Population Health Framework: evidence paper

4. Improving the health of Scotland’s population: preventative policy approaches

This section explores a range of evidence-based policy approaches that aim to improve population health through a focus on primary prevention and coordinated action across the whole system. The aim of the section is to outline the principles that underpin these approaches, what they look like in practice, and evidence of their effectiveness in improving population health and reducing health inequalities.

Key points

Evidence shows that policy approaches with the potential to improve population health in Scotland include:

• Those which seek to address the fundamental causes of health inequalities, which are inequalities in income, wealth, and power between groups. This includes, for example, the creation of a Wellbeing Economy, Community Wealth Building, and the adoption of proportionate universalism in the design and implementation of policies.
• Health in All Policies, a collaborative approach which involves incorporating health considerations into decision-making across sectors, policy, and service areas, to address the social determinants of health.
• The life course approach, which acknowledges that health status reflects cumulative life conditions and considers the critical stages, transitions, and settings where large differences can be made in promoting health and wellbeing.
• Place-based approaches, which recognise the interconnected impact of physical, economic, and social environments on individuals and communities, and emphasise collaborative, locally tailored interventions.
• Structural approaches to reducing health risks, such as fiscal and legislative policies that modify environments to minimise exposure to health harming products. There is limited evidence to suggest that interventions focused on individual behaviour change, such as the provision of information, services and support, have an impact on health outcomes at a population level.

4.1. Addressing the fundamental causes

As noted previously, the fundamental causes of health inequalities are inequalities in income, wealth, and power between groups (PHS, 2024b). In Scotland, both income and wealth inequality have been rising over an extended time period. To make meaningful progress, therefore, actions taken must seek to address the fundamental causes of health inequalities, which requires effective partnerships and collaboration across sectors beyond health. PHS (ibid.) discuss how there is potential for the fundamental causes to be undone through national policy action such as greater economic democracy through plural ownership of economic assets, progressive taxation, active labour market policies, and measures to reduce poverty (e.g. minimum income guarantee, basic income, increased benefits, and income maximisation).

In their report assessing the mortality changes that have occurred in Scotland since around 2012, McCartney et al. (2022) set out a range of recommendations that may help to address the fundamental causes of inequalities, which they arrange at different levels of governance (UK Government, Scottish Government and local government/health board level). The recommendations span macroeconomic policy, social security, work, taxation, public services, and material needs, and place emphasis on reversing the damaging effects of the austerity policies implemented since 2010, as well as reducing the obesogenic environment and its structural and commercial influences. For example, at the UK level, it is recommended that fiscal policy is designed to avoid austerity approaches and that social security benefits are increased, alongside progressive taxation and reforms to work conditions and public services. Meanwhile, Scottish and local governments are encouraged to supplement these by increasing benefits and supporting access to energy, transport, and affordable housing.

Richardson et al. (2020) assessed the effects of income-based policies on years of life lost (YLL) and inequalities in YLL in Scotland for the 2017-2021 period using scenario modelling. They found that policies that affect incomes could potentially have marked effects on health and health inequalities in Scotland, with the best policy for improving health and narrowing health inequalities a 50% increase to means-tested benefits. Citizen's Basic Income schemes also substantially narrowed inequalities. Overall, their model showed that the most effective income-based policies for reducing health inequalities were those that disproportionately increased incomes in the most deprived areas.

The 2023 Scottish Social Attitudes Survey showed that there is public support for redistribution of wealth in Scotland (Scottish Government, 2024i). Half of people (50%) agreed that the government should redistribute income from the better-off to those who are less well-off, while just under a quarter (23%) disagreed. In addition, almost half (47%) thought the government should increase taxes and spend more on health, education, and social benefits, although this decreased from 55% in 2019.

Wellbeing economy

A range of concepts and approaches to make the economy fairer have been proposed, one of which is the ‘wellbeing economy’ (WE) agenda. The WE agenda challenges the ideological dominance of GDP as the primary marker of progress and instead promotes economic systems that deliver human and ecological wellbeing (Fioramonti et al., 2022). This agenda grew from recognition that exclusively focusing on GDP growth has enabled unsustainable economic growth that does not account for environmental or health harms (Jackson, 2021). It has gained support amongst policymakers, business, and civil society in recent years. Several national governments, including Scotland as well as Iceland, New Zealand, Wales, and Finland, have joined the Wellbeing Economy Governments partnership (WEGo), a collaboration of national and regional governments interested in sharing expertise and transferrable policy practices to advance their common ambition of building WEs (Wellbeing Economy Alliance, 2022).

Friel et al. (2023) suggest that by adopting WE principles and frameworks that put the wellbeing of people and the planet first, some governments are engaging with new policy norms and directions which have the potential to evolve the current dominant social-economic system. Examples of approaches include circular economies (based on the reduction, reuse, recycle, and repair of materials and products) and universal basic incomes, which WHO (2023d) have highlighted as particularly innovative. The adoption of a Doughnut Economics model, a framework for sustainable development which balances social and ecological wellbeing, is also endorsed by WHO (2023e).

Delivery of a WE is being supported in Scotland in part through Community Wealth Building (CWB), an approach to economic development designed to tackle systemic challenges facing local, regional, and national economies by influencing the ways in which wealth is generated, circulated, and distributed (Economic Development Association Scotland, 2023). The five pillars of CWB are plural ownership of the economy, making financial powers work for local places, fair employment and just labour markets, progressive procurement, and socially productive use of land and property, which are the practical ways of increasing recirculation of wealth in communities (ibid.). CWB also emphasises the role of anchor institutions, examples of which include NHS Boards, colleges, universities, and local authorities, as well as private sector businesses.

PHS (2024q) conducted a health impact assessment (HIA) of CWB. HIA is “a practical way to systematically consider the potential, and sometimes unintended, effects a policy, strategy or service plan may have on the health of a population” (PHS, 2024r). The assessment found that the successful implementation of CWB is likely to have a variety of positive impacts on health, including through addressing some of the fundamental causes of health inequalities. In particular, it showed that positive health impacts may occur through pathways such as reductions in poverty, income, and wealth inequality, improved access to secure employment and working conditions, and enhancing community cohesion and resilience. Only one likely negative health impact of implementing CWB was found, relating to the potential for there to be increased demands placed upon individuals and communities as a result of increased community ownership and management of assets.

The HIA presented a range of recommendations, with key overarching recommendations to expand the scale and reach of efforts to implement all five pillars of CWB in Scotland; articulate the aims and assumptions underlying CWB in a way that allows them to be shared and tested; and monitor the success of CWB at local and national levels. It is also stated that to maximise impact, CWB should “form part of a wider approach and be supported by other policies to reshape the large existing inequalities in income and wealth that underpin unacceptable health inequalities in Scotland”, requiring sustained support and political commitment (PHS, 2024q: p70).

An evaluation of a CWB programme in Preston, England found that during the period in which the programme was introduced, there were fewer mental health problems than would have been expected compared with other similar areas as life satisfaction and economic measures improved (Rose et al., 2023). In particular, the introduction of the programme was associated with a 3% decline in antidepressant prescribing, a 2% decline in the prevalence of depression, a 9% improvement in life satisfaction, and an 11% increase in wages, compared with expected trends.

The SIPHER consortium used a wellbeing economy model to explore how non-health factors can be changed at sub-national level to maximise life expectancy and reduce health inequalities (Duro et al., 2024). Their analysis demonstrated that while improvements are possible, they require responses in different parts of Scotland and take time to manifest (at least five years). They also showed that larger improvements come at higher costs and uncertainty. For example, one scenario projected that by 2031, male life expectancy could be increased by 0.9 years and inequality between local authorities could fall by 32%, provided household incomes rose by £2,600 annually in Glasgow & Strathclyde and £2,400 in Scotland South alongside reductions in economic inactivity and increases in educational attainment. However, the model has limitations, including that it cannot cover all potential variables and effects and operates at a local authority level (so cannot make recommendations at lower-level geographies).

