#248      33 min 31 sec
Prey to temptation: Our struggle with irrational health choices

Social epidemiologist Prof Ichiro Kawachi describes how mental short-cuts affect our health choices, often for the worse, and what can be done to help us make better choices. Presented by Dr Dyani Lewis.

"I think the goal of public policy to improve behaviour should include this idea that everybody needs to act on a level playing field where the decisions they make are free from misleading advertising." -- Prof Ichiro Kawachi




Prof Ichiro Kawachi
Prof Ichiro Kawachi

Ichiro Kawachi, M.D., Ph.D., is Professor of Social Epidemiology, and Chair of the Department of Social and Behavioral Sciences at the Harvard School of Public Health. Kawachi received both his medical degree and Ph.D. (in epidemiology) from the University of Otago, New Zealand. He has taught at the Harvard School of Public Health since 1992. Kawachi has published over 400 articles on the social and economic determinants of population health. He was the co-editor (with Lisa Berkman) of the first textbook on Social Epidemiology, published by Oxford University Press in 2000. His other books include The Health of Nations with Bruce Kennedy (The New Press, 2002); Neighborhoods and Health with Lisa Berkman (Oxford University Press, 2003); Globalization and Health with Sarah Wamala of the Swedish National Institute of Public Health (Oxford University Press, 2006); and Social Capital and Health (Springer, 2008) co-edited with S.V. Subramanian and Daniel Kim.  Kawachi is the Senior Editor (Social Epidemiology) of the international journal Social Science & Medicine since 2000. He is an elected member of the Institute of Medicine of the US National Academy of Sciences.

Credits

Host: Dr Dyani Lewis
Producers: Eric van Bemmel, Kelvin Param, Dyani Lewis
Audio Engineer: Gavin Nebauer & Tony Brown
Voiceover: Nerissa Hannink
Series Creators: Kelvin Param & Eric van Bemmel

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VOICEOVER 
Welcome to Up Close, the research talk show from the University of Melbourne, Australia. 

DYANI LEWIS
I'm Dyani Lewis, thanks for joining us. We all like to think of ourselves as rational individuals making decisions according to the best available information for a beneficial outcome. But over the past few decades the burgeoning field of behavioural economics has made it abundantly clear that humans are not always rational beings. In many of the financial decisions we make we can fall victim to the mental shortcuts and rules of thumb that govern our behaviour. We end up making decisions that seem to defy logic and work against our own long term goals and desires. Work by Daniel Kahneman and the late Amos Tversky among others, that integrated behavioural psychology with economics, earned Kahneman the Nobel Prize in Economic Sciences in 2002. Researchers are now looking at how the principles of behavioural economics can be applied to fields beyond finance to understand how we make decisions in other areas of life. What better field than health where we often struggle to make the right choices usually despite a plethora of available information. To discuss how behavioural economics can be applied to public health and health behaviour change we are joined on Up Close today by Professor Ichiro Kawachi. Professor of Social Epidemiology and Chair of the Department of Social and Behavioural Sciences at the Harvard School of Public Health. He is visiting the University of Melbourne courtesy of the Melbourne Social Equity Institute. Welcome to Up Close, Ichiro.

ICHIRO KAWACHI
Hello. It's a pleasure to be here.

DYANI LEWIS
Daniel Kahneman's Nobel Prize was awarded according to the official citation for having integrated insights from psychological research into economic science, especially concerning human judgement and decision making under uncertainty. Now one of the main insights was this idea of mental shortcuts or heuristics. Could you explain for us why we turn to mental shortcuts when making decisions?

ICHIRO KAWACHI
I think we do it because when we think about how we lead our daily lives we have to make thousands of decisions in any given day. It's simply too wasteful and inefficient to have to pause and think about the risks and benefits and payoffs of every decision. From an evolutionary perspective it's quite reasonable that the human brain should be designed to make these shortcuts. That by-pass the careful weighing of consequences of decisions as well as the probability of different outcomes. That's where the idea of shortcuts or heuristics comes from.

