Title: Title: Smoking cessation support activities using health promotion -from the viewpoint of health promotion.
Health promotion is a 21st century health strategy, which is based on the health perspective proposed by the World Health Organization (WHO) in the 1986 Ottawa Charter and re-proposed in the 2005 Bangkok Charter. It is defined as ‘the process of enabling people to increase control over, and to improve, their health’. This paper will examine health promotion by looking at how certain Internet-based methods have been used to address cigarette smoking.
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In the United Kingdom (UK), smoking continues to be an essential wellbeing issue. According to Public Health England (PHE 2015), in 2014, 19% of the population were smokers. In contrast, in 1980, 39% of the population were smokers (General Lifestyle Survey 2008). Despite this trend, smoking still causes significant medical issues, including several types of infections, such as malignant growths, respiratory ailments and cardiovascular ailments. Moreover, it has been shown than one in three smokers die as a result of smoking (Jha et al. 2006; Frieden and Bloomberg 2007), and it is expected that chronic obstructive pulmonary disease (COPD) will lead to a rise in this death rate (WHO 2012).
To address these wellbeing issues, smoking prevention efforts are prevalent. Before those are reviewed, some of the challenges to quitting smoking must be examined. Nicotine, which is found in tobacco, contains subordinate substances that make it difficult to quit smoking (Healthline 2018). Indeed, this can be the greatest challenge to those endeavouring to stop smoking. There are other challenges as well. For instance, it is the earth encompassing them. This is basic in poor territories. Yet on the off chance that the encompassing smoking rate is high, it will be hard to turn awareness toward the smoking suspension.
Moreover, the home situations of young people can affect their ability to quit smoking. If their parents or guardians are smokers, they might not go to class, and they might miss relevant instruction on wellbeing. It is recommended that the effect on kids (Bell et al. 2010). This is called the wellbeing imbalance (Bartley 2017); however, a significant number of them incorporate social factors, such as poor families, poor regions and low instructive foundations (Bell et al. 2010).
Furthermore, one of the principal reasons that it is difficult to quit smoking is focus. Numerous other causes, such as working environments, work, human connections and tensions about the future can also be considered. Some smokers also use tobacco as a way to adapt to stress (Hajek et al. 2010); quitting smoking might be troublesome for individuals who use smoking in this way. Moreover, scientific evidence about the health effects of smoking might create a social weight, causing smokers to feel disgrace (Bell et al. 2010) and become pessimistic about smoking cessation.
In any case, smoking causes many issues, and smoking prevention ought to a high-priority for individual wellbeing and health promotion. In particular, social movements can help bring attention to smoking prevention, and these endeavours have become more prominent with the widespread use of the internet. In recent years, the internet has contributed to easy access to information; currently, 90% of people in the UK are internet users (Office for National Statistics [ONS] 2018), and the internet has helped people learn more about the harmful health effects of smoking.
One such movement, Stoptober, was established by Public Health England (PHE) in 2012 (2018). It is a 28-day stop smoking challenge, which begins on October 1st each year. Over 1.5 million people have attempted to quit, and it has been shown that leads to 5 times the usual success rate (Brown and West 2017). As an online health promotion initiative, Stoptober is a relatively new approach; therefore, it is useful to examine its adoption and consider its future prospects for widespread use.
Participants use the Stoptober app, Facebook and Twitter daily for reminders and motivation; they can also receive face-to-face advice from experts. PHE also recommends electronic cigarettes and nicotine gum as complementary products to help the quitting process. Brown and West (2017) reported quitting success rates over 19.8% for the first six months of 2017, which were significantly higher than the standard rate (15.7%) for the previous ten years.
In 2016, PHE had a £390.000 media budget for Stoptober, so it used only digital media to reduce expenses; however, the campaign occurred population biased. As a result, in 2017, the budget was raised to £2.1 million, allowing PHE to place advertisements in other media, such as television and radio.
Stoptober also focuses on the psychological aspects of smokers. In particular, it is possible to evaluate the psychological change of participants using the Stages of Change model (Prochaska and DiClemente 1983). The campaign primarily focuses on stage two, contemplation, stimulating smokers’ awareness by calling for a cessation of smoking through the media. The 28-day limit and the nationwide focus of Stoptober help encourage a sense of unity among smokers. The knowledge that others are also participating in the campaign can empower them, leading to more successful behaviour change (Lacina and Griffith 2017) and a sense of security, since they are not alone in trying to quit.
