The nanny state: how Whitehall is trying to make us all behave

Nothing brings a politician out in a rash of nerves quicker than a charge of nannying. Ever since Virginia Bottomley, the fragrant former Tory health secretary, urged us to eat "three egg-sized potatoes a day" a decade ago, Governments of every hue have run scared from telling us how to live our lives.

Hardened civil servants still recall with a shiver the toe-curling embarrassment caused by Ms Bottomley's precise instruction - not two potatoes or four, not marble-sized or apple-sized - which was mercilessly mocked by the Opposition.

But the tide could be turning. While nannying is still beyond the pale there is a new mood in Whitehall that something must be done about the tide of public health problems - obesity, smoking, drinking, sexually transmitted diseases - which threatens to overwhelm us.

Yesterday, in a paper entitled Personal Responsibility and Changing Behaviour, the Downing Street strategy unit floated the possibility of slapping a tax on fat. Exactly how the tax would be applied is not clear, but its aim would be to deter people from eating burgers, crisps, butter and whole milk in the hope that they would substitute healthier foods for the missing calories.

A second report yesterday suggested the Government is planning to put warning labels on wine, beer and spirits to alert drinkers to the dangers of alcohol. The move will be announced in the Government's long-awaited alcohol harm reduction strategy, expected next month.

These are not the only signs that the defence of the public health is moving up the political agenda. Next week, Sir Derek Wanless is due to publish his second report, commissioned by the Chancellor, Gordon Brown, examining the prospects for our health over the next two decades and the demands it is likely to impose on health and social services.

Observers are keenly waiting to see how much responsibility the Wanless report places on individuals to look after their own health through diet and exercise and how much it assigns to the broader social, fiscal and commercial environment which could be modified, for example, by a ban on advertising of junk food to children or a ban on smoking in public - both measures which ministers have so far resisted.

The acute political antennae of the Health Secretary, John Reid, have identified public health as the coming political issue. He plans to issue a White Paper in the summer. As a reformed 20-a-day smoker who gave up last year, he knows both the power of social pressure and the need for personal commitment to protect health.

He does not intend to make Ms Bottomley's mistake by attempting to meddle in what people put on their plate, but nor is he about to turn his back.

"We should be neither a nanny state nor a Pontius Pilate state that washes its hands of responsibility," he said last week, in response to the latest warning from the royal medical colleges about spiralling rates of obesity. But how will he strike the balance between nannying and washing his hands - and what measures will he take? Are government warnings necessary? And do they work?

Sian Griffiths, president of the Faculty of Public Health, who presented last week's report on obesity, said information and regulation should be the twin pillars of a public health strategy. "I am pro-choice and pro-regulation. On salt and sugar, for example, you start with better labelling and you move to getting the food industry to put less salt and sugar in their food, especially in kids' food.

"If you go with the philosophy of choice you have got to know what you are choosing. Food labels don't mean much to the average shopper. There has to be a simpler way of signifying the fat, salt and sugar content of food that would help people make choices."

Health warnings can work, but there are dangers. Messages on cigarette packs, such as "Smoking Kills", put some people off, but are ignored by others, research has shown. But ill-judged warnings can have the reverse effect. One of the most notorious examples was the campaign in the early 1990s against drug abuse which featured wasted individuals pictured semi-comatose in scenes of urban desolation. The images, far from delivering the knock-out punch intended, were adopted by the fashion industry and spawned the trend of "heroin chic". Professor Griffiths said: "We don't know what works because we haven't had a look to see. We have never done the research in this country."

Warnings about drinking on bottles of alcohol could risk increasing their appeal in a similar way to the heroin advertising, especially to the young bent on a night out and getting smashed, she said.

But Vivienne Nathanson, head of science policy at the British Medical Association (BMA), said that many people were interested in knowing how much alcohol they were drinking, and the "unit" - a glass of wine or half a pint of beer - was a poor guide when alcohol content of wines and beers varied so widely.

"People know how many pints they have drunk but not how much alcohol. We want to help people make choices, but it is also about giving them the right information. The message not to drink and drive has got across, but young people don't know that alcohol is a poison and can be lethal," she said.

The BMA considered calling for a tax on fat at its annual conference last July - and rejected it on the grounds that it would worsen inequality. The problem is that the poorest have the unhealthiest diet and would be hardest hit. If the price of improving their diet was that their children were undernourished, that would not be a desirable outcome.

Dr Nathanson favours better promotion of fruit and vegetables. "Why can't someone produce a piece of sexy advertising to make every kid want a piece of fruit in their lunch box?" she said.

Niall Dixon, newly appointed chief executive of the King's Fund, a health policy think tank, said that despite continuing political nervousness beliefs about what might work in public health were changing.

"The Government has at last realised there is a juggernaut coming towards it with all these health problems from obesity to drinking that didn't seem important a couple of years ago. I think the public is probably more prepared to accept state intervention in some of these areas than they were in the past simply because the problems are so much greater. There are practical difficulties about doing things but the Government shows every sign of wanting to pull the levers."

