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

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