Madeleine Murphy

Madeleine Murphy

Public health priorities vs. societal realities

29 August 2017

multicoloured graphic of a crowd drawn as individual silhouettes

Science and policy agree that smoking is bad for health, and breastfeeding is good – so why don’t public attitudes reflect this consensus?

Here are a couple of things we know, thanks to decades of scientific evidence:

  1. Smoking tobacco is bad for health.
  2. Breastfeeding is good for health.

Public health policy reflects this knowledge. In the EU, the revised Tobacco Products Directive in 2016 placed restrictions on the packaging, sale and marketing of cigarettes. In the UK, 2017 marks the 10-year anniversary of the ‘smoking ban’ – legislation that prohibits smoking in public places and workplaces. Smoking prevalence in the UK has since dropped from 20.9% to 16.1%.

Meanwhile, the World Health Organization (WHO) recommends that women breastfeed exclusively for the first six months of the infant’s life, then continue to breastfeed (alongside solid food) for up to two years. EU policy has long promoted breastfeeding, and health professionals advocate it as the best method of infant feeding. However, according to the WHO, the European region has the world’s lowest rates of breastfeeding.

Despite the compelling evidence to support the benefits of breastfeeding and the negative impact of tobacco, we make it easier for people to smoke than to express milk.

Social attitudes

Why has one of these public health messages been successful, and the other a comparative failure? Although the law says breastfeeding is acceptable everywhere, while smoking is unacceptable in many areas, social attitudes often don’t reflect this. News outlets frequently report breastfeeding women being asked to cover up or stop breastfeeding in public. This can cause shame; in a UK survey, 36% of women said breastfeeding in public was embarrassing. It may be a reason why some women discontinue breastfeeding earlier than recommended.

Smokers are not exempt from social reproach; there is evidence that some feel increasingly stigmatised. But the key difference is that the overall health effects of tobacco are harmful. Worldwide, it kills more than 7 million people every year. Breastfeeding, meanwhile, harms no one and brings numerous benefits to both infants and mothers.

Public health in the workplace

For women to adhere to the WHO recommendation of breastfeeding for up to two years, those who are in full-time employment must be able to express breast milk while at work. EU legislation requires employers to provide a rest break for all employees every six hours, but this may not be frequent enough – nor the individual breaks long enough – for women who need to express milk.

Normalisation of positive health behaviours is crucial. The more people see something, the more they accept it as part of life.

Employers in the UK are required to provide ‘suitable facilities for breastfeeding mothers to rest’. However, the reality faced by many women returning to work is that there isn’t an appropriate area for expressing milk. In many cases, the only space available might be an office or meeting room, offering limited privacy. Some women resort to expressing in toilets for want of a suitable space – an unhygienic and unpleasant experience.

Meanwhile, UK employers are not legally obliged to have designated external smoking areas for employees – yet many do. Despite the compelling evidence to support the benefits of breastfeeding and the negative impact of tobacco, we make it easier for people to smoke than to express milk.

Changing perceptions

If the problem is perception, what can be done to change people’s views? One crucial element may be normalisation of positive health behaviours. Health professionals and breastfeeding advocates have long argued that the solution to negative attitudes to public breastfeeding is promoting it as an everyday activity. The more people see something, the more they accept it as part of life. This is one of the key arguments against advertising infant formula, which can reduce women’s confidence in their ability to breastfeed.

This notion is not unique to breastfeeding. Many countries have banned tobacco advertising. Recent measures taken in the UK include the introduction of standardised ‘plain’ packaging for cigarettes. In Australia, where plain packaging was introduced in 2011, it has been shown to reduce the appeal of cigarettes to adolescents. There is also evidence that, just as peer pressure may encourage young people to take up smoking, supportive peer networks can have a positive influence on people trying to quit.

A holistic policy approach

Public health policy is based on evidence. Conveying this evidence in a way people understand and relate to is not always easy. Anti-smoking campaigns in several countries, particularly the UK, have had a positive impact. Breastfeeding promotion, meanwhile, has failed to strike a chord with the public, despite overwhelming evidence.

Perhaps we need to take a more holistic approach to health promotion. The Royal College of Paediatrics and Child Health recently recommended that ‘familiarity with breastfeeding’ should be included as part of statutory personal, social and health education in UK schools. An intersectoral approach could be effective in normalising breastfeeding and guiding public opinion. But it is essential to strike the right balance between recommendation and instruction. As soon as public health guidance starts to feel like pressure, there is a risk of alienating people. And that’s when messages stop getting through.

Achieving public health goals requires hard work, but the success of promotion around smoking cessation shows what can be achieved. To have a real effect on mainstream health behaviours, policy and public opinion must move in the same direction. This can be challenging, but it’s a challenge worth facing to improve the health of the population, both today and for generations to come.


The opinions expressed in this blog are those of the author and do not necessarily represent the views of The Health Policy Partnership.