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Jill Clark

The Importance of being SunSmart

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There has been a lot of coverage in the press about skin cancer just recently.  Bearing in mind, it is August and the long awaited (and no doubt) fleeting British summer has arrived, accessing the great outdoors and enjoying the sun may well be on many people’s minds.  However, all is not well in the great British summer. 

Melanoma

 Cancer Research UK has recently released data to outline the rise in incidences of melanoma – the most common form of skin cancer that is mainly caused by exposure to the sun’s UV rays.  CRUK estimates there will be 20,800 new cases of melanoma in the UK this year, continuing a trend in which cases have risen by more than a third in the past decade. In a temperate climate like the UK it is always important to have some sun exposure in order to access Vitamin D, but that is a totally different order from lying for hours on some beach in the Mediterranean, where people turn themselves into lobsters in the sun without a moment’s thought to the harm that the sun’s rays are doing to their skin.  The rise in melanoma cases is thought to be due to an increase in holidays in hot climates abroad by people with little understanding of the dangers of excessive sun.

There were 17,500 cases of melanoma in 2019 and 1,500 deaths in the UK, and this cancer is particularly fatal when it spreads to other organs.  Nevertheless, this is one of the most preventable of cancers, with almost 90% of all cases being considered preventable. Greater awareness of the dangers of the sun and the requirement to keep out of the hot midday sun and cover up when in the sun at any time, would be an important starting point.

Australian Campaigns

One of the most successful skin cancer prevention campaigns has been fought over the last 40 years in Australia where, as a white skinned population in a near tropical climate, the Australians are acutely aware of this particular cancer.  Their high profile “Slip (on some clothes), Slap (on a hat), Slop (on some sunscreen)” is one of the most well-known and successful cancer campaigns of all time.  The UK would do well to emulate it.

In the meantime in the UK ….

In the meantime, in the UK the LibDems have highlighted the growing incidence of skin cancer and the long waiting list for skin cancer treatment on the NHS.  They are suggesting removing VAT from the price of sunscreens in order to make them more affordable.  In practice, as many people have pointed out, if VAT were removed, the price would likely stay the same and the manufacturers would pocket the difference as profit.  Nevertheless, it has been an excellent publicity event and has highlighted the dangers of skin cancer as well as the long waiting lists to get it treated.

Better Information on Sunscreens

It would also be helpful if bottles of suncreen carried information about the dangers of the sun in a font that is large enough to be legible.  It is worth trying to read the details on the back of a container of sunscreen and seeing how much can be easily read.  It is often a mass of words where the print is too small to be comprehensible.  This is one of the rare examples in health campaigning where it would be highly beneficial if commercial interests were stronger and the manufacturers of sunscreen would promote their produce in a more effective manner. 

In Conclusion

CancerWatch will be promoting its SunSmart campaign every August to increase awareness of skin cancer and the hidden harm in the sun’s rays. We hope you will accompany us on this journey.

Ultra-processed foods: why the fuss and what’s the answer?

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UPFs: what are we talking about?

The term ‘ultra-processed foods’ (UPFs) arises from the NOVA food classification system. This distinguishes between unprocessed foods (i.e. wholefoods); processed culinary ingredients (e.g. salt, butter); processed foods (e.g. fresh bread, tinned vegetables, cheese, cured meats); and ultra-processed foods. Commonly consumed UPFs include mass-produced bread, microwave meals, sandwich ham, and biscuits.  

UPFs are typically industrially produced. They are normally manufactured to be ready to eat, drink or heat, typically with significantly longer shelf lives than less processed foods, which often means they are more convenient and cheaper. They usually contain high numbers of ingredients, including additives and chemicals used to preserve the food or to give them a certain look or taste that can make them more immediately or superficially appealing.

UPFs and health: recent evidence

The problem is there is a significant and growing body of evidence that these foods are bad for our health. To some extent, this is common sense. Many UPFs are high in saturated fats, sugar and salt, which we know are bad for us when consumed in high quantities. 

However, there is growing evidence of links between UPFs and a wide range of serious diseases, including cancer. The largest review of global evidence conducted so far found a direct link between consumption of UPFs and increased risk of cancer, heart disease, and type 2 diabetes, among 32 harmful health outcomes. 

Research from Imperial College found higher consumption of UPFs was associated with greater overall risk of developing cancer, and specifically with ovarian and brain cancers. 

What does it mean?

These findings do need to be placed in context. These studies are showing a link between UPFs and cancer. But we do not have evidence that this is a direct causal link. And the category is a broad one – some UPFs are likely to be significantly more harmful to our health than others. 

However, there are strong grounds for believing there is an indirect link between UPFs and cancer, through their impact on obesity – a major cause of preventable cancer – and through squeezing out of our diet those healthier foods that we know can help to prevent cancer. This should give us cause for concern, especially given the ubiquity of UPFs, which account for 56% of calories consumed in the UK and 64% of calories in school meals.

If we are looking to tackle the root causes of the thousands of cases of preventable cancers we see each week, then the impact of UPFs should be in our sights. 

