“Live free or die!” (New Hampshire State motto)
2Should individuals be free to make lifestyle decisions (such as what, when and how much to eat and how much physical activity to take), without undue interference from the state, even when their decisions may lead to negative consequences (obesity, heart disease, diabetes)?
3The UN Declaration of Human Rights enshrines the belief that “All human beings are born free and equal in dignity and rights”. The philosophy of Libertarianism (Locke) proposes that rights can be negative (e.g. the freedom to be free from outside interference) as well as positive (e.g. the right to certain benefits supplied by others). Robert Nozick, a proponent of Libertarianism, has argued that we have the right to make informed decisions about our lives without unnecessary interference. This entitlement requires that we exercise our rights only as far as they do not infringe the rights of others.
4The popular notion of the “Nanny State” (often used derogatively) is discussed, and the metaphor is extended to draw on the Super Nanny phenomenon, a reality television series that has been shown in numerous countries including the UK, the US, and Australia. It is argued in this paper that social marketing, when done well, can help create a “Super Nanny State” (implying positive connotations). In the “Nanny State” people are told what to do; in the “Super Nanny State” people are empowered to make healthier decisions.
5Social marketing applies commercial marketing principles to “sell” ideas (rather than goods or services) with the aim of improving the welfare of individuals and/or society. Where the common good may not be easily discerned, Donovan and Henley recommended using the UN Declaration of Human Rights as the baseline reference point. Social marketing is frequently used to persuade individuals to make healthier lifestyle decisions such as “eat less [saturated] fat”, “eat two fruits and five veg a day”, “find thirty minutes of physical activity a day”.
6Recent medical gains in immunisation, sanitation and treating infectious diseases mean that the health of a population can now be more improved by influencing lifestyle decisions than by treating illness (Rothschild). Social marketing activities worldwide are directed at influencing lifestyle decisions to prevent or minimise lifestyle diseases. “Globesity” is the new epidemic (Kline). Approximately one billion people globally are overweight or obese (compared to 850 million who are underweight); most worryingly, about 10% of children worldwide are now overweight or obese with rising incidence of type 2 diabetes in this population (Yach, Stuckler, and Brownwell).
7“Nanny state” is a term people often use derogatively to refer to government intervention (see Henley and Jackson). Knag (405) made a distinction between old-style, authoritarian “paternalism”, which chastised the individual using laws and sanctions, and a newer “maternalism” or “nanny state” which smothers the individual with “education and therapy (or rather, propaganda and regulation)”. Knag’s use of the term “Nanny State” still has pejorative connotations.
8In the “Nanny State”, governments are seen as using the tool of social marketing to tell people what they should and shouldn’t do, as if they were children being supervised by a nanny. At the extreme, people may be afraid that social marketing could be used by the State as a way to control the thoughts of the vulnerable, a view expressed some years ago by participants in a survey of attitudes towards social marketing (Laczniak, Lusch, and Murphy). More recently, the debate is more likely to focus on why social marketing often appears to be ineffective, rather than frighteningly effective (Hastings, Stead, and Macintosh). Another concern is the high level of fear being generated by much of the social marketing effort (Hastings and MacFadyen; Henley). It is as if nanny thinks she must scream at her children all the time to warn them that they will die if they don’t listen to her. However, by extension, I am suggesting that the “Super Nanny State” metaphor could have positive associations, with an authoritative (rather than authoritarian) parenting figure, one who explains appropriate sanctions (laws and regulations) but who is also capable of informing, inspiring and empowering.
9Still, the Libertarian ethical viewpoint would question whether governments, through social marketers, have the right to try to influence people’s lifestyle decisions such as what and how much to eat, how much to exercise, etc. In the rise of the “Nanny State”, Holt argued that governments are extending the range of their regulatory powers, restricting free markets and intruding into areas of personal responsibility, all under the guise of acting for the public’s good. A number of arguments, discussed below, can be proposed to justify interference by the State in the lifestyle decisions of individuals.
The Economic Argument
10One argument that is often quoted to justify interference by the State is that the economic costs of allowing unsafe/unhealthy behaviours have to be borne by the community. It has been estimated in the US that medical costs relating to diabetes (which is associated directly with obesity) increased from $44 billion to $92 billion in five years (Yach, et al). The economic argument can be useful for persuading governments to invest in prevention but is not sufficient as a fundamental justification for interference. If we say that we want people to eat more healthily because their health costs will be burdensome to the community, we imply that we would not ask them to do so if their health costs were not burdensome, even if they were dying prematurely as a result.
