Introduction

This chapter considers the way in which public health education initiatives are evaluated. In particular, our concern is with such evaluation when it is done in terms of behavioural outcomes, such as how many people give up smoking. Our main claim is that this method of evaluation is scientifically and ethically flawed. We use the example of initiatives on smoking and lung cancer. This is because smoking is known to be a hugely important contributor to illness and to health inequality, and because there have been many such initiatives. However, the criticisms we make of initiatives relating to smoking and lung cancer apply equally to many other public health initiatives. Indeed, some criticisms might apply more forcefully to lung cancer initiatives, given that the epidemiological evidence for the link between smoking and lung cancer is stronger than that available for any other link between behaviour and an illness.

We begin the chapter by looking at how health education initiatives in the area of smoking and lung cancer are evaluated. We show that this is done primarily in terms of behaviour change, particularly rates of quitting. We suggest that this is because behaviour change is a good marker for future health benefits which might only accrue over many years: a drop in rates of smoking now could be expected to deliver significant health benefits in the future. However, we argue that looking at behaviour change alone is problematic, because it ignores the possibility of unwanted effects from a public health initiative. We give some evidence for such unwanted effects, based on our own empirical research.