DYANI LEWIS
So this is definitely being used a lot in consumer behaviour and trying to modify consumer behaviour. And one of the incredible findings of behavioural economics is how easily people can be influenced simply be seeding their mind with a particular number. So if you put a label on a product in the supermarket that says limit 12 per customer then people will buy closer to that number of 12 than they would normally without this anchor number. So are there types of anchors that govern our health behaviours?

ICHIRO KAWACHI
Yes indeed. There are many different kind of shortcuts that the human mind makes. Sometimes you can appeal to emotions that make people make a mental leap. For example if you see an advertisement for a dangerous product such as cigarettes which evokes emotions for fun and pleasure that has a tendency to make people feel good about the product. Therefore causes us to by-pass inner rational considerations about the risks and consequences of the behaviour. That's called the affect heuristic to refer to the use of emotions to make people do these mental shortcuts.Another kind of heuristic that you just mentioned is the anchoring heuristic which is the notion that rather than thinking carefully about the features of a decision our mind makes shortcuts based upon the immediate information that's available to us. Now as we look around the world around us, our world is full of anchors of one kind or another. And these kinds of anchors can form what we call default options in our lives. For example if I serve you a bowl of muesli in a certain size bowl that serves as a kind of a default option. It's also an anchor that signals how much should you eat in a given meal.In other words one of the discovery of behavioural economics applied to the public health field is that most people don't decide how much to eat based upon how hungry or how satisfied they feel. But rather on anchoring queues such as whether the plate that we have in front of has been cleared or not. The implication of that observation is that if you want people to cut back on the amount that they eat in a given meal then you need to reduce the size of the anchor. In this case the size of the serving plate.

DYANI LEWIS
So how much of an effect can that simple act of changing the size of the plate have on people's behaviour?

ICHIRO KAWACHI
I think it can have profound effects. There have been a number of experiments by scientists such as Brian Wansink who coined the term mindless eating to describe what I just talked about. In his experiments people really are not cued to signals about how full they feel as they eat during the course of a meal. For example in a very famous experiment that he conducted he served people in his laboratory with an endless cup of soup. Which as the people ate the spoons of soup it was designed so that hidden underneath the table there was a tube which was constantly replenishing what was being consumed. And for the most part people don't notice that as they're eating that the level of soup is failing to go down. So they'll continue to eat way beyond the point at which they ought to have been satisfied. And it's from evidence like this that we know that the size of the serving containers serves as a visual anchor for how much we should consume during a meal. In another very famous experiment that Wansink conducted was called the popcorn experiment. In which on a given evening in a theatre somewhere in the Midwest of America movie goers were provided with two alternative serving sizes for popcorn, a small bag and an extra-large bucket. Then they're told this popcorn is free and please enjoy the movie. Well there was one catch, which was that the popcorn was five days old and according to Brian Wansink it tasted like Styrofoam packaging. But the experiment showed that nobody noticed and moreover the larger the size of the container of popcorn that people were given the more they consumed. Those people who were randomly given the larger popcorn bag ate on average seven or eight scoops more and that's another illustration of this anchoring heuristic.

DYANI LEWIS
Definitely an illustration of mindless eating if it wasn't even…

ICHIRO KAWACHI
Absolutely.

DYANI LEWIS
… tasty.

ICHIRO KAWACHI
So mindless that a number of customers complained afterwards and wanted their money back forgetting that they had been given the popcorn for free in the first place.

DYANI LEWIS
There are numerous other small things that we do every day that are simply part of our daily routine or things that are done in particular ways in society. How much do these kind of defaults affect how we set our health behaviours?

ICHIRO KAWACHI
I think they have a large and unappreciated but accumulative effect on our daily behaviour. When someone analysed all of the tens of thousands of individual actions and decisions that we make during the day a few of us actually are pausing to calculate whether we should do something or not in any given moment. A large proportion of our daily actions are in fact automatic. So given that they're automatic they're actually influenced by these features in our environment. These default options which lead us toward this kind of automatic behaviour. behavioural economics as applied in public health is simply a way of saying can encourage people to behave in healthier directions by changing these defaults in ways that nudge them toward healthier patterns. For instance if you go through a lunch line at a workplace cafeteria there are in fact many, many defaults already present that we don't know about. For instance as we line up - cue up to pile our trays full of food maybe the first item in the line of food might be the french fries. So without thinking we pile that on and by the time we come to the end of the lunch line the vegetables might be there. And guess what, there's not enough room on your plate for those vegetables and you check out.Well the behavioural economics approach is to utilise this automatic behaviour by reversing the defaults in ways that nudge people towards healthy behaviour. So instead of placing the french fries at the start you place them toward the end. So nowAnd hopefully most people's plates are piled high by the time they get to the french fry option.

