Royal Society of Edinburgh Joint event with the Arts and Humanities Research Council (AHRC) and the

Scottish Funding Council (SFC) A Healthy Message? Understanding the History and exploring the Future of Public Health Campaigns in Scotland
25 May 2011 Report by Jennifer Trueland Despite improvements in life expectancy, Scotland retains an unenviable health record. Although progress has been made on smoking, alcohol and obesity remain among the main public health challenges. So what can be done about it? Experts in public health, social marketing, health history and public relations gathered to discuss the issues and trade a few blows at this RSE discussion, which was supported by the Arts & Humanities Research Council and Scottish Funding Council. Introduction Scots still drink more, smoke more and have poorer diets than much of the rest of Western Europe, said Dr Magnus Linklater, who chaired the event. There has been much done to try to decipher the reasons for this and to find the solutions but the problems have still to be dismantled. There are two approaches top down (ie legislation) or bottom up, which aims to effect a change in culture. So what can the arts and humanities do? Dr Linklater recalled watching a documentary which compared the lung of a smoker with that of a non-smoker; he gave up smoking virtually overnight as a result. So what would it take, he said, to get health messages into the bloodstream of the nation? Dr Jim Mills, University of Strathclyde. Director of the Centre for the Social History of Health and Healthcare (CSHHH) Glasgow. Historians have an important contribution to make to public health, said Dr Mills, because they are equipped to explore and analyse the circumstances and events which have led to todays assumptions. Dr Mills began, however, by describing the great success of the 1957 public health campaign to tackle tuberculosis in Glasgow. The city wanted people to attend mobile radiography units for an x-ray and those who were found to be carriers of the disease were treated. A sophisticated marketing campaign, including advertising in newspapers and at the cinema and even a prize draw (to win a car) were deployed with the aim of attracting 250,000 people; in the event, 715,000 came forward. Dr Mills said, however, that lessons from this landmark public campaign could not really be applied to the situation today because there was no basis for comparison. The TB campaign involved one infectious disease, which no-one wanted and for which there was a quick technical fix. Todays public health concerns focus on more complex problems and behaviours including consumption of alcohol, tobacco and drugs, poor diets and approaches to mental health. There is no quick or technical fix and successive reports have found that any solutions would have to be holistic and that an honest debate is needed. Dr Mills believes that shifting the terms of the discussion and not relying on old assumptions is essential when trying to achieve the culture change which is generally accepted to be needed if our public health is to improve. He drew on his own work on cannabis control in Britain in the 20th Century, saying it was clear that the assumption and laws which make it a police problem date back to the 1920s and imperial politics of the League of Nations, rather than a rational or scientific debate about the substance itself. Understanding why we have the laws and approaches we have, is fundamental to testing how satisfactory is the status quo. In the case of cannabis, Dr Mills work has shown that the status quo is not satisfactory.

Dr Mills expressed some doubts about the use of social marketing that is, the use of commercial marketing techniques to influence behavioural change for a social good saying it was a bit like calling in the baker when the car had to be fixed. Instead, he believes that cultural technicians ie people from the arts and humanities should be employed when trying to change cultures. Imagination, creativity and understanding the dynamics of creative processes are qualities which could be used to help Scots think about their behaviours in new ways. Those best placed to help us understand how we find ourselves facing current challenges are historians; those best-placed to help us think in new ways about changing health cultures may well include artists, writers and performers the technicians of cultural change. By changing our terminology can we get closer to the people we want to engage with if binge drinking becomes chasing oblivion, for example, or can we come up with new strategies by reframing our objectives as providing calm and comfort? Would this be a new way to pursue cultural change? Professor Gerard Hastings, Director, Institute for Social Marketing, Stirling and the Open University Professor Hastings agreed that it is important to learn from history, but said that we dont have to pick one discipline or one toolbox, because changing cultures is about people. He described the history of public health campaigns including early "scaremongering" adverts in which we were warned that a host of things - from smoking to sex - could kill us.' The message was, he said, that the best thing to do is to hide under the bed clearly not helpful. Extensive research has shown that this approach does not work. People do not want to be lectured, they want to be helped; they want positive, not negative messages; they want empathy, not authoritarian approaches and they want to be seen as people, not as a set of behaviours. The human race has never come closer to finding the elixir of life, said Professor Hastings; the question is giving people access to it. This means finding positive ways to encourage people to want to eliminate the behaviours which will shorten their lives. Professor Hastings mentioned public health campaigns which promote the positive the be all you can be approach and which emphasise optimism and achievable goals. He also called on the audience to think of innovative ways to improve public health, specifically around high levels of smoking in prison. Former South African president (and famous prisoner) Nelson Mandela had his own method of persuading new fellow inmates not to smoke. He warned them that while the guards would help them get access to cigarettes, they would want something in return. It might start with a small need and a small favour, but could escalate to a great need and a big favour. Professor Hastings had told the same story in Palestine recently, he said, and had been approached by someone who said he, himself had stopped smoking when, as a prisoner, a guard had given him four cigarettes but no light. People need encouragement to be all they can be. If public health has taught us anything in the last 100 years, he said, its that it has to enable people to be heroes in their own stories. Professor Phil Hanlon, Professor of Public Health, University of Glasgow Professor Hanlon said he was an advocate of public health (as youd expect) but warned: Were stuffed. The beginning of wisdom is, however, realising that we are in this position, and recognising that we have to address our failures to deal with Scotlands very real set of public health problems, such as obesity, depression, loss of wellbeing, addictive behaviours and inequalities. This is all the more difficult because the situation has emerged from the very nature of modern society, so cannot be solved by the tools including marketing which caused the problems in the first place. Professor Hanlon summarised some of the events and processes which led to todays position. These included industrialisation in 1830 Glasgow life expectancy was 34 as people suffered the ill effects of a culture change