Proportionate universalism

Evidence supports wider adoption of the principle of proportionate universalism in the design and implementation of policies. Proportionate universalism describes interventions that are implemented for the whole population but with a scale and intensity proportionate to need (Marmot, 2010). The principle mainly relates to interventions delivered at an individual or household level rather than structural interventions which affect the physical, social, economic, or regulatory environment. Structural interventions tend to have more inherently proportionate impacts, as they do not rely on individual agency (Adams et al., 2016).

Proportionate universalism addresses the potential drawback of a purely universal approach, which may disproportionately benefit those most able to make use of services (Macdonald et al., 2014). It also addresses the disadvantages of purely targeting a subgroup deemed in need, such as risks of stigmatisation and of missing those who do not meet a particular threshold (PHS, 2024b). For example, McCartney and Hoggett (2023) found that less than half of low-income people live in the most deprived areas in Scotland, suggesting that targeting services and interventions to specific geographical places risks overlooking those residing outwith these areas. Proportionate universalism instead acknowledges the social gradient in health, aiming to improve the health of everyone while simultaneously improving the health of the most disadvantaged fastest (Everitt and Shaw, 2023).

There is evidence that the adoption of proportionate universalism can contribute to reductions in health inequalities. For example, Egan et al. (2016) explored whether city-wide investment in urban renewal in Glasgow was allocated to need and whether this reduced health inequalities. They found that the investment was allocated according to need and that this led to modest reductions in area-based inequalities in health after five years. However, the authors note that while the intervention was informed by proportionate universalism, it did not strictly align with the principle as the level of neighbourhood renewal funding was only scaled to need in deprived areas and not a universal programme.

Some practical challenges in applying proportionate universalism have been identified. These include the absence of an agreed definition of the term and difficulties in identifying appropriate thresholds or indicators of disadvantage (Francis-Oliviero et al., 2020). For example, developing and targeting interventions based on area deprivation indices may mean that more socioeconomically advantaged residents living in deprived areas use and benefit disproportionately from the increased intervention intensity provided in that area (Everitt and Shaw, 2023). Analysis by McCartney et al. (2023) shows that area-based multiple deprivation measures such as SIMD are not sensitive or specific in identifying income- or employment-deprived individuals, meaning their use risks misunderstanding the extent of need across spatial areas. Basing proportionate universalism on area deprivation indices therefore limits the extent to which outcome differences across individual-level deprivation can be identified, and could feasibly widen health inequalities (Everitt and Shaw, 2023).

Carey et al. (2015) developed a framework for the application of proportionate universalism which proposes that the focus be on need rather than means (i.e. income), due to evidence that means-tested systems show worse results than needs-based approaches in terms of equity. They also suggest a degree of particularism in the design of policies, meaning differentiation in the nature and supply of interventions and policies so that they are tailored to the specific needs of different groups. Application of the principle of ‘subsidiarity’ is also proposed, which emphasises that decisions should be made as close as possible to the citizens affected through a multi-layered system. The rationale for this is that local government and non-government organisations, embedded in local communities, are more likely than national governments to understand the needs of specific individuals and groups and how best to address them.

PHS (2025b) recently published an overview and guide on how to implement proportionate universalism approaches, highlighting key considerations for its application. For example, the need to raise awareness of what proportionate universalism is, being realistic about what it can achieve, avoiding short-termism, and building up the evidence base, evaluation and learning of applying proportionate universalism.

4.2. Health in All Policies

WHO (2010b) endorse a ‘Health in All Policies’ (HiAP) approach, which recognises that policy in every sector shapes population health and health inequalities. The HiAP approach is preventative and based on the notion that the greatest challenges for health are highly complex and linked through the social determinants of health. It therefore encourages a pragmatic, systematic, and systems-based approach to embedding health and health equity considerations across sectors, policies, and service areas, providing a practical way for the public health community to collaborate with others in shaping policies that influence the root causes of poor health and health inequalities (Greszczuk, 2019).

Green et al. (2021) propose a set of principles to underpin a HiAP approach:

Governance: HiAP approach aims to foster accountability and shared social responsibility for health and wellbeing. It facilitates and promotes transparency about the health implications of policy decisions.

Comprehensive: HiAP adopts a holistic approach to health. Rather than focusing on single health issues, it involves consideration of the range of health issues associated with each policy area or proposal.

Collaboration: HiAP builds partnerships with colleagues in other sectors. It seeks to identify ‘win–wins’ that support the priorities of the policy area and also benefit health and health inequalities.

Equity: HiAP considers not only overall health, but the distribution of health impacts across populations. It aims to reduce inequalities and prioritize the needs of populations with the poorest health.

Participation: HiAP includes engagement with affected stakeholders and populations, and seeks to ensure that their views are taken into account in developing policy recommendations.

Evidence-based: HiAP is based on the robust use of best available evidence, data, and intelligence from different disciplines, to understand links between the policy area and health.

Sustainability: HiAP considers impacts for both present and future generations. It seeks to balance environmental, social, and economic impacts, and contribute to meeting the United Nations sustainable development goals.

WHO (2010b) outline practical tools and processes to apply HiAP and embed health across sectors, which have been shown to be useful at different stages of the policy cycle. These include, for example, health impact assessments (HIA) (WHO, 2024f), Health Lens Analysis (a tool to facilitate collaboration between stakeholders working on policies which have health implications) (Eyk et al., 2017), and community consultations and Citizens’ Juries (Street et al., 2014).

Greszczuk (2019) outlines case studies illustrating practical attempts to implement a HiAP approach from a range of countries. For example, in Norway, legislation was developed to embed health considerations across all levels of government and ensure responsibility for health inequality across sectors, which included a legal duty on ministries to adopt a HiAP approach. A different example focused specifically on obesity comes from Canada, where a coalition of organisations, including planners, engineers, health charities, and local government, was formed to develop and share ways of embedding health in urban policy and planning.

In Wales, the Wales Public Health Act 2017 places a duty on the Welsh Ministers to make regulations which require public bodies to carry out HIA in specified circumstances (National Assembly for Wales, 2017). The Wales Health Impact Assessment Support Unit was established in 2004 to support the development of HIA practice in Wales (Welsh Government, 2023).

Greszczuk (2019) points to Scotland’s National Performance Framework (NPF) as an important tool for assessing the impact and value of policy decisions on health and wellbeing. Examples of a HiAP approach being applied in the Scottish context include the Scottish Health and Inequalities Impact Assessment Network – which has supported and promoted HiAP approaches (particularly HIA and consideration of health in other impact assessments) and produced evidence guides showing links between health and areas such as housing, transport, green space, and rural development – as well as the Place Standard tool, which involves collaboration between health and planning (Douglas, 2017; also see section 4.4). The PHS Health Impact Assessment Support Unit was also formed in 2022, which aims to support local partners in the use of HIA and to collaborate nationally to advocate for HIA as part of a HiAP approach (PHS, 2024r).

PHS (2022a) recommend adopting a HiAP in relation to physical activity in Scotland, including consideration of issues related to physical activity in relevant policies across key sectors such as planning, transport, social housing, education, and sports. PHS also worked with the Scottish Government to carry out a HIA on the draft Scottish National Adaptation Plan 3 (SNAP3) during the public consultation period. SNAP3 sets out the actions that the Scottish Government will take to prepare for and build Scotland’s resilience to the impacts of climate change between 2024 and 2029 (Scottish Government, 2024g). The HIA identified opportunities to maximise health and health equity gains and prevent or mitigate any potential harms from the response to Scotland's changing climate through the design and delivery of SNAP3.

