Analysing Fundamental Issues in Health Development

Synopsis

This report will focus on smoking behaviours in teenagers. Smoking is……………..? Smoking is the single greatest cause of preventable illness and early death and is an issue of great concern. The report is about behaviour change, models and approaches in teenage smoking. The two that will be looked at are the theory of reasoned action (TRA) and social learning theory (SLT). Section 1- describes the scale of the public health challenge for smoking and gives statistics whilst discussing the health risks associated with smoking. Section 2 - looks at polices that are in place with regards to health and adopting healthy behaviours and lifestyles. Section 3 -discusses behaviour and behaviour change in teenagers and salient areas of concern. Section 4 - looks at a range of behaviour change interventions to find out ‘what works’. It summarises the theory of reasoned action and compares it with the health belief model, it then goes on to Beatties typology and talks in detail of government, community, individual and the groups interventions regarding smoking and what each of these are doing in the area of teenage smoking. Then Section 5 looks at health promotion with regards to planning programmes to intervene and finally section 6 concludes with the reports finding.

Section 1 - Introduction

The chosen topic was selected by speaking to a convenient sample of people in the community in order to assess the implications and effects that health inequalities have on the nation. Many issues were raised in which they identified as impacting on their health; however smoking came top of the list. As smoking is such a vast area the report concentrates on smoking in teenagers as these youngsters are the adults of tomorrow and it is important to break this health affecting behaviour in order to help them refrain from smoking.
Research has shows that this nation is faced with many challenges in its efforts to reduce the number of smokers and improve the health status of all people living in the United Kingdom. Smoking is one of the biggest challenges of today as approximately 9 million adults continue to smoke (Department of Heath, 2008) and the health risks are devastating and carry many public health implications.
Smoking is a major concern that can lead to many illnesses and life threaten diseases in 2007 there were 82,900 smoking-related deaths among adults aged over 35. (Department of Health, 2008). In England in 2006 the smokers were 23 per cent of men and 21 per cent of women. The highest prevalence of smoking was among 20–24-year-olds and the lowest among those aged 60 and over. Overall the trend is moving in the right direction; with prevalence down from 39 per cent in 1980, smoking rates in England are currently the lowest on record (Department of Health, 2008).
Research has suggested that People on low incomes are more likely to smoke. Smoking remains one of the biggest causes of the substantial and growing inequality in health between higher and lower income groups (Townsend, 1994). In 2006, 17 per cent of people in non manual groups smoked compared with 28 per cent in manual groups (Information Centre for Health and Social Care 2008).
Smoking rates vary between ethnic groups. Among Bangladeshi, Irish, Pakistani and Black Caribbean men, the percentage of smokers is higher than the national average. The number of women from black and minority ethnic (BME) groups who smoke is lower than the national average, with the exception of Black Caribbean and Irish women (Information Centre for Health and Social Care 2006). Smokeless tobacco is an additional problem in some BME populations, particularly those from South Asia. Among the UK Bangladeshi community, for example, 9 per cent of men and 16 per cent of women regularly chew tobacco (Information Centre for Health and Social Care 2006).
Child and adolescent smoking causes serious risks to respiratory health both in the short and long term. Children who smoke are two to six times more susceptible to coughs and increased phlegm, wheeziness and shortness of breath than those who do not smoke (Strachan, 1997). Smoking impairs lung growth and initiates premature lung function decline which may lead to an increased risk of chronic obstructive lung disease later in life. The earlier children become regular smokers and persist in the habit as adults, the greater the risk of developing lung cancer or heart disease (Strachan, 1997).
Children are also more susceptible to the effects of passive smoking. Parental smoking is the main determinant of exposure in non-smoking children. Although levels of exposure in the home have declined in the UK in recent years, children living in the poorest households have the highest levels of exposure as measured by cotinine, a marker for nicotine (Going smoke free, 2005).
Unhealthy behaviours and the illnesses they cause represent a significant proportion of the disease burden facing the NHS. Treating smokers costs the NHS in England £2.7 billion a year, compared with £1.7 billion a decade ago (Action on Smoking and Health, 2008).
These statistics can reveal important trends, but they give only part of the picture. To change people’s behaviour, we first need to understand why they smoke and what motivates them to give up smoking.