DYANI LEWIS
So does this mean that if we were to have all fast food restaurants serving pieces of apple instead of fries and bottles of water instead of soft drink - I mean…

ICHIRO KAWACHI
Yes.

DYANI LEWIS
… are there limitations?

ICHIRO KAWACHI
No that's exactly what some fast food outlets have done. Actually I think Disney in the United States tried - for a period at least - a default option where with the children's menu instead of serving baked apple pie they gave children a piece of fruit. That's exactly an instance of a default option.Another default option we sometimes see in fast food franchises that as you order the meal the servers are trained to ask the customer would you like to supersize that. That's a default option. Well behaviour economists have turned that around and used the same principle to try and get people to reduce the calories they take in. The way they do this is by asking customers after they've made their choices instead of asking would you like to supersize it you simply ask them would you like to downsize what you just order. Instead of two scoops of fried rice would you be content with just one? Experiments have shown that when customers are offered this option about a third of them will volunteer to take the downsized option. That's a default option if you will to encourage people to reduce their daily intake of fatty foods.

DYANI LEWIS
Is there any way of knowing whether those people who took the smaller serving option did so simply because they thought that that was the social acceptable thing to do?

ICHIRO KAWACHI
I don't think the researchers asked about these perceptions and that may well be part of the effect. It's possible that some of them may have been motivated to do that because they were afraid of being viewed as greedy for instance. But in a way that conflict if you will exists within our own minds isn't it? I mean our own behaviours are often a tension between our greedy selves and our more rational selves which would like us to constrain gluttonous eating in the long-term interests of the self. So someone might say that by implementing a default option which jogs people at the point of consumption that they have a choice to reduce the amount they're going to eat you're kind of helping the rational side of our brain to come to the fore.

DYANI LEWIS
I'm Dyani Lewis and you're listening to Up Close. In this episode we're talking about health behaviours with Social Epidemiologist Professor Ichiro Kawachi.We're all familiar with advertising that appeals to our emotions. As you mentioned before with smoking ads showing healthy people living wonderfully fun lives. And they do that rather than just provide dry fact about a product. How can health promotion use this trick in its favour?

ICHIRO KAWACHI
Right. So for years public health has operated under a playing field that has not been level. In other words we have allowed advertisers of products such as cigarettes to use the affect heuristic to its maximal advantage. Namely connecting their product to images of pleasure and happiness. Which the science now shows that when people are under the influence of the affect heuristic and they see messages that are positive then they tend to reduce their perceptions about risk associated with a product. Even though the advertisement has said nothing about the risk side of the equation.In contrast to that in public health - well at least in the United States the public health countermeasure has been to print Surgeon General's warnings, which are written in words and warn customers about risks of cancer years down the line. I think that really hasn't been effective in terms of neutralising the affect heuristic used by the manufacturers of the product. So one approach to try to counteract this has been the use of graphic warning labels, which play to the affect heuristic in some way. Australia for example has effective series of advertisements of this type. And in the United States the country's food and drug administration is supposed to be introducing at some time a series of graphic warnings that also play to the affect heuristic. Now the interesting thing about when public health tends to use the affect heuristic there's been a tendency to run toward to the fear appeal. Which is to play up the horrible effects of cigarettes and producing disease and so forth. I think that's an example of affect heuristic but as we've now discovered it's only a tiny part of the palate of emotions that are possible to use in the affect heuristic. It's also possible through graphic advertisements to appeal to positive emotions such as the pride of someone who has successfully quite smoking. If you're going resort to using negative emotions you don't have to always appeal to fear you can also appeal to other emotions like sadness at the disease that - loss of a loved one through smoking. Or you might even appeal to other emotions like anger - anger at being manipulated by an industry, which might change people's intentions to stop.