4.3. The life course approach

Evidence highlights the benefits of adopting the ‘life course approach’ to prevention (Mikkelsen et al., 2019; Kuruvilla et al., 2018). The life course approach takes a temporal and societal perspective on physical and mental health and wellbeing, acknowledging how a person’s health at each stage of life affects health at later stages and also has cumulative effects across generations (WHO, 2017a; WHO, 2018b). It also recognises that there are certain life stages which are particularly critical, within which exposure to risk factors can be especially detrimental or beneficial for health and development (Pearce et al., 2019). For example, challenging early life experiences, such as exposure to stress, pollutants, or allergens, which trigger a strong immune response (i.e. inflammation) that remains activated for too long, can increase the risk of lifelong illness (Centre on the Developing Child, 2020).

Crucially, the life course approach emphasises how exposure to risk factors can accumulate over time (Pearce et al., 2019). For example, prolonged exposure to poverty can have lasting detrimental effects on adolescent health (Cooper and Stewart, 2013). Additionally, it highlights how exposure to one risk factor can trigger a chain of further risks such as financial insecurity leading to relationship strain, which can, in turn, result in separation and further economic hardship (ibid.) (Pearce et al., 2019).

Hommes et al. (2022) have highlighted several benefits of taking the life course approach, particularly ‘in the era of Covid-19 and beyond’. They identify four key reasons to adopt and implement the approach in public health at national and local levels: (i) it effectively responds to new health trends and evidence, (ii) it addresses longstanding gaps in care by promoting interventions during often-overlooked life stages (iii) it provides a comprehensive framework for tackling health inequities by allowing us to understand how disparities are perpetuated throughout a person’s life and across generations, and (iv) through its focus on prevention and targeting the most critical and sensitive life stages, it maximises impact while ensuring efficient use of available resources.

WHO (2011; 2018b; 2023f) also endorses the life course approach, stating that in recognising how experiences at each life stage – and the critical transitions between them – strongly influence current and future health and wellbeing, the approach offers multiple benefits, including reducing inequalities. They outline case studies from Iceland and Malta which illustrate efforts to translate life course evidence and principles into policy and practice to address complex public health challenges (WHO, 2018b).

Malta’s Healthy Weight for Life Strategy (2012-2020) was structured around the continuum of the life course, with initiatives designed to address barriers to and enablers of a healthy weight at each life stage or in each transition period and delivered in settings where people spend most of their time (for example, preschools/schools in childhood and adolescence, workplaces/communities in adulthood, and rest homes/day centres in old age) (ibid.). Reflecting the life course principle of acting early to promote the best possible start in life, it also focused on nutrition in the prenatal period and childhood, while initiatives focusing on parents and children together reflected the intergenerational perspective of the life course approach.

WHO (ibid.) highlight several mechanisms which facilitated the adoption of life course principles in Malta, including the use of epidemiological evidence about overweight and obesity and the effectiveness of interventions, as well as intersectoral working groups. However, achieving meaningful whole-of-government collaboration was a challenge, while limited resources and Malta’s reliance on the international food sector presented further difficulties (ibid.). An evaluation highlighted that while there were some positive developments resulting from the strategy, increasing rates of obesity and overweight in Malta demonstrate that efforts were not sufficiently comprehensive and effective (National Audit Office, 2023). The report highlighted a need for stronger political commitment to prioritising addressing obesity and overweight at a national level, the allocation of appropriate resources and funding, and efforts proportionate to the scale of the challenge (ibid.).

WHO (2018b) also highlight Iceland’s Welfare Watch initiative (2009-2013), which was developed in response to the economic crisis of 2008 and focused on taking early action to protect children from adversity and promote positive trajectories among adolescents and young adults through intersectoral collaboration. A key component of the strategy was the development of a set of social indicators to track welfare across social groups and over time to facilitate monitoring and inform policy and services.

WHO (ibid.) note that a key factor facilitating the adoption of the life course approach in Iceland was the establishment of an intersectoral steering committee alongside dedicated working groups focused on specific population groups and issues. The steering committee comprised representatives from government ministries, local authorities, interest groups, and nongovernmental actors, many of whom had direct engagement with the affected populations, offering valuable insights into their perspectives and experiences. However, barriers in translating principles into policy included a lack of information on how to implement the life course approach in practice and limited evidence on the most effective life course interventions. An evaluation of the initiative found that it played an important role in prioritising and raising awareness of key welfare issues, as well as in protecting welfare from budget cuts. Challenges included unclear task allocation within working groups and the need for stronger collaboration between these groups and the steering committee (ibid).

WHO (ibid.) state that both the Malta and Iceland case studies highlight enablers and barriers to advancing the life course approach as a policy framework. In particular, they underscore the importance of strong intersectoral partnerships across government and society for the successful adoption of life course principles, alongside the need for continuous monitoring, evaluation and knowledge exchange.

A focus on the early years

As noted above, the life course approach recognises that certain life stages are especially critical. The period from pre-birth to age three, ‘the early years’, is of particular importance, as exposures and experiences during this time shape the trajectory of physical and mental health over the lifespan (Academy of Medical Sciences, 2024). This is because it is during this period that the brain, metabolic, and immune systems – which are responsible for our lifelong health and wellbeing – develop fastest, laying the foundations for other outcomes in adulthood (Nelson and Gabard-Durnam, 2020; Berens et al., 2017; Centre on the Developing Child, 2020). Consequently, the environment and exposures experienced during these formative years, such as pollutants and chemicals encountered in utero and postnatally, as well as the quality and stability of relationships and interactions with caregivers, can have profound and long-lasting impacts (Centre on the Developing Child, 2020).

These early influences are particularly important for the development of the brain and lungs, which are highly sensitive to experiences during this critical period. For example, adverse conditions during the early years can lead to disease development through mechanisms such as hormonal dysregulation, alterations in brain maturation, immune system misfunctioning, and changes in metabolic health, all of which impact adult health outcomes (Academy of Medical Sciences, 2024). Notably, cardiovascular disease, diabetes, and depression all share a common association with elevated inflammation, which can be linked to recurrent hardships or threats in early childhood (Centre on the Developing Child, 2020).

The body’s ability to respond to environmental factors – defined as developmental plasticity – also reduces with age, meaning that the process of making changes becomes more difficult over time (Berens et al., 2017). The early years therefore provide a unique opportunity to impact the health of an individual across their whole life, provide cumulative benefits, and mitigate the greater challenge and costs of intervening later (Academy for Medical Sciences, 2024; UNICEF, 2025).

The Academy of Medical Sciences (ibid.) have called for a strong, sustained policy focus on improving health in the early years, noting that its importance is not always recognised in policy development. They highlight areas where evidence points to effective and impactful interventions, including those which promote emotional and cognitive development, increase vaccination rates and immunity, encourage breastfeeding, improve air quality, and enhance oral health (ibid.). While emphasising that this list is not exhaustive, they highlight how these have not only been shown to be effective in supporting children’s health in the short and long-term, but to also deliver a high rate of return on investment.

Other priorities for action in the early years include: reducing child poverty (Pearce et al., 2019) e.g. through action on family income such as the Scottish Child Payment (Scottish Government, 2022d); continued investment in high quality free early learning and childcare (van Huizen and Plantenga, 2018; Ulferts et al., 2016); flexible working and family friendly employment; planning for family friendly spaces (e.g. access to green space and play and connection, reduced health harms); and treating tobacco dependency in pregnancy (ScotPho, 2024b).

