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Public health interventions – what risks can we live with?

Covid has been the biggest and most acute public health challenge in our lifetime, and public health interventions including lockdowns and social distancing have affected every one of us. Politicians, epidemiologists, clinicians, scientists and armchair experts all battle to be heard in a heated conversation around our appetite for (or aversion to) curtailments to our freedoms to save lives and the NHS.

The national lockdowns were designed to protect the NHS as well as saving lives, but there are many interventions to save lives that for whatever reason are not countenanced – banning cars, for example, despite the deaths of five people every day on our roads.

ZPB’s Senior Analyst Anne Janssen and Communications Assistant Juliette Cosgrove have looked at the causes of death in this country and explore levels of support for public health interventions that would certainly save thousands of lives.

We look at death rates from both the flu and non-communicable diseases, such as heart and circulatory disease, to provide an understanding of what level of deaths society considers acceptable.

Deaths estimated to be attributable to smoking over time, Source: NHS data

Smoking related deaths

The first example covers deaths caused by smoking. According to NHS data, in 2019, 74,600 people died in England as a result of smoking. In 2018 this figure was higher, at 77,000. Numbers have decreased by 9% since 2009. These deaths could be significantly reduced by accelerating evidence-based policies such as increasing tax on tobacco and cigarettes. WHO estimates that a 10% increase in tobacco prices results in a 4% reduction in smoking rates. UK researchers estimated that the 2007 introduction of smoke-free workplaces, which outlawed smoking in all enclosed spaces in England, is likely to have saved 40,000 lives over the following decade. The debate about how far the government should go in terms of tobacco control is constantly evolving. In 2004, when 88,000 people died from tobacco related illness in England and Wales, the then Secretary of State for Health, John Reid, said smoking was “the only enjoyment for the poor”. Now the current government Tobacco Control Plan is focussed on reducing health inequalities – smoking accounts for half the life expectancy difference between the richest and poorest people in England.

Deaths registered for influenza and pneumonia over time, Source: ONS data

Deaths from flu and pneumonia

Covid is often compared to influenza and perhaps the most cited scenario of how we’re going to learn to live with Covid is the flu. While transmission and illness from flu and Covid are distinctly different, seasonal flu waves are a likely analogy to seasonal covid waves that we might expect in the future. The UK experiences flu waves every winter, which cause a lot of disruption to the health care system and unfortunately also result in many deaths each year. In a bad flu year an average of 30,000 people will die from flu and pneumonia. The fact that we do not find ourselves living with restrictions every winter suggests that at least to some extent we are willing to tolerate seasonal diseases and their consequences.

Obesity and cardiovascular disease

A quarter of all deaths in the UK are caused by heart and circulatory diseases. There is a clear link between obesity and heart disease – the National Institute for Health Research found that obese people with metabolic risk factors were two and a half times as likely to have heart disease compared to people with a normal weight[1]. In 2020, the NHS reported that 26% of men and 29% of women in the UK were obese. Just three weeks ago, the National Food Strategy called for the government to levy a £3bn sugar and salt tax to tackle the UK’s obesity problem. However, this was swiftly rejected by the Government, demonstrating a level of resistance to restrictive measures to tackle the obesity problem, notwithstanding the resulting deaths which could be avoided. These deaths, it seems, are implicitly accepted both by society and government. Interestingly, Boris Johnson echoed John Reid by saying he is not attracted to the idea of imposing an extra tax on salt and sugar which would hit “hard-working people” the hardest.

In the wake of the widespread devastation wreaked by Covid-19 over the past 18 months, and as the vaccination programme continues to reduce the impact of the virus,  conversations about ‘acceptable’ levels of death are an inevitable step as we reopen society and learn to live with this novel disease.  As we can see from other public health issues there will be an evolving conversation as we find collective comfort levels between the risks of infection and death versus the costs of lockdown restrictions.

[1] Separate and combined associations of obesity and metabolic health with coronary heart disease: a pan-European case-cohort analysis | European Heart Journal | Oxford Academic (

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