Taking action: cut UPF in school meals

This is why in our 2024 Cancer Prevention Manifesto CancerWatch called for a target to cut the amount of ultra-processed foods being used in school meals. How this target was set would need to be considered, and it might well make sense to target a group of UPFs which we know are worst for our health. 

But the general principle is a strong one. By introducing children from all backgrounds to eating healthier food from a young age, over time this could have an enormous impact on improving health outcomes and reducing preventable cancers. It would be a real example of the kind of structural change we need to see in the fight against cancer. 

And we are not alone in this. Last year, a group of charities and high-profile chefs and food writers and charities, wrote to the Prime Minister (then Rishi Sunak) calling for action on UPFs in school meals, including a percentage reduction target. The letter was organised by the Soil Association and was supported by the Children’s Food Campaign, run by Sustain as well as the Food Foundation and School Food Matters, among others. 

With a new Government now in office, together we need to continue to build pressure for healthier school meal and the beginning of real action to reduce the prevalence of ultra-processed foods.   

A Cancer Prevention Manifesto for 2024

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About CancerWatch

CancerWatch is a charity made up of people whose lives have been affected by cancer, and who are passionate about eliminating preventable cancers in the future. We campaign for more effective action to prevent cancer. We believe that currently too little is being done to tackle preventable cancers at their source. 

Cancer prevention: the forgotten mission

There are around 1,000 new cancer cases in the UK every day. Taken together those cases are a statistic. Individually each one of those cases is a story of someone whose life will be seriously affected or lost to cancer, with family and friends who also suffer.

All of us know someone whose life has been affected by cancer. Yet the evidence tells us that up to 40% of cancer cases could have been prevented. Each year many thousands of people are becoming ill and dying who would otherwise have enjoyed many more years of life and good health, because of cancers which could have been prevented. 

This is a call for a new national mission to minimise and eventually eliminate preventable cancer in the UK. As we achieve this we will:

  • Reduce the pain, ill-health, and loss of life caused by preventable cancer. 
  • Free up precious healthcare resources to spend on treating non-preventable cancers and other healthcare priorities. 
  • Reduce health inequalities, of which preventable cancers are a key driver.

It is not enough to focus only on treating and researching cancer, as vital as these aspects are. We now need a national drive to eliminate preventable cancers at source. We are calling on all major UK political parties to pick up this challenge and set out in their coming manifestos how they intend to tackle the scourge of preventable cancer. 

Preventable cancer and its causes

It is clear that the biggest causes of preventable cancer are lifestyle factors. Key among these are:

  • Smoking tobacco: Smoking is considered to be the most preventable cause of cancer. About 13% of the British population still smoke, and about 36,000 people a year die from lung cancer each year.
  • Drinking alcohol: Alcohol is an important risk factor in many cancers, including breast, bowel and oesophageal cancer. Drinking patterns have changed over time, and can be improved with appropriate action.
  • Food and diet: Diet is a major risk factor, particularly in relation to obesity, processed and red meat, and insufficient fibre, with growing evidence of a link between ultra-processed food and cancer risk. Obesity is a major cause of cancer, responsible for some 13 different types. Soaring obesity levels in the UK, among the worst in Europe, are largely down to changes in diet and food supply.

Other causes of preventable cancer include excessive sunlight which causes skin cancer, and viruses that cause cervical cancer.

Lung cancer and prevention: There are about 46,000 cases of lung cancer a year in the UK with about 36,000 deaths. Lung cancer accounts for about 20% of all cancer cases in the UK. As smoking is the main risk factor, it is estimated that about 90% of these cases are preventable. 

Bowel cancer and prevention: There are about 42,000 cases of bowel cancer (also known as colorectal cancer) a year in the UK, with about 16,000 deaths. It is estimated that 55% of these cases are preventable, with the keys to prevention being high fibre diets, low red meat consumption, physical exercise and reducing both smoking and alcohol.

All the above statistics are available from the www.cancerresearchuk.org website.

System change is needed

If we are serious about minimising and eventually eliminating preventable cancer, then our approach needs to go beyond relatively shallow discussions about individuals making healthier choices. The decisions producers and consumers make are shaped by a wide variety of social and economic factors, which can serve to make healthier choices extremely difficult, and unhealthy choices sometimes the rational choice to make. 

To seriously bear down on the rates of preventable cancer, we require structural change. We need structural change which seeks to shift our economy and society to a position where cancer-causing products and choices are less prevalent, and healthier alternatives are much more prevalent. Such structural change could also be one of the most important tools we have to tackle the ingrained health inequalities we see in our society. 

Structural change should not be principally a matter of restricting personal freedoms. Rather key elements of this approach should include:

  1. Modifying commercial behaviours – incentivising or requiring businesses to reformulate their products and marketing so as to minimise consumption which risks cancer.
  2. Additional incentives to consumers to change their patterns of consumption
  3. Advice, support and information which allows people to consider their behaviours and the risks of these. 
  4. Strong public health messaging and education.