The positive return on investment for interventions in the early years is demonstrated by a range of studies (Heckman, 2013). For example, evidence from the United States shows that high quality birth-to-five programmes, offering comprehensive developmental resources including nutrition, access to healthcare, and early learning, can provide a 13% return on investment for every year of a person’s life (Garcia et al., 2016). In Scotland, estimations of the costs of ChildSmile, a child oral health improvement programme in Scotland, found that the NHS costs associated with dental treatments for 5-year-old children decreased over time, and in the eighth year of the toothbrushing programme the expected savings were more than two and a half times the costs of implementation (Anopa et al., 2015). The Marmot Review (2010) also outlined the importance of investment in the early years, highlighting that return on such investment is higher than in adolescence.

It is important, however, that evidence-based early years interventions are implemented as part of a system-wide, interconnected approach that considers upstream drivers and the social determinants of health. The Academy of Medical Sciences (2024) highlight that improving health in the early years requires interventions both within and outside the health context. This reflects recommendations made by the WHO-UNICEF-Lancet Commission (Clark et al., 2020), which emphasised the need for all policies to include and consider children and their outcomes.

This has led to the development of the ‘Children in All Policies 2030’ initiative, which is working to ensure children’s health and wellbeing is prioritised across all sectors and service areas (Dalglish et al., 2021). The Children in all Policies approach advocates for a life course and intergenerational perspective, demonstrating that the benefits of intervening to improve child health and wellbeing are multiplied many times over the life of the child and their descendants, meaning there is a strong economic and ethical case for such action (Clark et al., 2020). Ensuring that children and their needs are included in broader population health approaches has also been highlighted, such as by addressing the commercial factors influencing child health (Modi and Hanson, 2024) and implementing place-based initiatives to improve child health (Burgemeister et al., 2021).

The Academy of Medical Sciences (2024) also emphasise the need to review existing mechanisms for collecting, accessing, and linking data on the social determinants of health and wellbeing in the early years as a priority. They state that improving the collection and accessibility of both qualitative and quantitative data across the life course – covering health, education, household income, social care, criminal justice, and the environment – presents a significant opportunity to better understand the drivers of health in the early years, model long-term trends, and identify areas for improvement. The inclusion of children across all areas of measurement frameworks (such as the NPF), with detailed age-specific breakdowns, would also support more effective policy development, decision-making, and implementation (ibid.).

The importance of the early years has been recognised in Scotland with the recent incorporation of the UN Convention on the Rights of the Child (UNCRC) into Scots law (Scottish Government, 2024j). Following the incorporation of the UNCRC, every public organisation needs to consider children’s rights in their operations and integrate the UNCRC into all policies and practices to ensure efforts positively impact children (Scottish Government, 2024k).

The latest Programme for Government sets out Scotland’s national aim for early child development: “we are committed to reducing developmental concerns at 27‑30 months by a quarter by 2030 – resulting in the lowest levels recorded – and supporting babies, children, and young people through the early, formative years of their life” (Scottish Government, 2025d: p20). This is underpinned by Scotland's 'Getting it right for every child' (GIRFEC) approach, a holistic, rights-based framework which facilitates a whole family approach to supporting babies, infants, children, and young people, including through the early years (Scottish Government, 2025e).

4.4. A place-based approach

Place is “the geographic area or physical environment where people of different ages, population groups, interests and identity live, learn, work, socialise and interact” (PHS, 2024s: p1). Air pollution, the availability of quality green space (such as parks, playgrounds, and forests), housing, traffic volumes, the strength and quality of social networks, economic opportunities, and access to affordable, healthy food are some aspects of place that can influence health (McGowan et al., 2021).

A place-based approach recognises the diverse and interlinked factors that encompass the experience of a place (Bynner, 2016), and focuses on understanding these issues, their interconnections and relationships, to coordinate action and investment (Improvement Service, 2016). This requires joint working and collaboration across the public, private, third, voluntary, and community sectors (PHS, 2024s).

While there are inherent challenges in evaluating place-based approaches due to the complexity of interventions, the length of time it takes for change to occur, and the difficulties in controlling for confounding factors (McGowan et al., 2021), several place-based interventions have strong evidence underpinning them. For example, green space interventions which seek to enhance and support the establishment of these in urban settings have been shown to deliver positive health, social, and environmental outcomes for all population groups, but particularly lower socioeconomic groups (WHO, 2017b; Hunter et al., 2019). Importantly, evidence highlights the importance of the quality and accessibility of green space, as well as proximity to people’s homes (WHO, 2016; PHE, 2020; Baka and Mabon, 2022).

A further place-based intervention supported by evidence is road space reallocation, which involves redirecting space from motor vehicles towards more sustainable uses such as pedestrian or cycling infrastructure, bus lanes and public transport links, local retail or hospitality, and green spaces (PHS, 2022d). Road space reallocation has been shown to contribute to multiple positive outcomes, such as increased physical activity where space is relocated to provide active travel infrastructure and reductions in the traffic which could reduce associated issues of air and motor noise pollution (ibid.).

In Scotland, the Shaping Places for Wellbeing Programme, which is being delivered by PHS and the Improvement Service, seeks to support local authorities, health boards, and their partners to consider ‘place’ in a comprehensive and consistent way, whilst delivering on interventions and a range of national ambitions and core government policy aspirations (Improvement Service, 2024). Key mechanisms include the Place and Wellbeing Outcomes and the Place Standard tool, which provide a quantitative and qualitative understanding of places, what works well, what needs to improve, and the priorities for change (PHS, 2022e). The Place Based Investment Programme is also being delivered, which includes funding that is allocated directly to Scotland's local authorities to accelerate ambitions for place, such as 20-minute neighbourhoods, town centre action, community led regeneration, and CWB (Scottish Government, 2023d).

PHS (2022a) highlight 20-minute neighbourhoods as a key example of a place-based approach which can enhance local environments and access to physical activity infrastructure and services across Scotland. The aim of 20-minute neighbourhoods is to provide access to the majority of daily needs (e.g. employment, essential services, and open spaces) within a 20-minute walk, wheel, or cycle from home (Scottish Government, 2024l). There is a growing body of evidence demonstrating the potential benefits of 20-minute neighbourhoods, including increased physical activity, improved mental health, reductions in traffic, and improved air quality (Chau et al., 2022). The fourth National Planning Framework (NPF4) names ‘local living’ as one of six spatial principles by which places should be planned in Scotland, including use of 20-minute neighbourhoods where feasible (Scottish Government, 2024m).

Other examples of place-based approaches that have been implemented in Scotland in recent years include the Green Infrastructure Strategic Intervention, delivered by NatureScot between 2016 and 2023, which created and improved multifunctional green infrastructure on a major scale in Scotland’s towns and cities (NatureScot, 2025). The Woods In and Around Town programme, delivered by Scottish Forestry, aimed to tackle the barriers people face to visiting and benefitting from woodlands regularly, focusing on the location, accessibility, and management of urban woodlands to encourage more use from local people (Scottish Forestry, 2025).

However, the quality of places in Scotland continues to vary, which contributes to negative health outcomes and widening health inequalities (PHS, 2024s). For example, evidence shows that more deprived areas have less and poorer quality green space, poorer quality buildings, and greater exposure to health-harming commodities due to greater numbers of alcohol, fast food, tobacco, and gambling outlets (Baka and Mabon, 2022; NatureScot, 2022; MacDonald et al., 2018), resulting in poorer physical and mental health. Rurality is another important dimension when considering the relationship between place and health in Scotland, as health inequalities in rural areas are exacerbated by factors such as increased living costs and limited access to services (PHS, 2022e).

PHS (2024s) have highlighted that, although Scotland has strong legislation and policy around supporting, engaging, and developing communities and places, the implementation and roll-out of this has been only partially successful thus far. They note three key areas where action is needed to deliver better places. The first focuses on strengthening leadership and governance to ensure policy and legislation has maximum impact on health and inequality. The second focuses on putting in place a robust data and intelligence system to assess, learn, and track over time the quality of local places and communities. The third focuses on action to improve each of the components of place that affect health, and putting in place a national learning system to collect and share the learning.