which drew them off the land into overcrowded cities. Then, with the public health movement, life changed for the better. Fresh water and sewers improved health and life expectancy dramatically, as did civil order and scientific discovery. There was enormous social, cultural and scientific change for example, the introduction of the welfare state and cures and inoculations for disease including smallpox. But although modernisation brought many advantages it also brought problems. For example, marketing was brought to play in persuading people to smoke. Freuds nephew Edward Bernays developed a hugely successful campaign targeting women: beautiful debutantes, all smoking cigarettes which were called torches of freedom. This linked female emancipation and glamour with cigarettes and was followed by a dramatic surge in numbers of women smoking. Society has become consumerist, individualistic and atomised, said Professor Hanlon, and although the welfare state made a difference, we now have a different set of problems. He called these dis-eases, and included in that obesity, addictive behaviours and depression symptoms, he said, of late modernity. More information is available here: www.afternow.co.uk/ Positive public health campaigns like Be all you can be were pissing in the wind he said, although they were better than the dont do it or youll die model. What is actually needed is another major cultural shift. Capitalism, individualism and consumerism have brought us to where we are; we need change as profound again. The price of oil might be the catalyst as it could be the economic driver to make us change our lives. We need a new culture, a new inner world and a new biology. Imagining Utopia might not seem practical, but history shows us that it is possible to bring about change. We should be bold in our imaginings and look for transformation to bring about the next wave of public health improvement. Martin Raymond, Cloudline PR Mr Raymond began by quoting from the poem Scotland by Alastair Reid, where the writer is brought up short when his rhapsodies about a beautiful day are given the response: Well pay for it. Reid recently burned the poem, saying Scotland no longer had need of it. Mr Raymond, however, believes we need it more than ever. He accepted that public health initiatives could be top down or bottom up, but said that the arts and humanities could provide some lubrication in between. He cited the hugely successful stinx advertising campaign, run by HEBS (the former Health Education Board for Scotland) when he headed its public affairs team. This advert showed a girl band of attractive teenage girls whose attempts to attract boyfriends were hampered by their smoking. The song reached number eight in the Scottish charts, received extensive radio play and is now enjoying a renaissance on YouTube, garnering well over 100,000 views and some very positive comments. As well as the coverage and awareness-raising at the time, stinx has entered the culture. Mr Raymond did not claim any causal link, but pointed out that after the smoking ban, 84 per cent of young people were proud that Scotlands public places were smoke-free, compared to 79 per cent of adults. Although the press is often seen as part of the problem, Mr Raymond said that The Suns backing for smoke-free legislation had been an important part of the mix. Sun readers tend to be young working-class men and thats a demographic which traditional public health initiatives struggle to reach. Its taken years of public relations activity around public health when proponents were often portrayed as the health police and similar, so getting tabloids on-side was a huge achievement.