Pursuing smoking cessation using the internet can be a convenient method for smokers. During contemplation, they recognize the importance of caring about their health; they search the internet for information about smoking cessation and can learn of the existence of Stoptober through its online postings. The Stoptober website explains the disadvantages of smoking and the merits of smoking cessation, so it is possible that smokers might be working on the health-conscious dominance. Smokers might familiar with the information about the health damages caused by smoking, which can be found on television, online or at school; however, by taking the time to review the campaign website, they may be able to face their own health consequences.
The convenience of using social media tools, such as Facebook and the Stoptober app, may also help participants quit smoking. As noted earlier, the prevalence of the internet makes it easy to find information on smoking cessation, but using these convenient tools can help integrate smoking cessation into everyday life. With conventional smoking programs, smokers have to go to regional health centres or their general practitioners; it can be hard for smokers to fit these visits into their schedules, considering their work, parenting or school responsibilities. However, as long as smokers have internet access, they can participate from anywhere; this can help smokers overcome any hesitation to try to address their smoking habits.
In addition, telephone consultations by experts contribute to the maintenance and improvement of anxiety disorders and self-efficacy (Bandura 1978). Some smokers may have failed when trying to quit smoking in the past. We cannot ignore the problem of self-stigma (Link 1987), by which a smoker can recognize himself or herself as a person with low social value, which leads to the deterioration of self-esteem, withdrawal from the community and decreased treatment behaviours (Corrigan et al. 2006) That is, stigma is required to deal with both public stigma and self-stigma. For such people, advice from experts will be the dominant advantage of a program like Stoptober.
There is also the possibility that some smokers will decide to quit, not only based on to their own health hazards, but also the harm caused by passive smoking (WHO 2018) and the recommendations of their family and friends. In this type of case, it is important to consider the next stage in the Stages of Change model, determination.
To realize behaviour change, it is important to focus on the improvement of self-efficacy during the determination stage. However, Stoptober’s campaign has a nationwide focus, so it is difficult to adapt it to individuals. This can be considered one of the problems of internet-based smoking cessation programs. Instead, Stoptober’s website covers the benefits of smoking cessation and the health damage caused by smoking, then tries to shift participants from determination to the next stage, action.
And the most important support is Active’s time which is challenging to quit smoking. The addictive nature of nicotine (Li 2018) leads to withdrawal symptoms, which occur several days after smoking cessation begins (Johnson et al. 2012), creating a major barrier to continuing the quitting process. According to Johnson et al (2012), psychological symptoms, such as anxiety and irritation, also appear as withdrawal symptoms. To alleviate these symptoms, Stoptober sends daily motivational messages as encouragement, reminding participants to continue following the campaign.
Encouragement and support have been shown to lead to behavioural preservation (Lacina and Griffith 2017), and Stopover’s reminders are expected to lead to this effect as well. However, only Munoz et al. (2006) showed clear evidence that the use of encouraging e-mails contributed to the success of smoking cessation or smoking reduction efforts in other internet-based smoking cessation programs.
Since Stoptober transmits its messages to all users simultaneously, it is difficult to create individual messages; however, artificial intelligence can be used to tailor messages to individual users. This can help improve self-efficacy, thereby, increasing participant motivation.
It should be noted that some users dislike receiving daily messages. If they feel that such frequent communication is troublesome, then internet-based intervention could be considered ineffective in these cases. However, there is insufficient clear qualitative data available on this point, so further analysis cannot be conducted at this time.
Nicotine replacement therapy is also recommended as a countermeasure to nicotine withdrawal symptoms. Electronic cigarettes are useful, safe alternatives for smokers, since they contain approximately one-tenth of the harmful substances found in cigarettes (Laugesen 2010; Brown-Johnson et al. 2016). In addition, electronic cigarettes containing nicotine are useful substitutes for cigarettes because the nicotine concentration in the body is maintained (Yan and D’Ruiz 2015). However, it has been shown that electronic cigarette smoke contains harmful substances, and smokers might use electronic cigarettes more frequently than cigarettes to combat withdrawal symptoms (Kawamura et al. 2018).