11The studies relating to the economic costs of obesity have not been as extensive as those relating to the economic costs of tobacco (Yach, et al), where some have argued that prematurely dying of smoking-related diseases is less costly to the State than the costs incurred in living to old age (Barendregt, et al). This conclusion has been disputed (Rasmussen et al), but even if true, would not provide sufficient justification to cease tobacco control efforts. Similarly, I think people would expect social marketing efforts relating to nutrition and physical activity to continue even if an economic analysis showed that people dying prematurely from obesity-related illnesses were costing the State less overall in health care costs than people living an additional twenty years.
The Consumer Protection Argument
12Some degree of interference by the State is desirable and often necessary because people are not entirely self-reliant in every circumstance (Mead). The social determinants of health (Marmot and Wilkinson) are sufficiently well-understood to justify government regulation to reduce inequalities in housing, education, access to health services, etc. Implicit in the criticism that the “Nanny State” treats people like children is the assumption that children are treated without dignity and respect. The positive parent or “Super Nanny” treats children with respect but recognises their vulnerability in unfamiliar or dangerous contexts.
13A survey of opinion in the UK in 2004 by the King’s Fund, an independent think tank, found that the public generally supported government initiatives to encourage healthier school meals; ensure cheaper fruit and vegetables; pass laws to limit salt, fat and sugar in foods; stop advertising junk foods for children and regulate for nutrition labels on food (UK public wants a “Nanny State”). The UK’s recently established National Social Marketing Centre has made recommendations for social marketing strategies to improve public health and Prime Minister Tony Blair has responded by making public health, especially the growing obesity problem, a central issue for government initiatives, offering a “helping hand” approach (Triggle).
The Better Alternative Argument
14Wikler considered the case for more punitive government intervention in the obesity debate by weighing the pros and cons of an interesting strategy: the introduction of a “fat tax” that would require citizens to be weighed and, if found to be overweight, require them to pay a surcharge. He concluded that this level of state interference would not be justified because there are other ways to appeal to the risk-taker’s autonomy, through education and therapeutic efforts. Governments can use social marketing as one of these better alternatives to punitive sanctions.
The Level Playing Field Argument
15Social marketers argue that many lifestyle behaviours are not entirely voluntary (O’Connell and Price). For example, it is argued that an individual’s choices about eating fast food, consuming sweetened soft drinks, and living sedentary lives have already been partially determined by commercial efforts. Thus, they argue that social marketing efforts are intended to level the playing field – educate, inform, and restore true personal autonomy to people, enabling them to make rational choices (Smith). For example, Kline’s media education program in Canada, with a component of “media risk reduction”, successfully educated young consumers (elementary school children) with strategies for “tuning out” by asking them to come up with a plan for what they would do if they “turned off TV, video games and PCs for a whole week?” (p. 249). The “tune out challenge” resulted in a reduction of media exposure (80%) displaced into active leisure pursuits. A critical aspect of this intervention was the contract drawn up in advance, with the children setting their own goals and strategies (Kline). In this view, the state is justified in trying to level the playing field, by using social marketing to offer information as well as alternative, healthier choices that can be freely accepted or rejected (Rothschild).
16A real concern is that when people are treated like children, they become like children, retaining their desires and appetites but abdicating responsibility for their individual choices to the state (Knag). Some smokers, for example, declare that they will continue to smoke until the government bans smoking (Brown).
17Governments and social marketers have a responsibility to fund/design campaigns so that the audience views the message as informative rather than proscriptive. Joffe and Mindell (967) advocated the notion of a “canny state” with “less reliance on telling people what to do and more emphasis on making healthy choices easier”.
18Finally, one of the central tenets of marketing is the concept of “exchange” – the marketer must identify the benefits to be gained from buying a product. In social marketing terms, interference in an individual’s right to act freely can be effective and justified when the benefits are clearly identifiable and credible. Rothschild described marketing’s role as providing a middle point between libertarianism and paternalism, offering free choice and incentives to behave in ways that benefit the common good. Rather than shaking a finger at the individual (along the lines of earlier “Don’t Do Drugs” campaigns), the “Super Nanny” state, via social marketing, can inform and engage individuals in ways that make healthier choices more appealing and the individual feel more empowered to choose them.