Regulation for health inequalities and non‐communicable diseases: In want of (effective) behavioural insights

Date01 November 2018
Published date01 November 2018
Regulation for health inequalities and non
communicable diseases: In want of (effective)
behavioural insights
Nikhil Gokani*
The death and disease burden of noncommunicable diseases falls disproportionately on members
of lower socioeconomic groups. This paper explores NCD prevention measures introduced through
EU consumer law in order to assess the impact these have had on health inequalities. It demon-
strates that these interventions often have limited impact, and therefore maintain inequalities.
Indeed, when interventions do work, they tend to be more effective with advantaged citizens than
disadvantaged citizens, and therefore increase inequalities. From a behavioural research perspective,
this paper demonstrates why these interventions which focus on regulating the consumer
information environment have failed to reduce health inequalities, and analyses the debate on
the extent to which behavioural research should act as a core consideration in public health related
consumer policy. The paper concludes that, while regulating consumer information is a useful tool
for NCD prevention, if informationbased interventions are to reduce health inequalities the EU will
need to incorporate greater insights from the way consumers actually behave. Moreover, there are
limitations to policies which regulate information, and therefore the EU should make more use of
other tools in its regulatory toolbox.
The global burden of noncommunicable diseases (NCDs) is staggering. NCDs account for 36 million deaths, or 63%
of global mortality.
The regional impact of NCDs is equally overwhelming: NCDs result in 86% of European deaths
and 77% of the European disease burden.
* Law and NonCommunicable Diseases Unit, School of Law and Social Justice, University of Liverpool, UK. I would like to thank Dr
Marine FriantPerrot with whom I have worked on the issues of health inequalities and noncommunicable diseases; this paper builds
on this research with her. I would also like to thank Professors Alberto Alemanno and Francis Snyder for their comments following my
earlier presentation on these issues at the 10th International WISH Conference. Special thanks go to Professor Amandine Garde for
her comments on a more developed draft. All limitations are, of course, my own.
Global Action Plan for the Prevention and Control of Noncommunicable Diseases 20132020(World Health Organization, 2013),
at 7.
Action Plan for Implementation of the European Strategy for the Prevention and Control of Noncommunicable Diseases 2012
2016(World Health Organization, 2012), at 12.
DOI: 10.1111/eulj.12219
490 © 2018 John Wiley & Sons Ltd. Eur Law J. 2018;
The Political Declaration on the Prevention and Control of Noncommunicable Diseases,
adopted in 2011
by the UN General Assembly, confirms that the threat and burden of NCDs represent a major challenge for
development in the 21st century. In reaffirming the right of everyone to the highest attainable standard of
physical and mental health, it recognises the urgent need for greater prevention and control. The Declaration
calls on Member States to deliver multisector, multilevel, populationwide, evidencebased, healthinall policy
action, which is not only affordable but also costeffective. In particular, the Declaration calls on Member States
to create healthpromoting environments which empower people to make healthy choices and lead healthy
lives. It confirms that the most prominent NCDsnamely cancers, cardiovascular diseases, chronic respiratory
diseases and obesityare linked inextricably with the conditions in which people live and their lifestyles
and behaviours.
These diseases are largely preventable, particularly through a reduction in exposure to the
modifiable risk factors of unhealthy diets, excessive consumption of alcohol, tobacco use, and a lack of physical
The distribution of these NCDs is far from equal amongst different groups of the population: there is a strong
socioeconomic gradient between the health status of the lower and higher socioeconomic groups. The lower
somebody's socioeconomic position (SEP), the worse his or her health is likely to be. People from lower SEP groups
live shorter lives than people from higher SEP groups, and they also live more of their shorter lives with disease.
These inequalities in health are linked inextricably with, again, the conditions in which people live and their
behaviours. These social determinants of health, and the health inequalities they result in, are in fact inequities which
demand action as a matter of social justice.
Following increasingly powerful calls to tackle the determinants of NCDs,
the European Union (EU) has given
the prevention of NCDs and the reduction of health inequalities greater thought.
Its actions on tackling the major
modifiable risk factors of unhealthy diets, tobacco use and excessive alcohol consumption have ranged from soft,
nonbinding measures in the case of alcohol, to stronger measures in the case of tobacco, with nutrition falling
somewhere inbetween.
Where the EU has taken legislative action, with the exception of product safety, this has centred primarily on
trying to influence consumers towards healthier behaviours through regulating the information environment in which
consumer live, work and play. These policies are not only insufficiently effective, but they have also failed to reduce
the inequalities in health which remain pervasive throughout the European populations.
United Nations, Political Declaration of the Highlevel Meeting of the General Assembly on the Prevention and Control of Noncom-
municable Diseases. A/RES/66/2.
This paper will use the phrase behavioursrather than lifestyles, as the latter frames public health at an individual leveleffectively
blaming individuals for making irrational decisions that are detrimental to their health The use of such descripti ve terms frames
public health actions in a pejorative and reductionist way, demonstrating that those who use them seemingly fail to understand or
communicate the broader nature of the range of determinants of health; thus perpetuating myths about the foundations of health
and health inequalities: P Lincoln, LifestyleA Plea to Abandon the Use of this Word in Public Health, available at www.
See, for instance, Global Strategy for the Prevention and Control of Noncommunicable Diseases, World Health Assembly Resolu-
tion 53.14, adopted 22 March 2000.
See, for instance, European Commission, Commission Implementing Decision of 28 November 2012 concerning the adoption of the
2013 work plan in the framework of the second programme of Community action in the field of health (20082013); European Com-
mission, The selection, award and other criteria for financial contributions to the actions of this programme and the EU payment to
the WHO Framework Convention on Tobacco Control, serving as a financing decision, OJ C 378/6, 8.12.2012. On the history of EU
calls and action on NCD prevention, see A. Alemanno and A. Garde, The Emergence of an EU Lifestyle Policy: The Case of Alcohol,
Tobacco and Unhealthy Diets(2013) 50 Common Market Law Review, 17451786, at 17461752.
A. Alemanno and A. Garde, Regulating Lifestyles in Europe: How to Prevent and Control NonCommunicable Diseases Associated
with Tobacco, Alcohol and Unhealthy Diets?(Swedish Institute for European Policy Studies, 2013); A. Garde and M. FriantPerrot,
The Regulation of Marketing Practices for Tobacco, Alcoholic Beverages and Foods High in Fat, Sugar and SaltA Highly
Fragmented Landscape, in A. Alemanno and A. Garde (eds), Regulating Lifestyle Risks: The EU, Alcohol, Tobacco and Unhealthy Diets
(Cambridge University Press, 2014).

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