DYANI LEWIS
The other challenge of course with anti-smoking campaigns is that the health benefit - as you mentioned - is so far removed from the immediate appeal that a cigarette might have for a smoker. So is this just down to an individual person's will power or grit?

ICHIRO KAWACHI
Yes. Often when we think about health behaviours most of them have this characteristic that the benefits and costs fall in different periods in time. So broadly speaking of all the things that public health professionals try to encourage the public to take up fall in to either the category of what we called sinful behaviour where the pleasure is now and the cost comes years down the line. Cigarette smoking, risky sex, sedentarism these are all examples where the pleasure is now and the cost comes later. Or they take the form of investment behaviours, which unfortunately involve pain now in order for gains later on. An example of that would be dental flossing or getting off the couch and going to the gym.Now whenever benefits and costs are separated in time and the further that they are separated the more difficult it is for most of us to put off gratification in order to benefit in the future. This is when problems of procrastination and short-sightedness - myopia comes into play. And cigarette smoking is a classic instance of that. If it's the question about having pleasure in the next minute by lighting up then all concerns about health effects that are 20 years down the line tend to fade away into the background. In order to overcome that procrastination problem behavioural economics teaches us that there are some new ways we have to put in place to encourage people to overcome their procrastination.An example is what we call pre-commitment devices of one kind or another. For example when the smoker is in a hot state craving a cigarette in the next minute it's almost impossible to overcome the problem of procrastination. The present is so appealing that all appeals to health fall by the wayside. But if we can appeal to the smoker whilst they're in the cold state - that is they're not craving a cigarette at the moment - then sometimes we can succeed in getting them to pre-commit to a healthier behaviour in the future. And one way in which behavioural economists have done this is to try to encourage smokers to begin to deposit a certain amount of money every month into an account for let's say the next six months. At the end of six months the goal is to quit by that time. And the nature of the deal is that if the person is still smoking at six months then they forfeit the savings, which they have accumulated over the past six months. And in the worst case scenario those savings might go to a charity that they intentionally dislike. That's motivating them to work harder toward meeting their goal.So the idea in this case is that we're trying to commit people to doing something in the future, which they would not do in the next minute. Those kind of pre-commitment devices seem to be quite helpful in encouraging some part of smokers to be able to quit successfully.

DYANI LEWIS
And I guess it also acknowledges that there are some times when people aren't going to have great levels of willpower but other times when they're going to have more.

ICHIRO KAWACHI
Right. That's right. Willpower as some psychologists have said is like a muscle and you can train it and like a muscle it can tire. So if you're under some kind of stress and feeling low in glucose then your willpower will tend to be lower. There was a very famous experiment in which people were randomised to memorise a two-digit number sequence or a seven-digit number sequence and whichever condition they were randomised to they were told to walk down the hallway to recite the numbers from memory. But along the way the experimenters had put in the hallway a trolley full of two kinds of snack. One was a healthy bowl of fruit salad and the other was a very scrumptious looking piece of chocolate cake. They discovered that when people are under cognitive strain of having to remember seven digits instead of two by far the majority of them went for the chocolate cake than for the fruit salad. So in that sense when the mind is under some pressure and people are suffering from what psychologists call ego depletion then they are certainly prey to temptation and it's much harder to be able to make rational decisions based upon long term self-interest.

DYANI LEWIS
So you spoke about smoking but I was wondering about health behaviours that are only occasional. Like things like vaccination. Is there anything we can do to make sure that people take up the option of something that they might only have to do once every now and then?

ICHIRO KAWACHI
Sure. So even in the case of one-time behaviours like vaccination or organ donation or whatever the behavioural economics has a lot to say. So in the case of vaccination there have been experiments in which people have been randomised to be sent out a reminder. One which was just a reminder that said you should turn up to your vaccination by such and such a date. Another version of this letter simply included a sticky that said I will come to clinic on such and such a date and such and such a time. So specifically asking the people to pre-commit themselves to turning up at the clinic at a particular time. And that one tiny intervention significantly increases the uptake of vaccination. We may also try to encourage vaccinations through the ways in which we frame the benefits of getting vaccinated. In behavioural economics there are large influence of what we call-framing effects. Whether we appeal to the positive of having a disease prevented versus whether we appeal to the negative side of regret from having come down with the illness that the vaccine was supposed to prevent. So depending on the way that decisions are framed we can see large differences in decision making there as well.