Three key ideas: A 2024 manifesto for cancer prevention 

1. A ‘polluter pays’ tax on tobacco industry profits to fund comprehensive smoking cessation programmes

The tobacco industry continues to make extraordinary profits on the back of products which kill and place a major burden on public resources.  Raising tobacco duties has proved effective in encouraging smokers to reduce and halt their consumption, but these taxes fall almost entirely on consumers. We should finally apply the ‘polluter pays’ principle to the tobacco industry in order to, among other things, fund the smoking cessation support we need. Examples of ‘polluter pay’ levies on the tobacco industry exist in other countries, including the US and France, and as recently as 2019 the Westminster government called for ideas on how a polluter pays model could work here. 

Smoking cessation support is a highly cost-effective policy intervention, but it needs sustained and higher levels of funding to effectively support smokers to quit, especially the most deprived and hardest-to-reach groups. Stronger support for smoking cessation is fully complementary to the existing smoke free generation policy, and will also be a necessary element if we are to achieve the goal of a smokefree UK by 2030

In order to ensure that any levy on the tobacco industry comes out of tobacco profits, we support the idea of a ‘utility style price cap’ developed by the APPG on Smoking and Health which would cap manufacturers’ prices for tobacco products at a level that would cover the costs of production and distribution plus a more moderate profit. The APPG estimates that this could raise up to £700 million a year, more than enough to fund a comprehensive smoking cessation service. This measure would also have the additional structural impact of incentivising this industry to begin to shift its investment and interest out of cancer-causing tobacco and into less dangerous products.

2. Mandatory alcohol labelling that provides information on key health risks

Alcohol is an important risk factor in seven cancers, including breast, bowel and oesophageal cancer. Yet, awareness of this risk is relatively low. There is strong evidence that health warning labels on alcohol can be effective in raising awareness of health risks and reducing consumption. Unlike smoking, drinking alcohol is not something we should be seeking to eliminate. But we should be seeking a healthier relationship with alcohol. Alcohol labelling can play an important role in this, helping to generate greater awareness and encourage people to moderate their use. Unlike food labelling which must meet mandatory standards, alcohol labelling in the UK currently follows voluntary and industry-run best practice guidelines.  At the moment, consumers are given far more health information on a bottle of orange juice than a bottle of wine.

Unlike smoking, drinking alcohol is not something we should be seeking to eliminate. But we should be seeking a healthier relationship with alcohol. Alcohol labelling can play an important role in this, helping to generate greater awareness and encourage people to moderate their use. Unlike food labelling which must meet mandatory standards, alcohol labelling in the UK currently follows voluntary and industry-run best practice guidelines. 

The Irish Government has recently introduced comprehensive health labelling for alcohol products. From 2026, alcohol in Ireland will need to meet mandatory labelling standards, which will include calorie content, risk of consuming when pregnant and risk of liver disease and certain cancers. The UK should follow suit and ensure that consumers in the UK have all the information they need to make informed decisions about their alcohol consumption.

3. A target to minimise the use of ultra-processed foods in school meals

Obesity is a major cause of cancer, and a risk factor for 13 different types of cancer. These include cancers of the breast and bowel (two of the most common types), pancreatic and oesophageal cancer (some of the hardest to treat), as well as cancers of the womb, kidney and liver. The relationship between diet and cancer is complex, but we could make significant in-roads into reducing preventable cancer by improving our food and diet. 

One area in which we need to look to do this is ultra-processed foods. The UK has the highest consumption of ultra-processed foods in Europe. Growing evidence links ultra-processed foods with increased risk of obesity and some cutting-edge research suggests a 10% increase in ultra-processed food intake is associated with a 10% increased cancer risk.

We should begin by reducing the amount of ultra-processed foods being fed to children in school meals. A study by Imperial College, which looked at the content of school lunches between 2008–2017, found that 64% of the calories in school meals come from ultra-processed foods. We should set and implement a target to drastically reduce this figure. By doing so we can enable structural change by introducing children from all backgrounds to, and encouraging them to enjoy, eating healthier food from a young age. 

Sector Review – Punching Below Our Weight – Cancer Prevention

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To commemorate World Cancer Day 4th February 2024, we are publishing our latest report “Punching Below Our Weight: A Review of the Cancer Charity Sector’s Attitudes to Cancer Prevention”, in which we review almost 50 organisations in the cancer charity sector for their attitudes to cancer prevention.

Although a widespread commitment to prevention exists among cancer charities, prevention is often outcompeted by other priorities, particularly by care and treatment issues that can be more immediately relevant to the beneficiaries. When charities do campaign on prevention, their work tends to focus on secondary prevention, by campaigning for improved detection of cancer, or primary prevention in the form of information and awareness-raising work to shape individual choices. Primordial prevention, which requires structural change at a societal level, rarely features.