The Improvement Service (2024) also emphasise that effective place-based action requires joined-up, collaborative work that is participatory and tailored to local needs, taking account of the unique blend of characteristics that exist in every place. Similarly, Klepac et al. (2023) highlight the need for governments to create a supportive policy environment for place-based approaches, for example by establishing policies that actively promote and facilitate cooperation across sectors, providing guidance on the types of governance arrangements that best support local decision-making, and on the types of systems and structures that enable communities to drive and implement place-based approaches. It is also important that place-based approaches are linked to, and do not replace, national action and investment on the social determinants of health and fundamental causes of health inequalities.

Evidence also indicates that policies or interventions targeting place are most appropriate where they can deliver a ‘triple win’ of improved mental and physical health and wellbeing, equity, and environmental sustainability (Bell et al., 2019a). The EU HORIZON 2020 INHERIT project (2016–2019) focused on identifying policies and practices that contribute to a triple win by creating conditions that enable people to adopt more sustainable behaviours in ways of living, moving, and consuming (ibid.). Examples of interventions which have the potential to deliver a triple win include those which seek to increase active travel, quality green space, and energy efficient housing. As stated by Bell et al. (2019b: p7), adopting a triple win mindset “means setting out with the intention of creating synergies across sectors” to create multiple, interconnected benefits.

4.5. Structural approaches to reducing health harms

Structural approaches to reducing health harms, which reach a broad segment of society and do not require individual agency, are the most impactful in improving population health (Beech et al., 2020). These approaches, which include national government fiscal and legislative policies that modify environments to minimise exposure to health harming products, are also more equitable, in that they do not depend on recipients using their personal resources (Adams et al., 2016). Some examples of these approaches, and the extent to which they have been implemented in Scotland, are outlined below. This is followed by discussion of some issues that should be taken into consideration in the design and implementation of such approaches.

Many of the approaches outlined are derived from WHO's (2024g) ‘best buys’ for preventing noncommunicable diseases (NCDs). These are policy interventions which target the four key risk factors for NCDs (tobacco use, harmful use of alcohol, poor diet, and physical inactivity) and which are evidence-based, highly cost-effective, and yield a significant return on investment.

Fiscal levers

Taxation

There is strong evidence that improvements in population health can be made through taxation (Everest et al., 2022), specifically ‘health taxes’. Health taxes are levies directed at products with a negative health impact, such as tobacco, alcohol, or sugar-sweetened beverages. By making these products less affordable, health taxes aim to reduce demand and consumption (WHO, 2025b). Health taxes can be designed in different ways to achieve different outcomes. Most health taxation is applied to goods and services (‘indirect taxes’) rather than on individuals, businesses or households (‘direct taxes’) (Beech et al., 2020). Health taxes can also be imposed at different points in the supply chain. For example, excise taxes are applied at the point of manufacture, while Value Added Tax (VAT) is applied at the point of sale.

WHO (2025b) state that excise taxes are the most effective tax measures for promoting health because they change the price of a harmful product relative to other goods and can be easily increased over time. WHO (2024g) recommend excise taxes on tobacco products and alcoholic beverages as a best buy. Evidence shows that excise taxes are a highly effective lever for reducing the consumption of alcohol and tobacco (Chaloupka et al., 2012, 2019; Elder et al., 2010), with many countries, including the UK, having implemented these to curb smoking and excess drinking (Papadaki, 2022).

In recent years several countries have also introduced new or higher excise taxes on a broader range of health harming products as a means of discouraging behaviours which are risk factors for NCDs (Beech et al., 2020). For example, Finland, France, Latvia, and Hungary have implemented taxes on both foods and beverages high in added sugar, Portugal and Hungary have implemented taxes on products high in salt, Hungary has implemented a tax on foods high in fat, while Denmark introduced (and later repealed) a tax on saturated fat (Lloyd-Williams et al., 2014). There have also been instances of excise taxes on sugar-sweetened beverages, such as in Mexico (ibid.).

Excise taxes can also be applied to specific ingredients to incentivise manufacturers to reformulate their products to lower the quantity of unhealthy components such as sugar, saturated fats, trans fats, and salt (WHO, 2022a). Reformulation policies for healthier food and beverage products are another best buy (WHO, 2024g). The UK soft drinks industry levy (SDIL) is an example of an excise tax which led to rapid product reformulation. Implemented in 2018, the SDIL applies a tiered tax on soft drinks with 5g or more sugar per 100ml (UK Government, 2016). The SDIL was associated with a reduction in the average sugar content in soft drinks (Scarborough et al., 2020), and recent research has shown that it has led to significant reductions in dietary free sugar consumption in children and adults in the UK (Rogers et al., 2024a). Evidence shows that reformulation policies are more likely to be successful if there is a mandated incentive for manufacturers (as with the SDIL), with voluntary reformulation targets having not led to significant changes in the nutritional quality of foods in the UK (Bandy et al., 2021).

In addition to UK-wide excise taxes applied to alcohol and tobacco products, from 2012 to 2015 the Public Health Supplement was introduced in Scotland. This innovative tax targeted large retailers (in effect large supermarkets) selling both alcohol and tobacco products, aiming to reduce the supply of alcohol and tobacco while raising revenue for health spending (Hellowell et al., 2016). While the Public Health Supplement was successful in achieving its aim of seeking to generate additional public funds, there is limited evidence to suggest that it stimulated substantial behavioural change among retailers or consumers (ibid.).

Subsidies

While taxation raises prices to discourage the consumption of health harming products, subsidies can also be used to reduce the price of healthy products or offer incentives for healthy behaviours (Beech et al., 2020). Evidence has shown that subsidies can influence dietary behaviour, reducing consumption of less nutritious foods and increasing the purchase and consumption of healthier options (An, 2013; Flores and Rivas, 2016; Huangfu et al., 2024). However, while a range of evidence around the effectiveness of subsidies exists, a need for more research has been identified on their long-term impacts and cost-effectiveness at the population level (Beech et al., 2020). Best Start Foods is an example of a direct subsidy offered in Scotland. Introduced in 2019^[18], Best Start Foods was designed to help low-income families buy nutritious food at the point of need (Scottish Government, 2022e). The evaluation of Best Start Foods found evidence to suggest that the scheme has contributed to better health and wellbeing for recipient families (ibid.)

Regulatory measures

Regulating availability

Regulation can be used to change the availability of products and influence the settings in which people make decisions. This can affect health in two ways: by limiting the availability of health harming products or ingredients, or by increasing the availability of healthy ones (Beech et al., 2020).

Alcohol

Placing restrictions on the availability of retailed alcohol, such as through licensing systems, regulations on the number and density of retail alcohol outlets, and restrictions on the hours and days during which alcohol may be sold, is recommended by WHO (2024g) as a best buy. A range of evidence has demonstrated that restrictions on the availability of alcohol can be effective in reducing excessive alcohol consumption and related harms (Anderson et al. 2009a; Campbell et al. 2009; Popova et al. 2009). For example, Popova et al. (2009) found that alcohol outlet density and hours and days of sale had an impact on overall alcohol consumption, drinking patterns, and damage from alcohol. However, WHO (2021) has stated that strategies to regulate the availability of alcohol are generally lacking in WHO European Region countries. The three Baltic countries (Estonia, Latvia and Lithuania) have been an exception in implementing a range of availability restrictions which have been associated with mortality decreases as well as deceases in hospitalisations and emergency room visits (Rehm et al., 2023; Jiang et al., 2022).