Section 2 - Literature review

With all the known health risks that smoking can cause the government, researchers and health care professionals alike have taken a great interest in helping the nation to stop smoking. There is overwhelming material related to smoking and its effect on ill health and since the Labour government came to power in 1997, it has introduced a number of policies that may help to reduce inequalities in health such as the minimum wage as for families on low incomes, the cost of smoking also plays a significant role in perpetuating child poverty and the ban on smoking in public places. These policies have focused on social, economic and environmental factors, all of which are important in delivering improvements in public health. But recent policy documents have signalled a greater emphasis on the role and responsibilities of individuals in adopting healthy behaviours and lifestyles.
Choosing Health: Making healthy choices easier (Department of Health 2004) emphasises the role and responsibilities of individuals in maintaining their own health. This White Paper set out recommendations to create a ‘health-promoting’ NHS, and suggested there was a role for retailers and advertisers to make healthy lifestyles ‘an easier option’ for people. Our Health, Our Care, Our Say (Department of Health 2006) stressed the need for health and social care services to support individuals to take more responsibility in managing their own health and health care. So although it is important that the government continues to implement policies to address the wider determinants of health, there is also an important role for the NHS to play in addressing the personal factors that influence lifestyle and health.

Section 3 - Behaviour change

Smoking is a highly addictive habit which is hard to kick, Smoking behaviour emerges at varying ages from early puberty to late adolescence and stems from a need to "fit in" socially, to portray a "cool" or "mature" image, and to rebel. Peer and family influence are also expressed as factors for starting the habit. As we all know smoking is highly addictive and many of those who take up smoking regularly continue to smoke up until the day they die, even though they have tried to give up this terrible addiction and not succeeded. Research has shown that the majority of smokers take up smoking in their school years, this places schools in the front line of the battle to reduce the massive death toll and illness caused by this addiction (NHS, 2003).
While the major behavioural change occurs during the teenage years, many of the predisposing factors develop at an earlier age. Beliefs, attitudes, and values begin to develop very early in life, and these influence later behavioural patterns.
The initiation of smoking tends to exist among young people who report having a home environment that includes difficulty communicating with parents, lack of parental understanding, low levels of trust, and a generally unhappy home life. This type of family setting creates conditions contributing to a lifestyle that includes smoking such predisposing factors are also evident as social networks expand during the teenage years. Other aspects of the social environment have promoted the acceptability of smoking, such as smoking by role models in the movie industry and the widespread visibility of smoking. Studies indicate that smokers tend to overestimate the prevalence of smoking and underestimate the health hazards. All these processes and conditions are set in place during the early years of socialisation, and they contribute toward a predisposition that smoking is acceptable and even desirable. Once individuals are predisposed toward the possibility of smoking, enabling factors facilitate the actual behaviour.
The behaviour change model states that helping patients change behaviour is an important role for health promoters and health care professionals alike. Change interventions are especially useful in addressing lifestyle modification for disease prevention and addictions such a smoking. Understanding patient readiness to make change, appreciating barriers to change and helping patients anticipate relapse can improve patient satisfaction and lower frustration during the change process.
The Theory of Reasoned Action (TRA) is a widely used behavioural prediction theory which represents a social-psychological approach to understanding and predicting the determinants of health-behaviour. Ajzen and Fishbein proposed that a person 's behaviour is determined by there intention to perform the behaviour and that this intention is, in turn, a function of his attitude toward the behaviour and his subjective norm. From the perspective of TRA, we behave in a certain way because we choose to do so and we use a rational decision-making process in choosing and planning our actions (Romano, 2008). According to Ajzen (….) behaviour is influenced by the intention to perform the behaviour and the likelihood that an individual will engage in health risk reduction depends upon how much s/he is convinced that healthy behaviors will prevent risk, and the degree to which s/he perceives the benefits will outweigh the costs.