From the perspective of individual charities, these choices are entirely understandable. However, our report sets out how we could develop a stronger approach to prevention in the sector. Based on the input we received from the sector, we propose three core elements for the sector’s policy approach on prevention:

a. Stronger emphasis on primordial prevention emphasising social and environmental conditions including regulatory and other legal changes

b. Continued emphasis on the need for improved public health and prevention services

c. Stronger focus on solutions that will modify commercial behaviours.

For more information on the results from this wide-ranging review, the links to the review itself and its executive summary are given below:

https://cancerwatchuk.org/wp-content/uploads/2024/01/PunchingBelowOurWeight_review.pdf

https://cancerwatchuk.org/wp-content/uploads/2024/01/ExecSummary_PunchingBelowOurWeightReview.pdf

What do cancer charities think about prevention?

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CancerWatch exists to campaign for improved cancer prevention, and we will take a major step forward when we achieve registration as a charity this year. From there, we will aim to build up our campaigning activity.

But what should that new activity look like? What work can we do that will not replicate what other charities are doing? What should be the top priorities that we campaign for? We have initial ideas about what the answers to those questions might be, but we don’t presume that we automatically know best. We want to have the best understanding we can of the policy challenges ahead, and the work of the wider sector, as we develop our work.

We are therefore reaching out to established cancer charities, public health campaigners and others, to ask for their input. How do they feel the UK is currently doing on cancer prevention? What’s the outlook for the future, and what are the priorities for improving it? We are approaching over 100 organisations and individuals, and asking them to complete our call for evidence.

To provide some context on the questions we’re asking, and why we have formed the views we have (so far), we have published this discussion paper. It expands on the themes we explored on our blog during Cancer Prevention Action Week, and outlines the need for improved cancer prevention. It suggests that a major policy shift is needed to create structural change, rather than encouraging healthier individual choices that not everyone can easily make. It also explores the role of the voluntary sector in securing previous changes such as the smoking ban, and asks what more it might be able to achieve in the future.

We will compile a full report of our findings, and publish it this autumn. Sign up to receive updates if you would like to be notified when it comes out.

State of play: screening

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Throughout this Cancer Prevention Action Week, we are reviewing the current state of public policy for the major risk factors in causing preventable cancers.

CancerWatch’s mission is to secure a reduction and ultimately the elimination of preventable cancers. Very technically, screening might seem to sit outside the scope of this work: if a screening programme identifies that someone has developed cancer, surely it’s too late to prevent it? In that case yes, but some screening is for pre-cancerous conditions rather than cancer itself.

What’s more, the screening programmes we already have are only part of the likely future picture. As the genetic causes of all sorts of diseases, including cancers, are increasingly understood, and with the cost of genetic testing now greatly reduced, it will become increasingly common for people to have the option to get their genome checked for potentially harmful mutations. The mutation of the BRCA1 and BRCA2 gene that greatly increases the likelihood of someone developing breast cancer, as perhaps made most famous by Angelina Jolie, is the highest profile example, but more genetic risk factors are regularly being discovered. More people will inevitably get themselves tested for more cancer risks in the future, and it is important that genetic counselling is available for anyone using these services.

However, concentrating on the here and now, there are currently screening programmes for cervical, breast and bowel cancer, all overseen by the UK-wide National Screening Committee. There may be scope for improving these programmes, although their effectiveness is surprisingly hard to identify, with figures on numbers of lives saved difficult to pin down with certainty.

That said, there certainly seems to be scope for expanding the scope of some of the programmes: according to Breast Cancer Now, a quarter of breast cancer cases occur in women aged 75 and over , but the screening programme only covers women aged 50 to 71. Similarly, the bowel screening programme covers people aged 60 to 74, but Bowel Cancer UK reports 59% of cases occurring over the age of 70, implying a significant number of cases occurring in people outside the scope of the programme.

There may also be scope for making greater use of the processes and infrastructure of the screening programmes, for instance by sending information on lifestyle choices to help reduce cancer risk alongside the communication to invite people in for tests. While our view is that the greatest gains are to be made from structural changes to reduce cancer risks, improved information to equip individuals to make healthy decisions has its place, and currently this feels like an obvious opportunity being missed.

Undoubtedly screening will become a larger part of the cancer treatment landscape over coming years, as new and better ways of identifying more types of cancer are developed. Screening for lung cancer is being rolled out, for example, alongside the new NHS lung health checks. It is important that these programmes are well devised, fully resourced, and regularly evaluated, to ensure that they are as effective as possible.

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State of play: alcohol

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Throughout this Cancer Prevention Action Week, we are reviewing the current state of public policy for the major risk factors in causing preventable cancers.

Like poor diet and smoking, alcohol can cause many illnesses. The most widely recognised are probably liver disease and the life-disrupting effects of alcohol addiction, but the causal link to cancer is also clear. Cancer is a known factor in causing seven cancers, and the alcohol itself is the problem: whether you consume it in wine, beer or spirits doesn’t matter. There is a further, secondary effect: alcoholic drinks can often be surprisingly calorific, and consuming excess calories raises the risk of obesity, which is itself a cause of cancer.