In Scotland, all of WHO’s suggested restrictions on the availability of alcohol are in place, but to varying degrees. Despite these restrictions, there is some evidence to suggest that alcohol may have become more widely available in recent years. Between 2012 and 2016, the total number of alcohol outlets in Scotland increased by 472 to 16,629, which was driven by an increase in off-sales outlets (Alcohol Focus Scotland, 2018). Moreover, in 2016 there were 40% more alcohol outlets in the most deprived neighbourhoods than in the least deprived neighbourhoods (ibid.).

Tobacco

A further WHO (2024g) best buy is the elimination of exposure to second-hand tobacco smoke (‘passive smoking’) in all indoor workplaces, public places, and public transport. There is consistent evidence showing that in countries where comprehensive smoke free legislation has been implemented, second-hand smoke exposure has reduced by 80-90% (Pell and Haw, 2009). However, Flor et al. (2024) argue that despite a worldwide gradual decline in smoking rates over time, exposure to second-hand smoke continues to cause harm to non-smokers. Flor et al. (2024) highlight a need to prioritise advancing efforts to reduce active and passive smoking through a combination of public health policies and education initiatives, as well as encouragement of the promotion of voluntary restrictions in homes.

In Scotland, smoking in enclosed public places and workplaces was prohibited in 2006 (ASH, 2020). In 2016 it became illegal to smoke in a vehicle carrying anyone under the age of 18, while a smoke-free perimeter around hospital buildings came into force in 2022 (Scottish Government, 2022f). The Take it Right Outside campaign launched in 2014 aimed to raise awareness of the effects of second-hand smoke in the home, setting a target to reduce the proportion of children exposed to second-hand smoke to 6% by 2020. This was met five years early in 2015 (Scottish Government, 2016b).

PHS (2024t) conducted a scoping review to identify evidence for two potential policies to restrict the sale and supply of tobacco to younger people: raising the legal smoking age each year to create a tobacco-free generation (TFG) and increasing the minimum legal age of sale (MLA) to 21 (MLA21) or 25 (MLA25). They found evidence that a TFG policy could reduce smoking prevalence, increase health-adjusted life years, and offer cost savings, though the benefits could take several decades to be realised. Evidence reviewed also found MLA21 reduced, or was projected to reduce, combustible tobacco cigarette prevalence, though this varied by demographics.

Food and drink

WHO (2024g) also recommend public food procurement and service policies for healthy diets. This involves criteria being set for food served or sold in public settings, such as schools, childcare facilities, and hospitals, or food purchased with government funds (WHO, 2022b). WHO (ibid.) state that through their wide reach, healthy food procurement and service policies have the potential to shape eating habits and shift demand towards healthier and more sustainable diets. However, they highlight that while many countries are implementing food procurement policies in schools, there is less action in other settings, meaning the potential of healthy public food procurement and service policies “is not yet being realised” (ibid.). They offer best practice examples of different approaches adopted, such as a comprehensive policy adopted in New York City that covered food procured for all city agencies.

In Scotland, the Nutritional Requirements for Food and Drink in Schools (Scotland) Regulations 2020 prescribe nutritional requirements for food and drink in schools (Scottish Government, 2021d). Research shows that children in the UK who consume school lunches are more likely to meet minimum recommendations for vegetables and fibre compared to those consuming packed lunches (Haney et al., 2022).

Prior to the Covid-19 pandemic there was a long-term general decline in uptake of free school meals in primary and secondary schools in Scotland (Scottish Government, 2024n). The Poverty and Inequality Commission published research highlighting effective approaches for raising uptake of free (and paid) school meals, such as involving children and young people in menu design and introducing measures to reduce queue times (McKendrick and Cathcart, 2021). The most recent data from the School Healthy Living Survey show that the overall uptake rate for free school meals across all sectors was 71.0% in 2024, up from 70.4% in 2023 but down from the series peak of 85.0% in 2014 (Scottish Government, 2024n).

Progress has also been made towards implementing regulations on NHS premises that improve the healthiness of food and drink that is available. The Healthcare Retail Standard (HRS) was introduced in Scotland in 2015 and sets mandatory requirements for all retail outlets in NHS premises, including that at least 50% of available foods meet nutritional standards (Scottish Government, 2015). An evaluation of the HRS showed that following its introduction people bought more of the healthier foods available and fewer of the less healthy products (Shipton, 2018). All hospital retail sites are required under the terms of their contract to adhere to the HRS criteria, and sites are assessed by Scottish Grocers Federation Healthy Living Programme (OAS, 2023). However, there is evidence that in some settings there remains a greater variety of unhealthy options than healthy options (Allan et al., 2021). OAS (2023) state that further interventions may be required to tip the balance towards healthier options as the norm, and emphasise the importance of not only increasing healthier options, but tackling the abundance of less healthy options.

Evidence also shows that planning policy can be used by both local and national governments to promote healthier food environments, for example through the regulation of takeaway food outlets. In 2015, Gateshead council, a local authority in the North East of England, implemented planning guidance which restricted new fast-food outlets near schools in certain localities (Gateshead Council, 2015). Research demonstrated that this approach significantly reduced the density and proportion of fast-food outlets compared with other local authorities in the North East, supporting a planning for health approach which can be implemented at local or national level (Brown et al., 2022). A study using public health modelling also indicated that ‘takeaway management zones’ which prevent new takeaways from opening (typically around schools) have the potential to meaningfully contribute towards reducing obesity prevalence and associated healthcare burden in the adult population, both at the local level and across the rural-urban spectrum (Rogers et al., 2024b).

Regulating marketing

There is evidence that marketing is effective in encouraging the purchase and consumption of health harming products, such as tobacco (Henriksen, 2012) and HFSS foods (Critchlow et al., 2020). Regulating marketing, for example by deciding who can be marketed to and through which channels, can therefore be used as a means to influence health behaviours (Beech et al., 2020).

Alcohol

WHO (2024g) recommend enacting and enforcing bans or comprehensive restrictions on exposure to alcohol advertising across multiple types of media as a best buy. Evidence strongly suggests that exposure to alcohol marketing increases consumption, particularly among adolescents (Anderson et al., 2009b; Jernigan et al., 2016; Smith and Foxcroft, 2009). A central aim of bans or comprehensive restrictions on alcohol advertising, promotion, and sponsorship is therefore to prevent young people being exposed, as well as to reduce the presence of alcohol cues that can induce reactivity and craving in alcohol-dependent persons (Babor et al., 2017) and prevent industry influence on social norms relating to consumption in general (WHO, 2019b).

Many countries have some form of restrictions on alcohol marketing in place. Iceland has a complete ban on advertising alcoholic drinks, while Norway, Estonia, and Lithuania have implemented almost complete bans (Purves et al., 2022). This extends to low/no alcohol beverages which carry the same branding or distinctive marking as alcoholic beverages in Norway (ibid.). However, WHO (2018c) state that more needs to be done to strengthen countries’ restrictions on alcohol marketing, including regulation of marketing across borders, particularly by digital means (WHO, 2022c).

There is a general lack of international evaluation evidence demonstrating the effectiveness of alcohol marketing restrictions (Scobie et al., 2022; Manthey et al., 2024). For example, a review found evidence of restrictions in Estonia, Finland, France, Ireland, Lithuania, Norway, and Sweden being followed by reductions in exposure to alcohol marketing, alcohol sales, and mortality, but did not find any evaluations of the implementation of restrictions in those countries (Scobie et al., 2022). However, Casswell et al. (2024) state that the body of available evidence provides a credible basis for the conclusion that reducing exposure to alcohol marketing will, over time, reduce the consumption of alcohol and the normalisation of alcohol products, and thereby reduce harm. The Scottish Government (2023e) recently sought views on a range of potential measures to restrict alcohol marketing and promotion in Scotland, and PHS have been commissioned by the Scottish Government to undertake an evidence review on the evidence base for alcohol marketing restrictions (Scottish Parliament, 2024).

