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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 December 8; 335(7631): 1177.
PMCID: PMC2128683

Smoking licences and cutting salt in food would reduce health inequalities

A former government adviser has said that a system of licensing on buying tobacco products and banning added salt in processed foods could help boost public health and reduce health inequalities in the UK population.

Speaking at a Fabian Society forum that examined how to cut health inequalities over the next decade, Julian Le Grand, professor of social policy at the London School of Economics, said that although the costs of tackling public health problems were immediate, the benefits were realised only in the long term. As a result neither the public nor commissioning trusts saw public health as a priority.

One way to overcome this was to create situations where people had to opt out of healthy habits rather than opt in.

An example would be for anyone wishing to buy tobacco to have to pay for an annual licence, which would involve “complicated forms, a photo ID—and possibly a doctor’s certificate,” said Professor Le Grand.

“That means every smoker every year would have to make a conscious decision to opt in to be a smoker. Breaking your new year’s resolution would have serious costs.”

Similarly, any company employing more than 500 staff should have to offer their staff an hour of exercise every day. “Employees could opt out, but the presumption would be that they would do [the exercise],” he said.

And he proposed banning salt in processed food so that people would have to make a conscious decision to add salt.

Noting that the capital budget of many primary care trusts was underspent, he also said that accounting rules could be changed to make public health a capital rather than a revenue item and so release extra resources.

Anna Coote, head of engaging patients and the public at the Healthcare Commission, urged closer links between public health organisations and the climate change lobby. Climate change would have an earlier and more severe effect on poor communities than on rich ones and therefore on their health, she said, but both public health and the environment could be tackled in similar ways: “You can address mental health, obesity, and carbon reduction by many of the same measures.”

One example was insulating homes, which could achieve the “triple whammy” of improving health, cutting deaths in winter, and reducing the country’s carbon footprint.

But Rosalind Raine, professor of health services research at University College London, believed that individual clinical decision making rather than organisational change held the key to why health inequalities in the United Kingdom continued to increase.

Even with breast cancer, which disproportionately affects well off people, research indicates that poor people still experienced longer delays in referral, less breast conservation, less radiotherapy, and worse outcomes.

“If you are poor, non-white, or marginalised you will have a very different experience with your GP,” she said. “The poor don’t know how to express their preferences and are not given the information they need. We need to think more about who our doctors are, how we train them, and how we measure the gaps in health care.”

Articles from The BMJ are provided here courtesy of BMJ Publishing Group