Among the main causes of preventable cancers, alcohol is the one where policy has diverged most sharply between the nations of the United Kingdom – or, perhaps more accurately, where English policy is lagging behind the rest of the country. Scotland and Wales have introduced minimum unit pricing (Northern Ireland consulted on it in 2022, with next steps still awaited), which has proved successful in restricting the availability of cheap high-strength alcohol.

More generally, English policy tends not to approach alcohol use as a population health issue in the way that the devolved nations tend to. There has been no new strategy on alcohol harm since 2012, when a bold strategy was published that promised minimum unit pricing, banning multi-buy alcohol promotions in shops, obliging local authorities to consider public health when making alcohol licensing decisions, and other population-level interventions. For the most part, these commitments were simply not implemented, often without any formal announcement or explanation. No further significant action on alcohol has been announced since then.

What action would be useful? As with the other main causes, change needs to be structural in nature. There will be a place for measures to equip individuals to make their own decisions, such as through better labelling of alcoholic drinks, but the interventions that will make the biggest difference will be those that shape our environments to make the healthy choice the easy one. Restrictions on the display of alcohol in shops would be one avenue to explore, as would many of the 2012 proposals, not least tightening the framework for local decision-making about licensing alcohol sales and, of course, minimum unit pricing.

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State of play: diet and food

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Throughout this Cancer Prevention Action Week, we are reviewing the current state of public policy for the major risk factors in causing preventable cancers.

There is a clear link between obesity and numerous cancers – 13, according to Cancer Research UK. This link is both statistically clear, and increasingly well understood in biomedical terms: fat cells do not simply sit in the body, but interact with its processes, particularly influencing growth and sex hormones and causing inflammation, all of which increases rates of cell division and therefore the risk of a cancer developing.

However, tackling obesity is a complex and sensitive topic. As we discussed in a previous article, the temptation to blame individuals for making poor choices is strong, but wrong-headed. The rise in obesity levels over recent decades has been overwhelmingly caused by changes in diet. The prevalence of obesity doubled from 1990 to 2020, following major structural changes to the food we buy and how we buy it. From the 1970s onwards, ready-made, “ultra-processed” foods high in salt, fat and sugar became more common in our diets: the UK has the highest consumption of these foods in Europe.

At the same time, supermarkets came to dominate food retail, spurred on by changes to planning laws that made large out-of-town shops feasible. Supermarkets achieved a dominance that enabled them to drive down prices for consumers, but also exert enormous influence over what is available for us to buy, and how attractive different products can seem.

Takeaway food options have also expanded enormously over recent decades, most commonly offer tasty but unhealthy meals, and are more common in economically deprived neighbourhoods.

The need for changes to diet and food supply

It is CancerWatch’s view that major structural changes are needed in order to reduce levels of preventable cancer. This must mean making changes to our food chain and distribution: while changing individual behaviours has its place in the mix, this sort of change is always easiest for people who are already relatively well-off and relatively advantaged. But that is not where change is most needed: the problems with our food supply are a key factor in health inequalities. Sir Michael Marmot’s second review of health inequalities identified the characteristics of an unhealthy high street: they include higher density of payday loan, alcohol, gambling and fast food outlets. And over a million people in the UK live in “food deserts”, meaning they lack access to cheap and nutritious food (in practice, this usually means access to a supermarket).

We therefore argue that this issue should be approached and framed in terms of food and diet, rather than obesity. There are several advantages to taking this approach. One is that it encompasses other food-related factors in causing cancer, such as processed and red meat, which are clearly established factors in causing bowel cancer, and heavily implicated in stomach and pancreatic cancer as well.

Even more importantly, discussion of healthy eating is more acceptable to public opinion. Obesity is still widely understood (or misunderstood) as a personal failing arising from individual choices, and many people are inclined to reject messaging suggesting that individual choice is not the main problem. However, people are generally more receptive to messages about healthy eating, or diet as a factor in improving their overall health, rather than focusing just on wider causes of obesity. Messages pointing out the role of health inequalities also tend to be better received when they relate to access to food, rather than to levels of obesity. This is therefore the route to achieving public buy-in for structural change (although entirely discounting the role of personal responsibility is understandably greeted with scepticism: people expect to continue to see it as part of the policy mix).

Cancer Research UK’s much-publicised advertising campaign in 2019, drawing attention to the link between obesity and cancer, therefore somewhat fell into the obvious trap. CRUK’s policy positioning on what is needed to reduce the incidence of preventable cancers by reducing obesity is entirely right, and it is true that the link between obesity and cancer is not as widely known as it needs to be. But their posters might have done better to call for a specific policy change to improve diets: without that, their messages were directed at an audience of individuals, which carried the implication (whether intentional or not) that it was for those individuals to do something about it, and nobody else.

