Baby Boomers - living out the great binge!

The human race has not devised any way of dissolving barriers, getting to know the other chap fast, breaking the ice, that is one-tenth as handy and efficient as letting you and the other chap, or chaps, cease to be totally sober at about the same rate in agreeable surroundings.

So said Kingsley Amis and for once he was right. Yet we're collapsing again into the stew of temperance by allowing the obsession with living forever to dictate to those who make the rules. And it seems that us Baby Boomers are the last bastions of sense and decency - OK call it hedonism - in this world. We created the great binge!

Between 1992 and 2006, the average weekly alcohol consumption for people aged 45–64 (capturing the majority of baby boomers) rose by 85%, compared with a 50% rise in those aged 65 and over, and a 45% rise in those aged 16–24. As baby boomers have aged, follow-up studies with this cohort reveal similar findings. Between 2005 and 2013, the percentage of men drinking eight or more units of alcohol (the equivalent of four pints of normal strength beer) on any one day in the past week changed by only 5% in the over 65s. In contrast, this rate of drinking fell by 30% among 16–24s, 19% among 22–44s, and 12% among those aged 45–64.

They hate us for this those New Puritans with their temperance.  The cult of the NHS demands that any health problem that might be seen as 'self-inflicted' must be dealt with. Drinking, smoking, eating too many burgers - these things are not to be tolerated. And when you or I respond with "it's none of your business", the fanatics from the Church of Public Health peer down at you and say: "but it is, think of the cost to the NHS". The argument is closed, action must be taken to stop us from enjoying ourselves by drinking just a little more than they think we should. For some - egged on by the old temperance lobby - even the merest drop of the demon drink will lead to perdition and doom (defined these days as a 'cost to the NHS').

The latest in a long line of misperceptions is that we - the baby boomers that is - don't understand that boozing carries health risks:

Trying to change baby boomers’ behaviour and attitudes towards drinking and drug use is a tough sell to a generation now steeped in lifelong attitudes shaped by a lack of awareness of the harms of alcohol and substance misuse.

This is, of course, utter claptrap. Of course we know it's bad for us, it's just that we're happy with the trade-off implied by hedonism. We're no more victims of advertising than smokers or kids wanting sweets. If not drinking now means we live longer - maybe - can we be so sure that extra bit of life will be a pleasure too? Or will it be an uncomfortable, perhaps painful, few months dribbling slowly to death in a nursing home? Us boomers look around at our friends and neighbours and decide to live for now rather than for some possible future.

There's another aspect of this claptrap. All this high octane living doesn't seem to be killing us off (rock stars aside and even there most aren't dropping dead). The pubs are filled with people in their 60s and 70s living happy and fulfilling lives. Look down the seats on your holiday flight and check out all those boomers spending the kids inheritance on cooking themselves in the Spanish sun (skin cancer - bring it on) and meandering round Florence, Prague and Madrid lapping up the culture (plus the food and wine, of course).

For the po-faced, narrow-minded, judgemental folk at the Church of Public Health all this won't do at all. We (the Boomers that is) need to be stopped because we're killing ourselves and worse still, we're setting a bad example to the young. Think of the children! So they agitate for advertising bans, for higher taxes, for distribution controls, for watering down the beer, and for draconian licensing regulations. Only when we've been nudged with a large baseball bat into cutting down our boozing will these zealots be happy.

The problem is that we aren't budging. Why the hell should we forgo pleasure now for the sake of an uncertain future. We don't want to die but we do at least recognise that this is going to happen, that we aren't going to live forever. So in the diminishing years left to us, why shouldn't we drink and eat for pleasure? Don't expect us to limit our drinking to a couple of pints on a night out and our eating to a fat-free, salt-free, sugar-free, meat-free, taste-free, overcooked pap. We're not going to do this and the more you nanny us the louder we'll get and the ruder we'll get about the fussbucketry of public health. If they want to live a stressful, dull life without pleasure that's fine by me but, for the rest of us, hedonism rocks. We started the great binge and boy do we intend to finish it!

A good example of 'nudge'. It's also a cracking idea.

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Most of the left-wing world (and plenty of the Tory world too) thinks that 'nudge' is about pricing, taxing and regulating the hell out of things so as to make people change their behaviour. As the creators of the concept were clear this isn't so.

This is nudge:

A speedometer that indicates your speed and additionally gives you a money counter. What’s the deal? Each car that passes and stays below the speed limit of 30 kilometers per hour raises €0,03 for the neighborhood.

The money is paid out by the city of Amsterdam and is meant to be used in local community projects. The city’s slogan: “Max 30 — Save for the Neighborhood”. An interesting take on conditioning local residents to bring forth good citizenship instead of punishing car drivers for breaking minor traffic laws when being slightly over the speed limit.