Section 4 - Health promotion

Health promotion techniques are employed to help people to change their behaviour, health promotion is the process of enabling people to exert control over the determinants of health and thereby improve their health to reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living (Ottawa, 1986). Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being. As a concept and set of practical strategies it remains an essential guide in addressing the major health challenges faced by developing and developed nations, health promotion is more than changing health behaviour (Ottawa, 1986). That theory of reasoned action model will be compared and contrasted with the social learning theory in relation to what is happening from the government’s perspectives, it will also look at community interventions and what the individual and the group are doing in order to address the situation.
There are a number of health behaviour models and theories available which have been developed over the years to explain and predict health behaviour. One of particular interest in recent years is the 'health belief model ' which has been the most widely used. Becker (1974) developed the concepts of a health belief model by expanding upon the works of Reoenstock (Galvin 1991). Health belief from Becker’s point of view is based upon the idea that an individual must have the willingness to participate in health interventions and believe that being healthy is a highly valued outcome. Therefore, it was possible to predict if an individual would engage in positive health behaviors by determining the individuals’ perception of the disease, illness, and the likelihood that the individual will take some action (Galvin 1991). Despite a wealth of evidence to support the model 's value in predicting health behaviour, often it is evident that there are a substantial number of factors involved in health behaviour which are not health related and are therefore not easily predicted by the model (Galvin 1991). Cigarette smoking is of interest here due to the many physiological and psychological factors involved that are not health related.
The health belief model is different from the theory of reasoned action in that there are no strict guidelines as to how the different variables predict behaviour. Instead the theory proposes independent variables are likely to contribute to the prediction of health behaviors. The theory of reasoned action, may be more useful in understanding such a complex behaviour as cigarette smoking as it relies not only on health beliefs but also takes into consideration personal factors which are seen as relevant by smokers such as social influence and the individuals positive or negative evaluation of giving up or continuing smoking and it is these factors according to the model, which underlie whether or not a person will intend to give up or continue to smoke. On the other hand however the flexibility of the health belief model may make it more adaptable to predicting a variety of behaviours.
Each model has unique aspects. For example, the HBM’s ‘perceived threat’ construct differs from all others contained in the TRA. Its specification also includes ‘objective’ demographic and other variables such as cues to action which not included in the TRA specifications (Rosenstock et al 1994). While the HBM is health behaviour focused, the TRA is framed at higher levels of generalisation (Ajzen 1998). Where it can be applied outside the health sphere. The TRA is arguably mathematically better specified than the HBM and more parsimonious in design. components. This may enhance the efficiency and consistency of their use. Yet there are also important structural commonalities.
Beattie’s typology has been employed to outline all the approaches being used by the government, the individual, health professionals and the group itself in order to address the situation. The interventions currently being implemented by government, including picture warnings on cigarette packs, mass media prevention programmes such as cigarette advertisements have disappeared from billboards and the pages of magazines and sporting events are no longer emblazoned with the colours and logos of tobacco brands (ASH, 2008).
Other government interventions include controlling the access of young people to tobacco products has been a long established strategy to restrict youth smoking. Access restrictions come in variety of forms including age restrictions, licensing provisions, enforcement provisions, and proof of age cards accompanied by bans on uncontrolled access. In the UK, the current age limit for purchasing cigarettes is now 18.
The most commonly used tactic in the UK to reduce the illegal sale of cigarettes to minors has been test purchasing whereby minors are intentionally sent into shops to try and buy cigarettes. If retailers are found to violate the law, they are usually cautioned and subsequently fined for repeated offences. Basic retailer education has shown to have little effect, and it has been these enforcement approaches that have been most effective on retailer behaviour. While these programmes do make it difficult for teens to purchase cigarettes, on the whole they do not affect teen smoking prevalence.
The government also place high rates of excise tax. Raising the price of tobacco products through increased taxation is a proven means of reducing consumption and helps smokers’ resolve in quitting smoking. Above all, no-one is forced to breathe tobacco smoke in the workplace or in enclosed public places since the smoking ban came into effect in July 2007 (ASH, 2008) There is also majority public support for removal of retail displays, prohibition of tobacco sales through vending machines, prohibition of smoking in cars carrying children, expansion of stop smoking services and increased access to nicotine replacement therapy (ASH, 2008)
Community based strategies for tackling tobacco use among young people aim to change the social environment in which young people take up smoking. They often involve organisations such as schools, youth centres, police as well as parents and others. These strategies are operated on many levels, tackling issues such as social attitudes to smoking, access to tobacco products, media campaigns and the role of parents. Often community programmes are seen to enhance school-based programmes as part of a wider tobacco prevention scheme. Community interventions are very diverse with the common element being to alter the social environment to make it supportive of non-smoking or cessation and the creation of NHS Stop Smoking Services. At the individual level, individuals must want to change behaviour and work with the health professionals in smoking cessation clinics and self help groups, and use aids in order to help them refrain from smoking. They must educate themselves of the health implications around the effect of smoking. At the group level they must encourage peers to help stop smoking and give support to one another.