Tobacco

WHO (2024g) also recommend enacting and enforcing comprehensive bans on tobacco advertising, promotion and sponsorship as a best buy. A range of evidence shows that comprehensive advertising bans lead to reductions in the numbers of people that start and continue to smoke. For example, a 2016 analysis of 66 countries with comprehensive tobacco advertising bans estimated that they reduced tobacco consumption by an average of 12% (US National Cancer Institute and WHO, 2016).

However, evidence indicates that, in response to the global spread of tobacco advertising bans, the tobacco industry has found alternative ways of promoting products, such as use of the internet, which are largely unregulated (ASH, 2019b). Freeman et al. (2022) state that while innovative restrictions are in place internationally, policies must continue to address evolving forms of promotion, particularly on social media platforms and in online entertainment. This is also relevant to marketing of other unhealthy commodities.

A review by PHS (2022f), which explored how the tobacco, alcoholic drinks, and HFSS food and drink industries respond to marketing restrictions, highlighted the importance of minimising inconsistencies in the settings, products, and circumstances to which such restrictions apply. It recommended that legislation be designed to withstand negative industry responses, either through the prevention of potential loopholes or by enabling quick updates in response to challenges.

Food and drink

A further best buy is the implementation of policies to protect children from the harmful impact of food marketing on diet (WHO, 2024g). A range of evidence indicates that the advertisement of HFSS foods is associated with preferences for HFSS products, requests for purchases, and higher consumption of HFSS products in children (Boyland et al., 2016; Sadeghirad et al., 2016; WHO, 2023g), making it a risk factor for the development of childhood obesity and NCDs (Smith et al., 2019). The restriction or elimination of unhealthy food marketing to children is therefore endorsed as a critical strategy for obesity prevention by WHO and public health scholars and advocates (Taillie et al., 2019). WHO (2023h) state that policies to restrict food marketing are most effective if they are mandatory, protect children of all ages, use a government-led nutrient profile model to classify foods to be restricted, and are sufficiently comprehensive to minimise the risk of migration to other age groups or media.

The UK implemented regulations to limit children’s exposure to HFSS foods through television in 2007. While Ofcom estimated that children saw 34% fewer HFSS advertisements as a result, other research suggested that, as the regulations only applied to programmes targeting children, there was displacement of advertising to television programmes aimed at a mixed audience (Yau et al., 2022). Adams et al. (2012) found that the restrictions had no effect on children’s overall exposure to HFSS advertising and increased exposure for the population as a whole. The UK Government (2024) has recently announced plans to introduce further advertising restrictions on HFSS products, including an intention to ban HFSS products being shown on TV and online before 9pm and a restriction on paid-for less healthy food and drink advertising online, from October 2025.

In 2019 Transport for London (TfL) implemented a ban on advertising HFSS foods across the city’s public transport network in an effort to help address London’s growing childhood obesity issue (Greater London Authority, 2018). Research found an association between the implementation of these restrictions and relative reductions in the energy, sugar, and fat purchased from HFSS products (Yau et al., 2022), with the policy estimated to have resulted in 94,867 (4.8%) fewer cases of obesity than would have been expected in Greater London 12 months after implementation (Thomas et al., 2022).

Breastfeeding

WHO (2024g) also recommend the protection, promotion and support of optimal breastfeeding practices. Across the UK, there are a range of marketing restrictions on infant formula and follow-on formula so as to not discourage breastfeeding. These include, for example, restrictions on the advertising of infant formula, including the promotion of price reductions, as well as a requirement for the labelling, presentation, and advertising of infant formula and follow-on formula to be clearly distinct from each other (Competition and Markets Authority (CMA), 2024). However, a recent review by the CMA (2024) has outlined how a combination of market features, including the limited ability and incentive to set lower prices due to regulatory restrictions, are leading to poor outcomes for consumers in terms of the prices they pay. They also highlighted a lack of timely, clear, and impartial information for parents and carers about formula. The CMA (ibid.) presented a range of recommendations to UK, Northern Ireland, Scottish, and Welsh governments, including measures aimed at improving information and supply in healthcare settings, enhancing transparency and competition in retail settings, clarifying, monitoring, and enforcing existing regulations, and strengthening labelling and advertising rules.

Information and warnings

Regulation can help to ensure that people have access to the information they need to make healthier choices, as well as providing warnings to discourage higher-risk behaviour (Beech et al., 2020).

Tobacco

Implementing large graphic health warnings on all tobacco packages, accompanied by standardised (plain) packaging, is recommended as a best buy (WHO, 2024g). Australia was the first country to require tobacco products to be sold in plain packaging in 2012, with 16 countries – including the UK – having now fully implemented this policy (Moodie et al., 2021). Evaluations, including in the UK, suggest that plain packaging has improved health outcomes and has not burdened retailers, but that tobacco companies have exploited loopholes to continue to promote their products, particularly through filter innovation (ibid.). Moodie et al. (ibid.) have highlighted opportunities for governments to strengthen plain packaging laws, such as banning brand variant name or allowing for health-promoting inserts and dissuasive cigarettes which have an unappealing colour or display a health warning label.

Food and drink

Implementing front-of-pack (FOP) nutrition labelling as a means of facilitating consumers’ understanding and choice of food for healthy diets is also recommended as a WHO (2024g) best buy. There has been increasing global interest in FOP labelling as a means of supporting consumers to make healthier food choices at the point of purchase, with a variety of FOP labelling approaches and designs now in use worldwide (Jones et al., 2019). Evidence suggests that systems which are mandatory, apply across all packaged food products, and that provide an indicator of product unhealthfulness are likely to be most helpful for consumers (UNICEF, 2021).

An example of a mandatory, nutrient-specific warning label system is that adopted in Chile. The Chilean warning label requires packaged foods and beverages containing added sugar, sodium, or saturated fat and exceeding set thresholds for these nutrients or for overall calorie content to carry front-of-package warning labels (black octagon(s) with the words high-in sugar, sodium, saturated fat, and/or calories) (Taillie et al., 2021). The implementation of this system was associated with reductions in calories, sugar, sodium, and saturated fat from unhealthy ‘high-in’ food and beverage purchases (ibid.).

In the UK, a voluntary traffic light labelling system has been adopted by some supermarkets and food manufacturers, with red (high), amber (medium), or green (low) labels used to indicate levels of total fat, saturated fat, sugars, and salt (Song et al., 2021). Evidence indicates that this system could be made more effective if it were mandatory, standardised, and consistent, with consideration given to the continuity of information being provided to the public surrounding labelling and calorie intake (OAS, 2020). The Scottish Government (2018) has previously committed to urging the UK Government to introduce mandatory FOP traffic light labelling, as well as to exploring how current labelling could be improved and considering the use of other labelling approaches (Scottish Government, 2017a).

Some have pointed to potential unintended consequences of FOP labelling, however. For example, FOP labels may lead consumers to use positive information about a specific nutrient to infer a general perception about the product’s overall healthiness, known as the ‘halo’ effect (Ikonen et al., 2019). In addition, while there is evidence that FOP labelling can help consumers to identify healthier options, their ability to influence their choices is more limited (ibid.).

Mandatory calorie labelling on menus in large food businesses (such as restaurants, cafes, and takeaways) with 250 or more employees came into force in England in 2022 and has also been adopted in some parts of Australia, Canada and the US (Essman et al., 2025). A review by FSS (2022) found that calorie labelling could lead to a reduction in population level calories being ordered and consumed in the OOH sector. It also found evidence that calorie labelling can reduce calories through reformulation, by providing impetus for businesses to reduce calories in their offerings. However, a Scottish Government consultation (2023f) identified concerns that the policy has the potential to encourage or compound disordered eating, a risk also highlighted in a review conducted by PHS (2024u). In a position paper, FSS (2024b) shifted its recommendation towards mandating calorie information on request, given the evidence base now shows that mandatory calorie labelling has a negative impact on a subgroup of the population, and there is low certainty with regard to population benefit through influencing consumer behaviour.