DYANI LEWIS
My guest today is Social Epidemiologist Ichiro Kawachi. We're talking about rational decision making in health here on Up Close. I'm Dyani Lewis.Ichiro what role does government play in influencing health behaviour?

ICHIRO KAWACHI
Government already plays a substantial role in behaviour in doing things like taxing cigarettes and subsidising healthy behaviours. So government already does have a - plays a substantial role in nudging people in one direction or another. The same applies for direct regulation such as requiring food manufacturers to post nutritional information on packages or frankly outright restrictions on lighting up cigarettes in indoor places and such. So governments is already heavily involved in regulating daily aspects of our health behaviours. What behavioural economics is saying is that in addition to these already existing economic and regulatory laws and regulations that are currently in place, we can also improve the outcomes of consumer behaviour by putting in for example default options or using information to make more effective the way we communicate the benefits and costs of behaviour to consumers. There's a term in behavioural economics called libertarian paternalism, which sounds like an oxymoron. But it's a way of trying to be paternalistic but also allowing consumers to choose something if they really want to do it. That's the libertarian part of it. To give an example in some parts of England there was a campaign to try and to reduce salt consumption in a fish and chip store. The traditional paternalistic approach would be to take away the saltshakers altogether thereby giving consumers no choice in the matter. We're just simply taking it away from you. The nudge approach - the libertarian paternalist approach is to change the default in the saltshaker.So the clever intervention they put in place was to reduce the number of holes in the saltshaker and to reduce the diameter of the holes through which the salt passed out. And when you leave these modified salt shakers on the tables most customers take three or four shakes on the chips that they're accustomed to using and none of them noticed that they were getting less salt. It just led to a substantial reduction in salt consumption simply through the default of introducing a differently designed saltshaker. That's the kind of libertarian paternalism you're not taking away people's rights to use salt but at the same time you're nudging behaviour toward and healthful direction.

DYANI LEWIS
Now several countries have toyed with the idea of taxing foods that are unhealthy for us.

ICHIRO KAWACHI
Yes.

DYANI LEWIS
Such as sugary drinks or foods that are very high in fats. Is this a good way of changing behaviour?

ICHIRO KAWACHI
Yes. I think in the case of cigarettes for example taxation is extremely effective. It's one of the few things that really do work in reducing consumption. And using that analogy I think some in public health have argued for taxing of unhealthy foods and conversely using that money to subsidise healthy foods as an analogy. I think the analogy only goes so far. I think once we begin to talk about taxing foods it becomes immediately complicated.It becomes complicated because there are thousands of foods and unlike cigarettes some foods have both unhealthy and healthful elements in them. So one gets into an immediate debate about which foods should be taxed. If you do tax some foods no doubt someone else will argue why was their product levied a tax, and not someone else's - a competitors. That's one reason.The other is that unlike cigarettes, which are a single product, food has many substitutes. Whenever we take one category of unhealthy food we always have to be mindful of so-called substitution effects. For instance if you tax sugar sweetened beverages then one consequence might be that people will be driven toward consuming more fruit drinks, energy drinks and chocolate milk and whatever else isn't included in that tax. These substitution effects may end up cancelling the intended actions from a food tax.So for that reason I think we need to think more carefully about what is the extent to which the analogy works. Taxation itself is not an insight from behavioural economics, taxes are an insight from traditional economics and they work in some cases. But I think a lot more work needs to be done to understand how effective they might be in the realm of foods.

DYANI LEWIS
Then in comparison to taxes the flipside would be subsidising healthy foods.

ICHIRO KAWACHI
Yes.

DYANI LEWIS
Is that effective at all?