Section 5 - A plan for intervention

In order to help the group refrain from smoking governments should work in partnership with individuals, communities, organisations and populations to plan interventions and programmes to change health-related behaviour (NICE, 2007).
The plan should be based on a needs assessment or knowledge of the target audience in question and take into account the circumstances in which people live, especially the socioeconomic and cultural context in order to aim to develop and build on people’s strengths. The government should then set out how the target population, community or group will be involved in the development, evaluation and implementation of the intervention, whilst specifying the theoretical link between the intervention and its outcome (NICE, 2007). The plan needs to prioritise the intervention that are based on the best available evidence of efficacy and cost effectiveness and work with what works best, The plan needs be tailored to tackle the individual beliefs, attitudes, intentions, skills and knowledge associated with the target behaviour and developed in collaboration with the target population and take account of lay wisdom about barriers and change. Interventions need to be consistent with other local or national interventions and use key life stages or times when people are more likely to be open to change such as pregnancy, starting or leaving school and entering or leaving the workforce.
Primary care trusts, local authorities and other members of local strategic partnerships should adopt smoking prevalence targets as core commitments within local area agreements. Local efforts to reduce smoking prevalence are currently hampered by a lack of local data (ASH, 2008). This forces primary care trusts and local authorities to work without a clear understanding of the scale of the problem they face, to forego meaningful targets and to proceed without the means to fully evaluate the effectiveness of their interventions. This problem should be addressed nationally, as part of a review of population research into smoking prevalence.
This will also require greater efforts by local health services to assess, target and monitor public health needs at a local level. Behaviour change interventions and strategies should be clear about the nature of the behaviour they are tackling, as well as whom they are targeting (The kings fund 2008). Geodemographics the science of profiling people based on where they live and social marketing alongside the use of commercial marketing techniques to promote socially desirable outcomes this can then give commissioners insights into the needs and behaviours of different kinds of people. Investment should be made in developing these skills among PCT staff and in improving both the quality and the quantity of data on local public health needs that they use in their work. Understanding how to use social marketing tools and having reliable data on local needs are vital first steps to finding solutions (The kings fund 2008).

6 - Conclusion

This report summarises what is known about smoking among teenagers, including patterns and trends in smoking prevalence, factors associated with smoking initiation and maintenance, the consequences of smoking for children’s health, and interventions for smoking cessation and prevention.
The report concludes that the underlying causes of smoking are complex and deeply rooted, and the necessary research on smoking continues to expand. Public health advocates recognise the need for comprehensive tobacco control strategies. Interventions to change behaviour have enormous potential to alter current patterns of disease. Social circumstances can also be difficult to change, at least in the short to medium term. By comparison, people’s behaviour as individuals may be easier to change. However, many attempts to do this have been unsuccessful, or only partially successful. Often, this has been because they fail to take account of the theories and principles of successful planning, delivery and evaluation (NICE. 2007).These social changes and changes in individual behaviour are required to achieve a significant reduction in tobacco use. At present, there is no strategic approach to behaviour change across government, the NHS or other sectors, and many different models, methods and theories are being used in an uncoordinated way (NICE. 2007).
The evidence from this report suggests awareness of smoking risks might not be a sufficient deterrent to starting to smoke. Therefore intervention and prevention programs should address motivation as a core factor. Moving forward, researchers and public health works should develop different messages targeting separate population segments based on their differing motivations and smoking behaviors. A long-term smoker with entrenched tobacco addiction should not be targeted in the same way as a new smoker who recently began to smoke and is not yet dependent. Public health workers must address the unique demographic attributes of population segments to effectively prevent or treat smoking and its associated motivations.

Word count 3098

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