Kate PickettProfessor Kate Pickett is a Cancer Research UK-funded health researcher, and co-author of The Spirit Level.

In this guest blog post, she discusses the latest research and insights into the causes of inequalities in health, and gives us her opinions on what government should do to tackle them…

A tube platform with the sign 'mind the gap' on it

We need to close the 'health gap' between rich and poor

Britain has a long and distinguished record of research into how people’s health is affected by social factors such as where they live, where they go to school and how much they earn.

In fact, we were the first country in the world to properly examine how social class affected death rates – and, over the years, British governments have commissioned a number of important reviews of health inequalities, from the Black Report in 1987 to this year’s Marmot Review of Health Inequalities.

British research has also benefited from investment in the British birth cohort studies of 1946, 1958, 1970 and the Millennium Cohort Study, as well as other large research projects, such as the Whitehall Studies of civil servants, the UK Women’s Cohort Study, and the Avon Longitudinal Study of Parents and Children. These studies follow large groups of people throughout their lives and collect information on their health, education, employment and other aspects of the social environment in which they live.

As a result, we have an increasingly sophisticated understanding of how these factors affect both average levels of health in the general population, and the differences between people from different backgrounds and in different areas.

Yet, as the Marmot Review and recent research shows, these inequalities in health have not improved in recent decades.

So why have we failed to close the gap?

Translating research into policy

Many researchers are frustrated by the fact that all this research hasn’t yet translated into effective policies that actually improve the nation’s health.

As the Marmot review showed, unhealthy behaviours, such as smoking, substance abuse, poor diet and lack of physical exercise – whilst harmful – do not on their own account for the stark differences in people’s health, or account for the full extent of the gap between rich and poor. We know full well how difficult people can find it to change their behaviour. And we know the complex difficulties and challenges that characterise their lives.

My own research for Cancer Research UK focuses on smoking in pregnancy. Along with colleagues in the USA, I’ve long been interested in whether or not smoking whilst pregnant causes behavioural problems in children.

As an important part of this research programme, we have been trying to understand the reasons why women are able or unable to quit smoking when they become pregnant. We’ve studied women in the US and the UK and find a consistent picture – women who continue to smoke whilst pregnant tend to have a number of complex problems.

In our US study, we found that women who continued to smoke were more likely as teenagers to have run away from home and been in physical fights. They were more likely to have children with multiple partners and to have problematic relationships with their partners and other people.

They also were more likely to have dropped out of school, to have stolen things or been arrested, they lacked skills for living, and had more difficult life circumstances, such as a partner in jail or problems with money. As well as smoking, they tended to come late to antenatal care.

In our UK study, we found that pregnant smokers were more likely than those who quit or who had never smoked to come from broken families and to have no relationship with their parents, no time with friends, no one to talk to or share feelings with, and were more likely to experience domestic abuse. They suffered more from distress, low self-esteem, low sense of control and competence.

Shift in focus

Other unhealthy behaviours are also strongly linked to problems with relationships and functioning. So it’s not surprising that they are so difficult to change. Even the most innovative and intensive efforts to change the behaviour itself have low success rates.

And yet, in recent years, policies to reduce health inequalities have shifted to more of a focus on encouraging people to change their behaviour than on actually addressing the social problems that are linked to this behaviour.

The shift began with the Department of Health’s 2003 strategy “Tackling health inequalities: a Program for Action”, which placed more emphasis on individual behaviour change than previous strategies. Now we have a Coalition Government, which believes that:

…we need action to promote public health, and encourage behaviour change to help people live healthier lives. We need an ambitious strategy to prevent ill-health which harnesses innovative techniques to help people take responsibility for their own health” (Emphases added)

And we also have Dr Steve Field, chairman of the Royal College of General Practitioners, calling for people to take more responsibility for their health. Writing in The Observer, he states:

“Ask a parent to give up smoking and they might refuse – but demonstrate how smoking at home will damage their children’s lungs, leading to bronchial illness, asthma and a lifetime of ill health and they might start to see things differently. Similarly, drinkers who are confronted with the reality of their consumption might be spurred into cutting down rather than if they were just told to do it.”

But all the evidence suggests, as Professor Sir Michael Marmot has so pithily remarked “that simply telling people to behave more responsibly is no more likely to be effective than telling someone who is depressed to pull his socks up.”

We know differences in income and wealth matter, and that relative poverty is harmful to health; we also know that unemployment, stressful work conditions and deprived communities matter. So we need to take serious and sustained action to reduce social inequalities, such as establishing a minimum income for healthy living, if we want to imbue people with the sense of control that allows them to take positive actions to protect their health.

And we need to strive to create environments that support people’s individual efforts, for example by further restricting cigarette advertising by removing point of sale displays in shops and restricting the advertising of junk food to children.

Cancer Research UK stresses this need for such a balance between personal responsibility and government-led regulation, and many of the researchers it funds continue to produce the evidence that both are essential for improving the nation’s health.

Professor Kate Pickett,
University of York


Wakschlag, L., et al (2003). Pregnant smokers who quit, pregnant smokers who don’t: does history of problem behavior make a difference? Social Science & Medicine, 56 (12), 2449-2460 DOI: 10.1016/S0277-9536(02)00248-4

Pickett, K., Wilkinson, R., & Wakschlag, L. (2009). The psychosocial context of pregnancy smoking and quitting in the Millennium Cohort Study Journal of Epidemiology & Community Health, 63 (6), 474-480 DOI: 10.1136/jech.2008.082594