ICHIRO KAWACHI
Yes I think behavioural economics tell us that because of the phenomenon called loss aversion consumers tend to be much more responsive to losing something than gaining something. So the prediction is that taxing a bad is going to be much more effective than subsidising a good thing. For that reason - although I think it's important to subsidise healthy foods - it may not be the answer. That just because you lower the price of fruits and vegetables that more people are going to purchase it. There have been some experimental evidence to suggest that that has its limits.

DYANI LEWIS
So this concept of loss aversion is the same thing that you were mentioning before in the case of financial pre-commitments to change health behaviour.

ICHIRO KAWACHI
Yes in the example of pre-commitments for contracts for cigarette smoking and for smoking cessation loss aversion works there because people hate to lose the money that they have been accumulating. That prospect of regretting that loss is highly motivating.

DYANI LEWIS
Humans are very social animals and so it matters to us what everyone else around us is doing. It matters to us what others around us are thinking of us. Can this effect be used in health promotion to influence what might be acceptable, or does it take a long time for those changes to take place?

ICHIRO KAWACHI
All right. You're referring to the influence in social norms in behaviour and I think that's quite right. Unlike the model of homo economicus, which is that we're all selfish agents and uninfluenced by others around us, the behavioural economics notion of people is that we are connected to other people and hence fall under their social influence.It follows that if we can change norms in some way that this may be a powerful driver of behaviours as well. The most obvious example of this kind of effect is in legislation to restrict smoking in public places. If you recall that legislation was originally introduced in most countries to protect the health of non-smokers. But what it actually did along the way was to make smoking much less normative and must less acceptable. The real payoff for public health of this legislation has come not so much from the protection of the health of non-smokers but from the fact that hundreds of thousands smokers have quit smoking because it became non-normative or socially unacceptable to light up. And as you can image there's a virtuous cycle that happens when such legislation is introduced. So one day smoking is allowed in doors, the next day it's not allowed, which makes exposure to second-hand smoke much less common. And that makes non-smokers react even more negatively when it does happen and that causes smokers to try to give up even more. So there's this kind of cycle - virtuous cycle which is set in train that eventually those norms lead to a change where lighting up even in private places becomes unacceptable.

DYANI LEWIS
So clearly government and society have a huge influence on individual behaviour. But what about the role of the individual in all of this? I mean is there a way that each of us can overcome the types of mental biases that are part of our makeup rather than placing the onus on government regulations to influence our behaviour?

ICHIRO KAWACHI
Right. I think very few individuals can escape the influence of these heuristics and judgement errors and such. I mean if you're read Dan Kahneman's book Thinking Fast and Slow even he admits that he is not free from these kinds of decisional errors. I don't think that we're going to make much headway by lecturing people that so much of their behaviour's automatic. Instead what we need to do is to put in place these kinds of default options that make it easier for people to behave in their self-interest. So it's this nudge idea. And I think the goal of public policy to improve behaviour should include this idea that everybody needs to act on a level playing field where the decisions they make is free from misleading advertising by the food industry and tobacco industry for example. That if these advertisements are going to use these behavioural principles then at least the other side, namely the public health side ought to be given the same tools to try to counteract them. To that extent, I think the things that public health agencies and governments can do to try to level the playing field for consumers deciding and choosing to behave in certain ways.

DYANI LEWIS
Ichiro Kawachi thank you for being my guest today on Up Close and talking about how to improve public health with behavioural economics.

ICHIRO KAWACHI
Thank you very much. It's been a pleasure.

DYANI LEWIS
Ichiro Kawachi is Professor of Social Epidemiology and Chair of the Department of Social and Behavioural Sciences at the Harvard School of Public Health.Relevant links, a full transcript and more info on this episode can be found on our website at upclose.unimelb.edu.au. Up Close is a production of the University of Melbourne, Australia. This episode was recorded on 3 May 2013. Producers were Kelvin Param, Eric van Bemmel and myself Dyani Lewis. Audio engineering by Gavin Nebauer. Up Close is created by Eric van Bemmel and Kelvin Param. Until next time goodbye.

VOICEOVER 
You've been listening to Up Close.  We're also on Twitter and Facebook.  For more info visit upclose.unimelb.edu.au.  Copyright 2013, the University of Melbourne.


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