Rather than the sign leading - as speed cameras do - to a fine and to punishment, we have a little gentle incentive. Slow down and the community gets some cash.

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What public health can learn from Reader's Digest

Over 25 years ago I stumbled – more or less accidentally – into the world of direct marketing. And many of things I’ve learned from practicing that craft can be applied elsewhere. So it is with “nudge” and the practical application of what the clever folk chose to call “behavioural economics”. You know, the bit that starts with Steven Landsburg’s famous quote:

“Most of economics can be summarized in four words: “People respond to incentives.” The rest is commentary.”

And then continues to the Thaler & Sunstein idea of “nudge”:

“The trick is to promote actual freedom – not just by giving people lots of choices (though that can help) but also by putting people in a good position to choose what would be best.”

The thing is that mail order people and direct marketers had being doing this stuff for 50 years before all the trendy policy wonks picked it up. We’d been carefully learning a whole load of things about human behaviour. And many of those techniques came from the fertile and creative mind of Walter Weintz – someone who the typical academic behavioural economist should have heard of but probably hasn’t. He said:

Once the basic principles and techniques of mail-order promotion are understood, they can be applied in the most unlikely places, and for unexpected products. Although my own initial mail-order experience happened to do with magazines and books, the same rules would have applied had I been working on a correspondence course in accounting, the mail-order sale of Christmas hams or Chesapeake crabmeat, securing leads for Ford cars, or, indeed, getting political candidates elected or fund raising for a political organization...

And of course social policy and public health!

The name may be new to you but his biggest success – the brand that he made famous – is very familiar: Reader’s Digest. And this great man set out the story – as every in his slightly folksy style – in a book: The SolidGold Mailbox. The essence of this direct marketing – of the strategies that Weintz pioneered - lies in two things – incentives and testing.

So when someone arrives with a seemingly wonderful idea – that we can use things other than price or availability to incentivise behaviour – they are merely generalising the specific thing that direct marketers learned from Weintz and others. Things like:

·         The power of words – as Rush Limbaugh famously said: “words mean things”. Words like “free”, “new”, “exclusive”, “limited”, “bestseller” – these are real magic words that trip positive behaviour in people. I know this because it’s been tested and proven by direct marketers hundreds and hundreds of times.

·         The impact of reward - do this and you’ll get (or win or ‘qualify for’)something. It may be a free gift or an “exclusive” discount. Perhaps it’s an entry into a draw or a qualification for a “prize”. Our choice is rewarded – subscribe to the magazine and you are showered with wonders! Choose not to subscribe and these things will be torn from your very grasp.

·         How we love our name. Do you look up, even in a crowded room, when your name is mentioned? You do – that’s why even the clunky personalisation used in Reader’s Digest mailings worked. And because we love our name – think of the silly Starbucks thing about writing your name on the cup – we love to hear others use it. Even when it mispronounced or misspelled! There’s more too – because we like to hear our names, we like to use names too. So asking you to call Ethel or Steve on 0800 123456 works better that call us at that number. It’s a real person!

The point here is to remind us that the idea of “nudge” isn’t about price or regulations but is about language, about the order in which things are written and the way in which the choice is placed before us.  And direct marketers have been playing games with language, with the presentation of offers and incentives, for decades. We can tell you that long letters are more responsive than short letters, that past behaviour (such as buying mail order) is always a good guide to future behaviour and that people don’t read letters the way you think they do. Oh, and if you don’t ask for a response you won’t get one!

All of these things – these little games with words, with design and with non-financial incentives – can be applied to public policy whether it’s getting people to recycle, register to vote, stop smoking or visit the local clinic. Just one simple example will suffice – if you put a map of the clinic location on appointment letters for medical check-ups people are more likely to attend. Even when you know that they know exactly where the clinic is located because they’ve been there dozens of times.

This is “nudge”. Minimum pricing isn’t “nudge”, banning advertising isn’t “nudge”, passing regulations about packaging isn’t “nudge”. Look back at that Cass & Sunstein quote – the bit about promoting “actual freedom”. It’s about the words used and the choices offered – rather than saying “smoking is bad don’t do it” we should argue for point-of-sale-displays setting out the rewards of not smoking not for scary pictures or hiding the product away.

I’m not sure whether “The Solid Gold Mail Box” is still in print but it would be a great boon to effective – and genuinely liberal – social policy and public health campaigns if those creating them read the book. But then I recall a Director of Public Health who rejected a direct marketing approach to a campaign (on HIV/AIDS) because it involved another little thing that Weintz – and every other direct marketing – knows works: targeting those most interested in what you offer. Or, in the case at issue, those most at risk.

Public health hasn’t moved on. It still prefers the general to the targeted – introducing minimum prices that affect everyone rather than targeting campaigns to those most at risk. And they still prefer to say “you mustn’t do that” or “stop that” rather than “wouldn’t it be better if you did this instead?” 