The scale of the challenge was set out in an interim report from Sir Derek Wanless, published in December, which charted the nation's present poor state of health and the inefficiency of our health system in dealing with it. It compared the main causes of mortality in Australia, Denmark, Canada, Finland, France, Germany, the Netherlands and Sweden - selected because they had similar populations, wealth and health systems.

Life expectancy at birth was low in England compared with some other countries and mortality rates for some of the main chronic diseases, such as cancer and heart conditions, were high, it said.

It showed that deaths from respiratory diseases in Britain were at least 50 per cent higher among women and 30 per cent higher among men than in all other countries. Britain topped the table for infant mortality, which was 70 per cent higher than in Finland. Cancer deaths among women were second only to Denmark and 25 per cent higher than in France.

Next week Sir Derek is due to reveal in his final report what measures are necessary to reduce this heavy burden of ill health. Unless we can do so, sustaining the NHS over the next 20 years will be made much more difficult.

EATING

As obesity levels soar, tackling the omnipresent temptation of junk food has risen on the Government agenda.

At present, one in five adults is obese, a condition that causes at least 30,000 deaths a year in the UK from conditions such as heart disease, stroke and diabetes. Government attempts to make Britons eat healthier has gathered pace in the past few years.

Two years ago, a pilot scheme providing schoolchildren with free fruit was launched. The initiative was based on research showing that it would result in children having better attention spans and healthier lives.

Last year, reports that the Government was considering health contracts to encourage overweight people to lead healthier lifestyles were met with a storm of protest. The contracts would ensure a certain standard of treatment in return for people following doctors' advice and attending appointments. Doctors could refuse treatment to overweight people if they did not diet.

Several months later, MPs also hit out at celebrities who promote junk food, as the Commons health committee urged stars to reconsider their deals.

This year, the Government announced an £80m investment to tackle obesity, including plans to give children aged four to six fruit each day.

Funds will also cover cookery classes, advice on preparing healthy packed lunches and a trial of vending machines selling milk, water and fruit at 500 schools.

However, the most radical proposal, recently revealed in a leaked Government report, was the so-called fat tax, which would mean extra VAT on burgers, chips and chocolates.

SMOKING

Although tobacco first wended its way into Europe from the New World in the 15th century, it took another 500 years before it made the transition from medicinal cure to symbol of sophistication. Levels of smoking peaked after the Second World War with the celebrity endorsement of half of Hollywood, from Frank Sinatra to Laurence Olivier.

It was not until the 1960s that the health implications of smoking became clear for the first time. In 1965, television advertising was banned, and six years later, strict guidelines were issued preventing cigarette companies from suggesting that smoking was glamorous, popular or relaxing. For many, however, these steps came too late. By 1974, 51 per cent of men and 41 per cent of women smoked cigarettes. Today, there are 13 million adults who smoke, causing 120,000 premature deaths every year, according to the Department of Health.

In 1997, EU health ministers voted to phase in restrictions on tobacco advertising and sponsorship over eight years. A UK ban on newspaper, magazine and billboard advertising came into force last year, after the Government overcame legal action from tobacco companies. The move, enforced by £31m of government anti-smoking campaigns, aimed to save 3,000 lives a year and cut annual NHS bills by £40m.

Following the US example, the next step is a total smoking ban in public places. Under next month's White Paper, the Government plans to give councils the power to outlaw smoking in public places, including pubs, restaurants and shopping centres. Meanwhile, the Republic of Ireland will outlaw smoking in pubs, restaurants, bars and other enclosed workplaces from 29 March.

Last week the Government proposed that graphic images of yellowed teeth should be pasted on to packs of cigarettes in a further effort to discourage smoking.

DRINKING

Young Britons persistently top the polls as the heaviest drinkers in Europe, a tradition which goes back centuries.

It was in 15th-century England that excessive use of distilled spirits was first noted. Amid widespread Elizabethan inebriation, the Government passed the 1606 Parliamentary Act to Repress the Odious and Loathsome Sin of Drunkenness, followed by the introduction of a swingeing excise tax on distilled spirits. Today, the Government's well-chronicled battle against heavy drinking continues, with a culture of binge-drinking currently costing Britain an estimated £20bn a year in terms of lost work days, extra health and police expenses.

Reports this week claimed that the Government is planning to spend hundreds of millions of pounds on highlighting the dangers of excessive drinking, as part of a harm-reduction strategy expected to be published next month.

New measures may include health warnings on alcoholic beverages, detailing the dangers of binge-drinking and the number of alcohol units the drinks contain.

A total ban on alcohol will definitely not be included in the strategy. However, there will reportedly be a crackdown on the current advertising code, which is policed by Advertising Standards Authority. The code forbids linking alcohol with "sexual capabilities, popularity, attractiveness, masculinity, femininity or sporting achievements", or suggesting it is "the main reason for the success of any personal relationship".