tax rises and information campaigns, but what they’ve tended to do in the past is ignore the surrounding environment in which many choices are made,” Dr Dominic King, Clinical Lecturer in Surgery, Imperial College London and co-author of the MINDSPACE report explains.
It is not an either or situation, he stresses. Rather elements of MINDSPACE can be used to complement and enhance conventional policy tools and strengthen the desired message.
“We want to be providing information that is salient to the population that is being targeted. When targeting 17 years olds who you want to stop smoking and stop drinking, you want to be giving them very different statistics to 60 and 70 year olds. 18 year olds may not worry too much about impotence or lung cancer, but they will worry about a campaign that says people won’t find them attractive if they smell of smoke.”
And yet despite the enthusiasm for it in Westminster, nudge is not without its critics. In a recent article in the BMJ Professor Tim Lang and Dr Geof Rayner, both from the Centre for Food Policy at City University in London, describe nudge as, “a smokescreen for, at best, inaction and, at worst, publicly endorsed marketing,” and argue it allows governments to shy away from taking tough and potentially unpopular action, such as raising taxes or supporting legislation that restricts or bans unhealthy habits.
King acknowledges the criticisms, however, he points out that in any environment there are features that can influence decisions, noticed and unnoticed, and so he argues it is better to recognise that and seek to design the environment in such a way that improves outcomes.
The canteen provides a useful example, he says. “If you put healthy food at the front of the display more people will pick it. So someone has to make the decision about what you do. The decision can be you are taking it to make people healthy, are you taking it to make people unhealthy, or are you just leaving it up to chance?
“Now that we recognise elements in the choice environment have an effect on behaviour we should be, where we can, designing the choice environment in such a way that we can improve outcomes. Now, some people would say that is paternalistic and I very much agree that there is concern about pushing these kind of policies too far, but we should be doing what we can to improve outcomes, I think, rather than worsening them.”
And while such techniques may seem softer than hard-touch regulations, they can still spark heated debate. King highlights a programme that has been piloted in Dundee where pregnant women are provided with shopping vouchers as an incentive to quit smoking as one that has attracted a lot of attention in government circles south of the border. NHS Tayside spent two years piloting the programme during which time it found that the four-week quit rate for participants averaged between 46-52 per cent, compared with an average four-week quit rate of around 28 per cent for other smoking cessation programmes. The board has said it will now continue to fund the programme and it has already been extended to north Perth, with other Scottish boards said to be considering similar plans.
“That is the sort of thing we have been talking about with MINDSPACE,” says King.
“I agree that these sort of things will always generate headlines in the Daily Mail and controversy amongst libertarians about paying people to change their behaviour, and it really comes down to whether these people think, one, it is normatively acceptable and, secondly, if we want to stop pregnant women smoking we can if we want to continue to spend millions of pounds on advertising, but we are talking about what is actually very small sums of money to incentivise smoking with hard cash. And no one wants to use hard cash to stop pregnant women smoking but if it only costs £100 or £150 to stop a pregnant woman smoking and that will lead to her child being born without the myriad of problems that we see when women smoke during pregnancy, is that a good thing or a bad thing?”
While King confesses that he “sits on the fence a bit” on this particular issue, he says that if the decision is taken to roll out such a scheme more widely, here again an insight into behaviour may prove useful.
“Now there are all sorts of issues in terms of if you start paying people to start smoking you get people starting smoking so they get paid to stop. These things, again if you have insight into people’s behaviour, then you can negate some of these things. So whether we should role that out universally – probably not, because you will get these negative things happening. But more focused and more local approaches in these more problem areas as, for example, in Dundee, maybe there is room for it.”
Given that this approach has already been made to feel welcome south of the border, what would King’s message be to a newly-appointed Scottish Government?
“I think you have to recognise that we have an increasing body of evidence and literature about how people actually behave as opposed to how we think they behave, or how we’ve always thought they behave, and too much public policy at the moment is based on what we think people do in perfect situations and they really don’t behave that way.”
The burden of poor decision making is significant and increasing, he continues, and so governments need to have an approach to influencing behaviour in a positive way.
“Now that we have this body of evidence we should be using it. Obviously there are democratic and ethical concerns with some of these policies, because often they are working at unconscious levels, but we need to understand that many of these interventions do have an impact and we should be trying to nudge people towards positive outcomes, rather than nudging them towards poorer outcomes.”
King is the keynote speaker at Holyrood magazine’s Social Marketing conference, which takes place in Edinburgh on Wednesday 27 April. For more information visit socialmarketing.holyrood.com