Policy options, and action to date

So, what action could be taken, and how much is already on course to happen? The good news is that action can be taken on many fronts: there is no shortage of possibilities. Planning reforms could be deployed to address unhealthy high streets, for example, and food deserts could be targeted through a collaborative approach between supermarkets and government both locally and centrally. The power of supermarkets more broadly could be leveraged to good effect: they are being prohibited from heavily promoting unhealthy foods from October this year (albeit this measure is much delayed), but could potentially use their dominant market position to promote healthy choices more heavily.

Measures to prompt the reformulation of food and drink to be more healthy could also be developed. The Soft Drinks Industry Levy (better known as the sugar tax) led many manufacturers to reformulate their products, and has enjoyed widespread public support. More measures of this sort are surely viable.

Public Health England undertook much valuable policy development work in this area, prior to its abolition (for example this paper on calorie reduction and this on a whole system approach to obesity). Unfortunately the Government Food Strategy published last year falls well short of taking the bold structural action needed, including failing to adopt many of the recommendations of the independent National Food Strategy that it had previously commissioned. Until much stronger action is taken, the costs of our current food supply and dietary problems will continue to be passed on to the NHS, and many people will continue to develop preventable cancers.

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State of play: smoking

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Throughout this Cancer Prevention Action Week, we are reviewing the current state of public policy for the major risk factors in causing preventable cancers.

Tobacco use is the area where historically there has been the strongest policy action to prevent harm. Much of the progress in extending life expectancy over the later part of the twentieth century and early part of the twenty-first can be attributed directly to success in reducing levels of smoking, and the UK has been a world leader in this. It is also the lifestyle factor whose link to cancer is most widely known and accepted.

Why do people smoke?

Why people start smoking and why they continue to smoke are subtly different questions, but the answers to both lie in wider determinants of health: socio-economic background and personal circumstances are major drivers of smoking behaviour.

Analysis by the Office for National Statistics and Public Health England shows that the likelihood of someone smoking increases in line with the level of deprivation in their neighbourhood. Smoking also correlates very clearly with a person’s housing tenure (renters are more likely to smoke than owner-occupiers) and occupational group (workers in routine and manual occupations are more likely to smoke).

Smoking uptake flows through generations: young people who are exposed to smoking behaviour, for instance via their parents, are more likely to see smoking as normal, more likely to have ready access to tobacco, and more likely to try it. Once they are addicted, they also find it harder to quit: in communities where smoking is still very visible, quit rates are lower (although attempts at quitting are no less common), and these trends reinforce each other. The reverse is seen in communities where smoking is less common: each generation is less likely to see it as normal, less likely to take it up, and more likely to find it easy to quit when they try.

As this implies, changing patterns of smoking behaviour is hard and takes time. Growing awareness of the harms caused by smoking brought rates down in the later decades of the last century, but more so among better off and more educated people. The ban on smoking in indoor spaces in 2007 built on many years of shops, restaurants and other facilities first having no-smoking areas, and then often banning smoking entirely. These changes made smoking more and more inconvenient, and marginal in society, an effect amplified by a ban on tobacco advertising, and requirements to sell cigarettes in plain packaging, and hide them from view in shops.

Smoking cigarettes has also been made more expensive. From November 1993, there was a commitment to increase tobacco duty by at least 3% per year, and by at least 5% from 1997; and it had been on a rising trajectory even before that. A slightly more complex set of rules was introduced in 2017, which has maintained the effect of annual rises.

Current policy

However, despite a history of strong action in the past, tobacco policy in the UK appears to be faltering. The Government set a strong ambition in 2019, for England to be smoke-free (defined as only 5% of the population smoking) by 2030. Wales has also set a target of 2030, and Scotland 2034. However, the independent Khan Review, which published its findings last year, reported that the English target will be missed by seven years without further policy action, and by 14 years in the least well-off parts of the country. Cancer Research UK has separately estimated that the England target is due to be missed by nine years.

The Government has yet to respond to the Khan Report: it has committed to doing so as part of a health disparities white paper, which has been subject to delay and was even reported to have been cancelled by the Truss administration (although health ministers later confirmed that it would be published). A new Tobacco Control Plan should then follow, but is similarly overdue. The bold interventions recommended in the report would, if implemented, be a striking but welcome departure from recent policy approaches. The recommendations include:

  • Increasing tobacco duty markedly more steeply than recent rises
  • Significant investment in smoking cessation services across the NHS
  • Progressively increasing the age at which tobacco may be bought, effectively prohibiting its purchase by people born after a certain date
  • Licensing for tobacco sales, to reduce the number of outlets where it can be bought
  • A “polluter pays” approach, in which the costs of these measures would be met at least partly by a levy on tobacco manufacturers.

Scotland, Wales and Northern Ireland all have tobacco control plans of their own, although some of the tougher actions proposed in the Khan Report would require UK-wide legislation by Parliament.

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Cancer prevention needs structural change: individual responsibility isn’t enough

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It’s a remarkable statistic that around 40% of cancers in the UK are preventable. It offers great hope for improvements in the future, but at the same time makes depressingly clear how many people are becoming ill and dying who would otherwise have enjoyed years of good health.

