The world Health Organization (WHO 2014) recognises that engaging in risk behaviours, puts you at greater exposure of mortality and morbidity. A risk behaviour has been defined as something that intentionally or unintentionally puts that person at greater risk to themselves, of injury or disease. This essay will look at the risk of smoking in young people, including the health implications, epidemiology and prevalence. An age range of 12-21 year olds will be used when identifying literature. There will be a primary focus on policies and guidance for health improvement in Scotland. In addition legislation and reports from the whole of the UK will support the discussion of health improvement in young people. It will aim to analyse literature to try to determine the reasons why young people smoke, and also consider the rise in social media and electronic cigarettes. Furthermore, it will explore the context of care within schools and the community, and discuss health inequalities. Additionally, this essay will Identify and critique a recent Health improvement Campaign video, aimed at young people. The content and design of the video will be discussed in detail, to analyse the appropriateness for the target age group. Throughout the critique, it will make reference to underpinning models of behaviour change, and health improvement within Scotland and the UK.
Health improvement is at the forefront of Scotland’s current policies and aims. The mission is to build a healthier Scotland, focus on inequalities and develop actions that will improve the overall population health (NHS Scotland 2014a). Policies aim to support everyone in Scotland to live healthier and longer lives, delivered by quality healthcare. The government has set aside national approaches to target underlying causes of poor health, such as smoking (The Scottish Government 2010). The Scottish government recognises that smoking is still one of the leading causes of preventable deaths. It aims to make Scotland a smoke free generation, by targeting health promotion towards young people, in an effort to reduce poor health in later life (The Scottish Government 2008).
In Scotland, a quarter of all deaths are smoking related, with 56,000 people being admitted to hospital each year from smoking related illnesses (ASH 2014). This figure continues to put substantial strain on our national health service (ScotPHO 2012). Smoking increases the risk of Cancers, heart attacks, and stokes. It also worsens and prolongs conditions such as asthma and respiratory diseases (NHS 2013). Early exposure to harmful toxins in tobacco puts you at a greater risk of related cancers. Young smokers are also prone to short and long term respiratory conditions such as wheezing, coughing and phlegm. Girls, in particular, who start smoking at a younger age are 79% more likely to develop bronchitis or emphysema in later life, compared to those who began smoking in adult life (Home Office 2002). The total annual cost of treating smoking related illnesses in Scotland is estimated at around ??409 million. Consequently, one of the NHS Scotland’s heat targets for 2013/2014 was to deliver at least 80,000 successful quits before march 2014 (Gov 2014 Scotland Heat Targets).
A young person is classified by the World health organisation (WHO 2015) and the NHS as those ranging from ages 10 and 24 years old (NHS Health Scotland 2014c). Around 15,000 young people in Scotland start smoking each year (NHS health Scotland 2014b). Although this figure is high, the proportion of young people who have ever smoked, has dropped dramatically by half in the last decade. There has been an improved reduction from 42% of young people in 2003 smoking, to 22% in 2013 (ASH 2014). Evidence has shown that the younger a person begins to smoke, the more likely they are to continue during adulthood. This puts them at increased risk or morbidity and mortality in later life (RCP 2010). It has been discussed that risk behaviours can set life patterns, and similarly have long lasting negative future effects on the persons health and wellbeing (WHO 2015). Most smokers begin smoking before the age of 18, which is why health improvement in young people, is of high importance in the UK (The Information Centre 2006). The UK laws have changed considerably within the last decade in an effort to reduce smoking. In 2007, the legal age a person could purchase tobacco products was increased from the age of 16 to 18 years old (The Secretary of State for Health 2007). One year prior the UK parliament introduced the smoking ban, which prohibited smoking in any public premise (The Secretary of State for Health 2006). The main focus of this legislation, was the protection and health of young people. Early intervention is said to be one of the key areas in reducing mortality and morbidity for young people (Department of health 2013).
More recently, the government have highlighted new concerns about the rise in popularity of electronic cigarettes. There are fears that electronic cigarettes could normalise smoking, thus backtracking on the efforts of the past decade to de-normalise it (Britton and Bogdanovica 2014). There is a real debate on whether electronic cigarettes appeal to young people. Electronic cigarettes come in a variety of exciting flavours such as bubblegum and banana and are marketed in colourful and fun packages, that may be appealing to young people (Public health England 2015). Statistically, however, it has been shown that young people’s use of electronic cigarettes is primarily confined to those who are already experimenting with regular cigarettes (Office For National Statistics 2012). Electronic cigarette use is found to be rare amongst young people who have never smoked before (Ash 2014).