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Cabinet Office backs e-cigs ...

Or at least is seems that way:

The government's "nudge unit" wants to encourage the use of smokeless nicotine cigarettes, banned in many countries around the world, in an attempt to reduce the numbers killed in the UK by smoking diseases each year.

The Cabinet Office's behavioural insight team – better known as the nudge unit – wants to adopt the new technology because policy officials believe the rigid "quit or die" approach to smoking advice no longer works. Rather, they want nicotine addiction to be managed to help smokers who otherwise won't quit – an approach the unit believes could prevent millions of smoking deaths.

This is perhaps the first sensible thing that has come out from government on this issue. I'm now waiting for the onslaught from the agents of pharmaceutical nicotine delivery, who are desperate to kill off e-cigs in the interests of their paymasters.

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"Healthy Lives, Healthy People" - welcome to the land of nudge, to Lansley's Brave New World

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I have been reading “Healthy Lives, Healthy People”, the Government’s ‘strategy for public health in England. And a fine read it is too, reflecting as we might expect the current obsession with ‘behavioural science’ and the nudging of people into making the right ‘lifestyle choices. Mind you some of those ‘nudges’ are more akin to a robust shoulder charge than a gentle shove!

As you know, dear reader, I am not enamoured of this approach to public health. Indeed, the entire conception of ‘public health’ has moved from ensuring a safe environment to influencing individual choices – up to and including bans. However, this little piece isn’t about all that – although my observations are pertinent to that aspect of debate. It's more about missing the point!

The most striking thing about “Healthy Lives, Healthy People” isn’t just the dominating obsession with smoking (a word that appears on nearly every page) but with a recurring observation about the ‘causes’ poor health:

“People living in the poorest areas will, on average, die 7 years earlier than people living in richer areas and spend up to 17 more years living with poor health. They have higher rates of mental illness; of harm from alcohol, drugs and smoking; and of childhood emotional and behavioural problems.”

Not exactly a surprise really. So why, instead of targeting our efforts at the ultimate cause of health inequality – poverty – do we concentrate instead on whether people make the right or wrong lifestyle choices?

People living in these places have a pretty low quality of life – to put it bluntly, their lives are crap. And they know it so they indulge – booze, smoking, drugs, reality telly, McDonalds, fizzy drinks, chocolate bars plus, of course, sex. Plenty of sex.

Using these cosy middle-class nudges to change behaviour is an insult when we leave them in poor housing, we fail to educate their children adequately and we provide a debilitating drip feed of benefits. So you take the nice stuff away, the things that make the crap life a little more tolerable – either by manipulating the price or through bans and controls – and these people will live a few years longer. Another couple of years living in a damp council flat or worse being spoon-fed in some tatty old people’s home. Now that really is something to look forward to!

And yes, my Conservative friends, pretending that it isn’t poverty causing the problem is just as bad as moralising about people’s behaviour. Here are some samples from “Healthy Lives, Healthy People”:

“Rates (of maternal depression) are nearly twice as high among mothers living in poverty and three times as high for teenage mothers.”

“Smoking rates during pregnancy are much higher among lower socio-economic groups and teenage mothers.”

“Rates (of childhood obesity) are higher among some black and minority ethnic
(BME) communities and in lower socioeconomic groups.”

“There is evidence that mental ill health disproportionately impacts on people from the black and minority communities, the homeless and other socially excluded groups.”

I could go on with quote after quote – being poor is a disaster for your health. But out masters see it as a matter of persuasion rather than of action to reduce levels of poverty:

“The latest insights from behavioural science need to be harnessed to help and guide people’s everyday decisions…”

All a bit, ‘Brave New World’ it seems to me. And it gets worse:

“At the same time, we do not have total control over our lives or the circumstances in which we live. A wide range of factors constrain and influence what we do, both positively and negatively.”

So my choice to drink or abstain, to smoke or moan endless about its smell or to eat a great big, fat, juicy burger with loads of chips and not a lettuce – these choices aren’t made by me but by a set of environmental influences. I am entirely a victim of advertising! Not only wrong – and dangerously wrong – but irresponsible and immoral to boot.

The report on public health makes just one brief mention of housing, ignores the importing of diseases like TB and says nothing about wider environmental contributors to disease and ill-health. Although reference is made to how those in work have better health outcomes (duh?), the authors seem more concerned with time off work through ‘smoking-related’ or ‘alcohol-related’ problems than in getting those poor – and more likely to be sick – people back into work.

It seems to me that directing the £4bn spent on 'public health' into making houses drier and warmer, helping people get into work, providing community mental health support, and giving people some practical independent living skills - budgeting, cleanliness, cooking and so on - would be of more value to both the health of the nation and wider society than all the smoking cessation clinics, 'alcohol strategies' and obesity campaigns put together.

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