Overwhelmingly, the things that make these cases preventable are to do with lifestyle: the major factors in causing cancer that can be changed, and therefore bring that figure down, are smoking, diet (mostly by causing obesity) and drinking alcohol. Yet this immediately creates the temptation to argue that individuals simply need to make better choices for themselves. Unfortunately, “simply” is the most important and most misleading word in that sentence: in truth, there is nothing simple about altering people’s lifestyles to reduce cancer. If it were simple, we would have cracked it by now, and that 40% figure would have been reduced to almost nothing.

Our central aim as CancerWatch is therefore to push for the structural changes that are necessary to reduce and eventually eliminate avoidable cancers. This article explores what that means: why the tempting narrative of personal responsibility has led to policy failure, and what sorts of changes are actually necessary. Over the rest of Cancer Prevention Action Week, we will be publishing articles looking at the state of play in each relevant policy area: smoking, diet, alcohol, and screening.

What drives people’s choices?

Advocates of an approach that focuses solely on personal responsibility often argue that people can be relied upon to make rational choices. They are of course correct – indeed, more correct than they realise.

For someone leaving work late and tired after a long day, picking up food from one of the many takeaway outlets on their way home, rather than cooking a healthy meal from scratch, will be a rational choice. For someone who has to feed a family on a tight budget and who doesn’t have the use of a car, buying cheap processed food from the nearby convenience store, rather than finding a way to travel to a large supermarket to buy fresh food, will be a rational choice. For someone who has grown up around people smoking and drinking regularly, joining in with the behaviour of their peers will be a rational choice. Satisfying a craving, or even a passing fancy, whether for a cigarette, a drink or a slice of cake, will often be a rational choice, compared to expending the effort and enduring the distraction needed to resist it – provided, of course, that the cigarette, drink or cake are easily at hand.

It will be clear from these examples that a person’s circumstances have a huge bearing on the choices they make. This includes people’s social and economic circumstances, which determine what they can afford to do, what they have time to do, and what other people around them encourage them to do. The basic geography of where they live will matter a great deal: most commonly in the United Kingdom, cheap and healthy food can only readily be obtained at a supermarket, so if you live a long way from one of those but nearer to numerous takeaways and convenience stores, location is likely to shape your choices. Equally, if you are under ongoing financial pressure, or live in a poor quality home, or have to deal with a difficult family life, things like quitting smoking or cooking healthy meals will very naturally not seem like high priorities.

From this, it will be obvious not only how circumstances shape people’s health, but also how this drives inequalities across our society, with the people who consistently make healthy choices generally being those who have the money and time to do so.

The argument is not won

Set out in this way, it all seems like common sense to suggest that wider factors need to be addressed, and that unhealthy choices are not simply the product of individual failings. Unfortunately, recognition of this idea, let alone support for it, is lacking.

Research by Nesta and the Behavioural Insights Team in 2021, which looked specifically at food and diet choices, found that the public overall tends towards the “personal responsibility” view. There is a correlation between the level of support enjoyed by a public health measure and the extent to which people believe it will be effective: the more likely people feel it is to work, the more likely they are to support it. Unfortunately, there is widespread belief that the best way to improve health is to enable individuals to make healthier decisions, mostly by providing information and encouragement. Other interventions to change the food choices available to people, or the incentives for different choices, clearly enjoy less public support.

Where stronger interventions have been applied, such as with the ban on smoking in enclosed public places or the sugar tax that prompted many manufacturers to reformulate their products to reduce sugar levels, they have enjoyed public support and there is no significant public pressure to repeal them. It may be that stronger measures can be expected to attract support after their implementation, but certainly many potential interventions appear unlikely to enjoy much support at the moment.

However, those earlier successful measures show the path we need to be taking. Crucially, this does not simply involve regulation to curtail personal freedom. That may be part of the mix, such as tougher restrictions on smoking in public places, whether enclosed or not. But often regulatory solutions will address business behaviours: it might mean restricting advertising of unhealthy products further, using planning rules to reduce proliferations of takeaways, or incentivising more reformulation of unhealthy products. None of those measures would strictly prevent people from consuming unhealthy substances, but it would need to be a deliberate and active choice, rather than the natural or obvious one.

For Cancer Prevention Action Week, therefore, we need to be clear about what sort of action is needed. By all means, people should be given information and encouragement to make healthy choices, but the action that is required above all else is bold, structural change. Healthy choices should be made the easiest, most convenient and most affordable choices for everyone. Substantial reform of how tobacco, food and alcohol are consumed and regarded in our society is the only way to achieve this.

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Image by Howard Lake on Flickr, reproduced under Creative Commons licence BY-SA 2.0

Obesity and Planning Permission

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The obesogenic nature of our inner cities has long been a cause of concern for activists campaigning against poor health, and the key instrument for control of inner city environments is planning permission. In the post war years such permission has become fiercely complex and very much the realm of lawyers, yet normal inhabitants of any town have to interact with it if they want to complain about commercial and retail development in their urban environment.