Although statistically the UK and Scotland have shown that smoking in young people seems to be on the decline, it is still clear that a sizable minority of young people still continue to start smoking (Ash 2014). In order to try to campaign for a smoke free nation, it is important to understand the reasons behind why young people smoke. It has been noted that young people are susceptible to what is attractive and risky. Like following fashion, media and the internet, young people want to be in with the crowd. Where you live plays a big role, alongside if your parents or friends smoke. To add to this, positive tobacco advertisement pave the wave for young people to see smoking at exciting and relatively normal (BMA Board of Science 2008). A recent report (Amos et al 2009) summarized their findings on the key reasons young people smoke. These included individual beliefs and self image, social factors such as parents or friends smoking, community factors and ease of access to tobacco. Gough et al (2009) conducted a focus group study. The study invited 87 males and females, aged between 16 and 24 years to talk about reasons for smoking. Although a relatively small study, the focus group found that young people understood smoking to be a rational decision. Although the young people had a very clear awareness of health issues, the majority did not link smoking in young age and health as something to be worried, about until they are ‘older’ (Gough Et al 2009). A larger study in Romania found strong peer influence, alongside lower self-efficiency to be the primary reason for smoking in 13 to 14 year olds (Lotrean 2012). The age range of 13 to 14 year old was not sufficient enough to make a valid argument for the term young people. The latter two of these studies also did not delve much into the connections of youth smoking, being associated with social deprivation. There still continues to still be a strong association of smoking alongside health inequalities. In Scotland it was found that smoking in the most deprived areas equated to 36% of the figures, with only 10% in the least deprived areas (ASH Scotland 2014). Health inequalities is at the heart of public health improvement. The overall health of the public seems to be improving, yet the inequalities of health have worsened and the gap has increased (Health development agency 2005). Other levels of influences noted were price, marketing and promotion, self esteem and values and beliefs (Edwards 2010). A person’s values and beliefs can also play a role in health behaviours.
When looking at health improvement in young people, it is important that everyone working in national and local government, healthcare, social care, and the school and education system all contribute (Department of Health 2012). It has been recognised that school plays a vital role in the education and promotion of young people’s health, to build knowledge of personal wellbeing . School nurses play an important role in health promotion and health education, and can be incredibly valuable members of staff for early intervention. It has been suggested that school nurses, may have a lifelong impact on a young person’s health in adulthood, through early intervention (RCN 2012).Current guidelines dictate that every school must have a no smoking policy. These policies should be widely available, and be visible all over the school so that young people are aware. Schools and school nurses should also support smoking cessation information in partnership with NHS services, and offer help, information and health education to young people on smoking (NICE 2010). However A systematic review of school interventions to stop young people smoking, found no significant effect of interventions in schools to discourage smoking. There was however positive data for interventions which taught young people how to be socially competent, and resist social influences. The strength of this study is the size of the systematic review, which included 134 studies and 428,293 participants. Two authors independently reviewed the data in order to compare and contrast the evidence. On the contrary bias may have been introduced at low level due to the high variability of outcome measures that were used. The trial looked at the age range of five to 18, which only addressed some of the focused age range of youths aged 12-20 (Thomas et al 2013).
Another systematic review and meta-analysis found strong associations between parental and sibling smoking, as a factor for Young people’s uptake of smoking themselves. The analyses confirmed that when young people are exposed to smoke in the household, the chances of them starting smoking themselves are significantly increased (Leonardi-Bee et al 2011). It can be debated therefore that education on health promotion should also start at home, and in communities. The earlier the interventions the more effective it is in preventing health damaging behaviours. Actions need to be taken into a social, environmental and economic level, as well as legislative factors (NICE 2007).
Current UK guidelines advise using a range of strategies to change young people’s perceptions of smoking, and promote health improvement. Resources include posters, leaflets, campaigns and creating new opportunities from arising social media. All of which in an effort to alert young people of the dangers of smoking (NICE 2010). In November 2014 Cancer Research UK launched a UK-wide campaign via YouTube. The video urges young people to use social media, to protest against the tobacco industry (Cancer research 2014). The YouTube video features UK recognised Olympic gold medallist Nicola Adams, and music star wretch 32. The video tells the tobacco industry that young people are no longer puppets on a string and will not be contributing to their industry profits, which make more than coca cola, McDonalds and Microsoft combined. It invites young people to take a ‘selfie’ giving two fingers up to the tobacco industry and post it via twitter and Facebook. The campaign is also supported by UK tobacco control agency ASH. As of March 2015 the YouTube video has received almost a quarter of a million views in just 4 months.
We are currently in a new digital age where social media, and technology are part of daily life for young people. If the government are serious about reaching out to young people they need to step into the new social media and technology world of young people, and fully embrace it (nicholson 2014). The YouTube video by Cancer research aims to get to the very heart of young people, by doing just that. This resource is accessible and approachable for young people, as users can view in privacy, watch on their mobile phones or with friends. The language in the video is very focused on connecting with young people. The video uses words such as “selfie”, “coca cola”, “McDonalds” and “Hashtag”. These are modern words and brands that most young people will recognise. The video is also empowering and revolutionary with inspiring words such as “connected”, “informed” and “talk back”, thus creating a positive message that our generation is smarter, and makes better choices. “Be a part of it” is a phrase near the end, which creates a feeling of wanting to be part of something, and in a group. Recent social media statistics for the UK (Social Media Today 2014) show Facebook now has 31.5 million users, and Twitter has 15 million users. Social media can provide health promotion opportunities for patients, and be used as a communication tool for nurses. Social media can be incredibly powerful), however as professional nurses we must also adhere to professional boundaries (Farrelly 2014) such as NMC guidance for misuse of the internet (NMC 2009).