Regulating price

The price of products can also be regulated to improve health. While fiscal levers like excise taxes allow manufacturers or retailers to absorb additional costs or savings so that consumers are not affected, price regulation directly affects the cost of a product, thereby influencing consumer choices at the point of sale (Beech et al., 2020). Pricing policies have been shown to have a range of beneficial impacts, including modifying individual behaviours as well as signalling the healthiness of behaviours (PHE, 2018). Sassi et al. (2018) demonstrate that the health benefits generated by price policies tend to be larger for people of lower socioeconomic status due to their stronger response to price changes. However, they highlight that governments must design policies carefully to minimise unhealthy substitutions in consumption.

Governments have most commonly tried to regulate the minimum price of alcohol and tobacco products. Scotland was one of the first countries in the world to set a minimum price for alcohol. Enforced in 2018, minimum unit pricing (MUP) reduced the affordability of certain types of alcohol, particularly high-strength, low price products (PHS, 2023c). Minimum alcohol prices are an important example of price regulation aimed at curbing the most harmful types of alcohol consumption, having the potential to provide additional benefits over and above those so far achieved with taxation due to the improved targeting of the highest-risk alcohol consumption behaviours (PHE, 2018). Research conducted by PHS and the University of Glasgow estimated that MUP had reduced alcohol-attributable deaths by 13.4% (156 a year) (PHS, 2023c).

Recent research commissioned by PHS (2024v) also assessed the potential effects of minimum pricing thresholds for tobacco. The research aimed to identify what impact a minimum price for hand-rolled and factory-made cigarettes would have on the number of people who smoke in Scotland, as well as the potential health outcomes. It found that increasing the price of the cheapest tobacco products through minimum pricing could lead to reductions in smoking prevalence, especially among disadvantaged groups where smoking related harms are highest. The report recommended combining minimum pricing with increased tax to help recoup industry profits associated with any price rises.

The Scottish Government (2024o) has also recently sought views on the detail of proposed regulations to restrict the promotion of HFSS foods where they are sold to the public, including across retail and out of home settings. Views were sought on promotion types such as multi-buys, temporary price reductions, meal deals and positioning restrictions, among others (ibid.). OAS (2022) stated that regulation of price and promotions of HFSS is urgently required in Scotland in light of evidence that promotions encourage unnecessary, unplanned, and health harming purchases that would not have been made if the promotions weren’t there (e.g. Coker et al., 2019; Watt et al., 2020).

A recent systematic review highlighted that if sustained, price reductions targeted at fruit and vegetables (and potentially other healthier foods) could lead to significant changes in purchases and consumption that are substantial enough to yield health benefits (Huangfu et al., 2024).

Modelling by the Scottish Government (2022g) showed that restricting all types of price promotions on HFSS products could result in an estimated net reduction in calorie intake of 613kcal per person per week in Scotland. However, it was also demonstrated that this reduction could only be achieved if all types of promotions were restricted. If only multi-buy promotions were restricted, the modelled calorie reduction that would be achieved decreases to 155kcal per person per week (Scottish Government, 2022h).

Policy considerations

The design and implementation of fiscal and regulatory measures

While fiscal and regulatory measures have been shown to be effective at preventing health harms and reducing health inequalities, Beech et al. (2020) highlight a range of issues to take into consideration in the design and implementation of such approaches. These include the possibility that people may switch to alternative health harming products in response to fiscal and regulatory measures (Mytton et al., 2007), and the need to take action to prevent industry undermining these measures by lobbying or other means (Bødker et al., 2015; Vallgårda et al., 2015) (also see section 3.5). The level of government at which such policies are implemented is also significant. While regulatory policy measures are often implemented at a national level, Beech et al. (2020) highlight a range of potential benefits to increasing the scope for regulatory policy measures to be tailored and enacted at the local level (e.g. if the health problem that requires attention is specific to certain localities or groups).

Public acceptability is another important consideration when using fiscal and regulatory levers to improve health. While some research has highlighted public mistrust of a ‘nanny state’ approach to health (Burkitt et al., 2018), there is increasing evidence that the public support policies aimed at reducing health harms and limiting the power health-harming industries possess over people’s lives. For example, the 2023 ASH Smokefree GB Survey found that the public felt the government was not doing enough to limit harm from tobacco, alcohol, and unhealthy food industries (ASH, 2023). Majorities supported levies on these industries to reduce harm, although opinions varied depending on the commodity targeted (77% for tobacco, 62% for alcohol, 59% for unhealthy food) (ibid.). Overall, evidence shows that policies related to labelling (Reynolds et al., 2019), availability, and marketing/promotions restrictions (Carters-White et al., 2022; Ford et al., 2020) tend to receive high levels of support, while there is less consensus on price-based interventions (Buss et al., 2025; Reynolds et al., 2019; Moodie et al., 2016; Hopkins and Furber, 2024).

However, much research examining public acceptability of fiscal and regulatory policies does not use methods which move beyond survey methods or short qualitative studies, limiting our understanding of the drivers and barriers to public support. Studies employing deliberative methods, such as the citizens’ juries conducted in Glasgow in 2024 (Hopkins and Furber, 2024), demonstrate the utility of deliberative methods as a means for adequately engaging people in public health policy debates that directly impact their lives.

A further broader consideration relates to measuring the impact of population-level approaches. Although they are more equitable, it can be challenging to demonstrate the effectiveness of upstream interventions on health outcomes. Benefits of these changes can be difficult to measure and may not be apparent for a long period of time following implementation. Beech et al. (2020) suggest that when considering these policies, it is important to weigh up the breadth of available research, taking into account the strength of underlying assumptions and international consensus around the policy.

Behavioural interventions

Although evidence shows that structural interventions – designed to address the complex system of influences that shape behaviours and improve the circumstances in which people live – are the most effective in improving health and reducing health inequalities, some behavioural interventions, which aim to change individual health behaviours through the provision of information, services and support, are also covered within the WHO (2024g) best buys. For example, the best buys include information campaigns which seek to educate the public about the harms of smoking/tobacco use and second-hand smoke, encourage healthy diets and physical activity, and support optimal breastfeeding practices.

In general, there is limited evidence to suggest that behavioural interventions have an impact on health outcomes at a population level. This is largely because they rely on a high level of agency, requiring individuals to be both motivated and able to engage with the advice and support provided (Everest et al., 2022). Exerting agency depends on access to social, material, and time resources, factors that are shaped by socioeconomic inequalities. There is therefore evidence which indicates that these measures can unintentionally reinforce or exacerbate health inequalities (Adams et al., 2016).

However, this is not to say that such interventions have no role to play in strategies aimed at improving population health. Evidence shows that where the risks associated with specific behaviours are particularly high (e.g. smoking, poor diet, and alcohol misuse), or where habitual behaviours create resistance to change, it is important to consider the cumulative effect of policies (Beech et al., 2020). While high-agency interventions alone have the least impact at a population level, they can complement low-agency interventions, enhancing the effectiveness of a multi-component approach (Adams et al., 2016). For example, reductions in smoking rates across the UK have been achieved through a coordinated strategy combining tax and regulatory measures with information and advice to support individuals in quitting (Everest et al., 2022). The cumulative impact of a range of less intrusive (higher agency) measures may reduce the need for highest level of intrusion (lowest agency) measures such as large tax restrictions on single products (Beech et al., 2020).