Planning permission determines the character of the built environment, and nowhere is this more true than in the case of restaurants and retail food outlets. For those of us who are concerned about obesity, the fast food and hot food takeaway sector is an area of significant focus. We are not talking about lunchtime takeaway shops, whose staple is sandwiches and salads, many of which are quite healthy We are talking about the evening purveyors of kebabs, chips, fried chicken wings, oversized pizzas, king sized burgers and such like, where the calorific content is significant but the nutritional contents in minimal.

The poor quality of inner city environments also has the effect of discriminating against the poorer and less advantaged members of society, due to the high level of social housing and poor quality of rented accommodation that often exists in the inner city. The middle class leafy suburbs have traditionally been more insistent at keeping low quality fast food restaurants and take-aways out of their areas; they have a better understanding of the damage these retail units do to the environment in which they live.

Public health is not normally considered an adequate reason for refusing planning permission, but increasingly local councils with poor health metrics in their areas are taking action. Within the planning system, local government can control development by using Planning Directives, and these are increasingly being used. Other such tools include Supplementary Planning Documents, and a number of local councils, such as Dagenham and Coventry City council have used these as tools to reduce the prevalence of fast food takeaways in their areas.

It is unfortunate that local authorities often use child (as opposed to adult) obesity as a diversionary tactic, emphasising how they prohibit hot fast food take-aways from operating close to schools, and other no doubt worthy child health policies, but they fail to address the key issue of adult obesity caused by the overall poor quality of the inner city environment. Making the matter especially difficult, of course, is that at a time of hollowing out of town centres, councils try to attract retail outlets to their inner city areas, encouraged by the need for councils to attract business rates to their locality at a time of budgetary cuts from central government.

Unfortunately, there is no quick fix for obesity. In practice to make policies effective they have to be used with other anti-obesity tactics. But anti-obesity campaigners should increasingly ask why these poor quality hot fast food retails outlets exist in their cities at all.

The Problem with Children’s Obesity

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During the lockdown, my front door has been the recipient of countless leaflets promoting take-away food of a distinctly dubious nutritional quality. This caused me to write to my local council complaining about high fat, fast food take-aways and the effect they had on obesity. I received a fulsome letter back from the local councillor in charge of health, but it talked only about childhood obesity.

Good cause to worry? UK children are the fattest in Europe and have become fatter since the lockdown according to figures released in autumn 2020 by the National Child Measurement programme.

When children start school more than a fifth of four year olds are classed as overweight and a tenth as obese, meaning they have a BMI of 30 or above. By the time they go to secondary school more than a third of children are overweight and a fifth are obese. Across England, childhood obesity has risen while the gap between the rich and the poor has widened.

The Conservatives pledged to “tackle childhood obesity” in the party’s 2019 manifesto. In 2018 the Tories had committed to halving the problem by 2030.

The campaign is very worthy and well meaning, but there is a more subtle aspect to it. Obesity is a major risk factor for many lifestyle (ie preventable) cancers, so it is important that obesity should be controlled and eliminated.

A number of cancers are caused by obesity: bowel cancer, uterine cancer, oesophageal cancer, breast cancer and others. Indeed, some campaigners are now saying that obesity causes more cancer than smoking. Other lifestyle diseases, such as diabetes or cardiovascular disease are also diseases of the overweight.

However, a characteristic of lifestyle cancers is that they tend to affect the elderly, not the young. For example the average person who gets cancer of the oesophagus is aged 70. The average age of a child is half 18, thus aged 9. So there is a 60 year gap between the cancer itself and the precautionary action being taken. In a sense, you could argue that in the case of cancer of the oesophagus, for example, you have to wait 60 years to know if the child obesity campaign has really been successful. Similar figures would apply to other lifestyle diseases.

No government department works to a 60 year time horizon so why did the Department of Health and Social Care (DHSC) embark on this? The answer is that it is an easy option for them. It is “doable” (Amsterdam has already succeeded), it is measurable, and because children are involved, everybody sees it as a “good thing” rather than part of a so-called nanny state.

Unfortunately, worthy as it is, in my opinion, the campaign against child obesity is also acting as a decoy, a diversionary tactic for what really needs to be tackled, which is adult obesity. It is adult obesity that needs to be tackled now, not in 60 years time. It may be easier and more convenient for the DHSC to turn a battle against “obesity” into a battle against “child obesity” but the two are very different, and the battle against the latter risks sidelining the battle against the former.

After all, the battle against adult obesity would lead you into concepts such as “fat taxes”, finger wagging and concepts alien to a “free society”, whatever that is. It is easier to advocate policies that have already been shown not to work, but apply them to children, where you have more control, and therefore make weak policies seem more successful.

Of course, the assumption is that if you can fix child obesity you will fix adult obesity. I would argue that the logic is the other way around, not to mention that the time horizons are just too long to carry any meaning. Perhaps you can hope that putting emphasis on preventing obesity generally through the child obesity drive will leach through to adult obesity. But I say fix adult obesity first, then you will find child obesity will fix itself.

JMC March 2021