Lessons have been learned from the years of public health campaigning. These include recognising the importance of dialogue, of listening, of having respect for those you are trying to reach and trying to gain a real understanding of their lives and motivations. Is it a rational process? Perhaps not. As David Hume said, Reason is, and ought only to be, the slave of the passions. Its all about people and their passions, said Mr Raymond. The non-rational is important, and that includes things like peer pressure, wanting to be part of a community, being attracted by perceived glamour and aspiration. Panel Discussion In a short question and answer session, the panel was confronted by a member of the audience who said he was a capitalist who smoked and drank alcohol and that he loved life but didnt want it to last forever. Professor Hastings responded that he was going the right way about achieving that aim. Another member of the audience, a cancer surgeon, suggested that hedonists were being selfish by not considering the healthcare resources which would be required to treat them due to the consequences of such behaviours. Professor Hanlon pointed out that although life expectancy was around 80, healthy life expectancy ended some 24 years before that perhaps hedonists might want to think about these last unhealthy years. Dr Linklater had kicked off the discussion by asking whether reaching parts of Scotland which reject public health messages was an immediate task, or whether we should wait for cultural change. Professor Hanlon said that while it was fine to use the tools of the devil (ie marketing) to get messages across, this without much money was only useful on the margins. The real thing is to tackle health inequalities, he said. Professor Hastings warned against setting up false dichotomies: while you dont want to wait or to force people, theres a lot that can be done; small budgets can have a big impact, he said. Asked if it had been the ban on smoking in public places which made the difference to smoking rates, Dr Mills reminded us that the reasons for peoples behaviours are complex and that we have to look at the larger picture. While smoking rates are indeed, declining, cannabis use is growing, he said. Mr Raymond said that while the smoking legislation had been successful, that was probably because the argument had already been won so people didnt flout the ban. Discussion sessions The speakers each led a discussion with smaller groups of members of the audience to explore further the themes of the evening, in particular the role actual and potential played by the arts and humanities in public health and, indeed, the health sector. A representative of each group fed back a short summary of points discussed. Group 1 (hosted by Dr Mills) This group considered how the arts and humanities could work with the health sector to produce more effective communication with Scottish communities, as well as looking at what the arts and humanities could reveal about the experience of being healthy and being ill, and how this could contribute to effective public health campaigns. The group concluded that a linear approach to public health campaigning doesnt work and that the imagination and creativity of artists could help lead to cultural change. If artists were encouraged, for example, to represent good or poor health it could be a useful tool, but this should not be propaganda or in any way forced, or it would shut down the artists creativity. Its really about encouraging dialogue between artists and the health sector building a bridge to enable this and seeing what grows as a result. Group 2 (hosted by Professor Hastings) This group considered health behaviours that they would like to change and discussed why they hadnt yet been changed. They also looked at what behaviour change messages they had found appealing. They concluded that there were obstacles to changing unhealthy behaviours even when people wanted to. For example, while smoking is increasingly stigmatised, alcohol is seen as acceptable particularly in certain age groups. So perception

is important. Economic issues can also be a barrier eg being able to find fresh, healthy, affordable food locally. They believe that the solution involves finding positive, easy and cost-effective ways to encourage change. That might be technological eg promoting electric cigarettes to help people quit tobacco or it could involve persuading large grocery stores to set up small branches in small localities. Group 3 (hosted by Professor Hanlon) No one strategy will achieve the public health change that is wanted and needed in Scotland, this group concluded; a cross-disciplinary approach is required. There needs to be communication between the arts and humanities and health services, but this should be twoway. The arts already work in health very effectively and could have more of a role in helping to frame public health messages, but telling people in the arts and humanities what to say wont work. Climate change is an important issue, but we need to look at the short as well as the long term and use the tools that are available. We also need responsible journalism so that we can have a basic trust in messages reported in the media. Group 4 (hosted by Mr Raymond) This group discussed individualism and family culture and their impact on health. Hedonism might be a more individualist philosophy, while family and other community structures can have a modifying and positive effect on behaviours. For example, in southern European countries, children learn to enjoy a glass of wine with food rather than seeing alcohol as something to binge drink at weekends although some universities in these countries are concerned about students starting to binge drink. Families can have great influence in other ways too for example, a child persuading a father to give up smoking by asking if he is going to die of lung cancer like the man in an advert. The media does have a role to play and it can be a positive force for public health in Scotland. Concluding remarks Dr Linklater asked each of the speakers to sum up his main message from the evening. Dr Mills said that the arts and humanities were well-equipped to contribute to the public health effort. Professor Hastings said that yes, there is lots of complexity, but that there is a lot we can do about it, as the example of smoking showed. He said that Scotlands former first minister Jack McConnell had been against the smoke-free legislation until he spent a weekend in Dublin (which had already implemented a ban on smoking in public places) and was told by the health minister that he wished he had done more, sooner. Mr Raymond said that we have to keep our eye on long-term goals while recognising achievements (such as decline in smoking rates). The media does have an influence, he said and the arts and humanities can help foster an understanding of health issues. Its also about humanity and being human and putting respect at the heart of public health. Professor Hanlon said he believes that we needed a major shift which could be brought about by climate change. If we used less stuff, were less materialistic and learned to grow more food locally then we might find we had healthier lives. He accepted, however, that we ought to use all tools at our disposal (including social marketing) to tackle the urgent problems of Scotlands public health. Dr Linklater said the smoking ban had been important, not just because of what the legislation did, but that it signalled an important cultural message about the unacceptability of smoking. He is hopeful that the Scottish Governments proposal to introduce a minimum price per unit of alcohol might also send out important messages and help promote constructive change in Scotlands culture.

Opinions expressed here do not necessarily represent the views of the RSE, nor of its Fellows The Royal Society of Edinburgh, Scotlands National Academy, is Scottish Charity No. SC000470