In order to change risk behaviours, it has been noted that Key elements for success include using resources that are targeted and tailored to the specific age and gender. Similarly alternative choices to risk behaviours should be given, rather than just simply telling an individual to do something (Health Development Agency 2004). The video is encouraging to young people, as the content has connotations of choice.
The YouTube video is unlike current leaflets and posters promoting anti-smoking messages to young people. Instead of listing shock tactics and diseases associated with smoking, it is instead focusing on trying to make smoking sound ridiculous from a financial point of view. It does this by expressing how much money the tobacco industry makes. The characters in the video are relatable, with varying genders and accents. This broadens the appeal of the campaign, instead of focusing on just one target group. The video also asks viewers to upload a picture of themselves to social media, giving the fingers up to the tobacco industry and using the hashtag #smokethis. This appeals to young people, who use social media nowadays as a way of spreading messages and connecting to others. A leaflet or poster may not have the same effect, as there is no social interaction. A twitter or Facebook post, however, can be shared and viewed worldwide. This enables young people to feel like they have a voice and a sense of empowerment. Social media is powerful. Although the video is about promoting anti-smoking, it may also be accessible for young people to share worldwide in negative forms. The hashtag #smokethis has recently been used showing young people uploading photos of themselves smoking both cigarettes and cannabis, in rebellion.
The world health organisation identified key underlying principles of health promotion in their Health for All and Health 21 movements (WHO 1999). These included equity, empowerment, participation, co-operation and primary care. The #Smokethis campaign encompassed both empowerment and participation. The video encourages participation by social media, and empowerment by standing up for something. A new revised health improvement model by Tannahil (2005) suggests that one of the biggest factors in health promotion is social and economic factors. The video encompasses both by showing how much money is wasted on the tobacco industry. It is also relevant to his earlier model of health improvement where he mentions the importance of health education and prevention. This video is very much preventative, in that it is trying to prevent the uptake of young smokers.
Cancer research have been clever in taking a new social media approach. In 2010, (Jepson et al 2010) did a study. They found that although some evidence suggests that media interventions may be effective in reducing the uptake of smoking in young people, the overall evidence was not strong. It would be interesting to see the findings of a more recent study, given the rise of social media in the last 5 years.
The main theme of the video is to try to recruit 100,000 young people to not start smoking this year. It is estimated that in the whole of the UK, 207,000 young people start smoking each year (Hopkinson 2013). Given this figure, if it were possible to half the amount of young people who start smoking each year, it would have a dramatic impact on the relevance for clinical practice. Not only would it decrease the amount of admissions in GP practices for symptoms such as coughing and wheezing, it would also have an incredible effect on later life hospital admissions such as heart disease, stokes and cancers.
The only negative about this video is that there is also the possibility for young people to share pictures of themselves smoking online, as a rebellious stance. This may influence the views of other young people. Is it still does not address the issue of health inequalities and community factors either, which remains an issue in the background as a reason for smoking. It has been well documented by the 1980 The Black Report to show that those in a lower social class have a higher risk of illness and premature death than those in a higher class. Rates of substance abuse are also higher (Department of Health 1980). As well as health promotion online and UK campaigns, there still needs to be community, social, school and family interventions to tackle those who are less deprived. An example is a study by Bond et all (2011), in which they found residents in disadvantaged areas of Glasgow had higher rates of smoking, and less likelihood of quitting smoking. The study found that area with better housing had better rates of quitting suggesting that your environment plays a key part in your health.
As a whole, the Cancer Research video is inventive, modern and appropriate for the target age range. It is easily accessible and creates discussion and the opportunity to be involved in something. Mass media campaigns can promote health improvement. However, there still needs to be approaches such as family, community and school interventions to address health inequalities and social circumstances affecting behaviour. The statistics have shown a steady decline in young people smoking, which is encouraging. The UK is currently in the process of introducing plain packaging on all tobacco products, in a further effort to discourage people from smoking (Barber and Conway 2015).
Statistically the UK and Scotland show that each year, fewer young people begin smoking. Despite the efforts of the government, legislation and regulations may not always discourage young people from smoking. As the UK prepares for further legislation to introduce plain tobacco packaging, it is evident that it is becoming increasing more difficult for young people to access tobacco. It is indisputable however that social factors, peer pressure and health inequalities continue to be an underlying cause of risk behaviours. There is also some contrasting literature on whether health promotion in schools can discourage young people smoking. Despite this, best practice would suggest early intervention is better than no intervention. Social media is on the rise and is quickly becoming a daily habit for young people. They use is to connect, talk, share and interact. It is constantly changing and requires healthcare professionals to be up to date on it. More recent studies would be beneficial to determine the effect of health improvement interventions via YouTube and Facebook. It could potentially become one of the biggest communication tools, for nurses in future practice when looking to get the heart of young people.
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