Although PHE recommends electronic cigarettes as substitute for cigarettes, few studies exist about the long-term harm caused by electronic cigarettes. Their usefulness is also questioned; there is a possibility that the effectiveness of electronic cigarettes as a substitution therapy may be dependent on nicotine. Therefore, it is necessary to educate people on electronic cigarette use, especially usage duration.
Despite the benefits of the Stoptober campaign, there are several limitations to this web-based smoking cessation method. One is the low effect on pre-contemplation, the first stage in the Stages of Change model. People who are not interested in smoking cessation are unlikely to search for terms, such as ‘smoke-free’, on the internet, and the effect of Stoptober television and radio advertisements on this group is unclear. However, as mentioned earlier, the reduced advertising expenditures for Stoptober in 2016, led to a decline in participation among relatively poor people. It is unknown whether the smokers in this participant category are at the pre-contemplation stage, but the publicity of television and radio will be noticed by some people.
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Health damage and health disparity can make smoking cessation difficult (Bartley 2017); however, they can also be considered social problems. When social status is low (Q1), 33% of males and 25% of females have high quitting rates (ONS 2012). It is thought that wanting to receive adequate health education is a cause of this phenomenon, and it can also be influenced by the surrounding smoking environment and a low interest in smoking cessation. The background of such health inequalities is that social determinants of health are involved (PHE 2017) but smokers ignore them since they are in the pre-contemplation stage, further expanding the health disparity. A relationship between smoking and income has also been suggested (Press et al. 2018), and smoking issues need to be reviewed throughout society from the perspective of widening economic disparity.
Stoptober is regarded as important in terms of individuality because the smoker pushes the participation button; in that respect, participation can be regarded as an individual health behaviour, which is in line with the philosophy of health promotion. In contrast, smokers who are not interested in quitting at all need to be nudged.
It is clear that, for Stoptober to be effective, smokers need to be interested in smoking cessation, since, as described above, self-stigma can have a negative impact on disease treatment, recovery and interpersonal relationships (Corrigan et al. 2006) As an alternative method, it may be necessary to intervene with the health belief model (Becker 1974) to effectively make smokers conscious of their own health. Moreover, some participants may fail in their attempt at smoking cessation during the campaign period. These smokers may feel self-stigma, and the effects of this relapse on their self-efficacy are unclear.
However, for those in the pre-contemplation stage, the act of ‘encouraging smoking cessation’ itself may have a public stigma (Bell et al. 2010) instead of a self-stigma. Even if smokers understand social health activities, deviation from pre-contemplation may be hard if they feel that they are aversions to themselves. However, it is possible that participants will be biased, as occurred in Stoptober 2016, considering that they stop smoking campaigns, so the health belief model will also be needed to scrutinize the intervention methods.
Another limitation is that people who do not frequently use the internet cannot take advantage of this smoking cessation method. Although the penetration rate of the internet is increasing annually, the internet usage rate in England for those over 75 years old is 44%, which is less than half the rate of young people (90%) (ONS 2018). People who cannot use smart phones well, those with learning disabilities and those with mental illnesses may also be unable to easily participate in this type of smoking cessation program.
Overall, Stoptober may be very effective for the contemplation stage. It is easy to participate using apps and text messages. Since the campaign is nationwide, participants can feel a sense of unity with one another and may avoid feelings of loneliness during the quitting process. It is possible to create a poster to raise health consciousness by raising individual health awareness through health promotion.
Other limitations include concerns about advertising expenses and questions about the usefulness of the reminder effect during the smoking cessation challenge, as well as the health damages resulting from the use of alternatives, such as electronic cigarettes.
To further develop health promotion regarding smoking cessation, offline reminders should also be considered. However, financial and staffing obstacles for this measure will need to be addressed. From the viewpoint of public health, it is indispensable to raise awareness about individual health, but it is also necessary to simultaneously reconsider existing health improvement and environmental service creation laws. Health benefits, social benefits and economic benefits obtained by smoking can be planned in the future, so it is possible to reduce smoking rates by considering how to quit the web based on the future.
In conclusion, Stoptober is suitable for the modern internet society; it follows the ideas of health promotion, such as active participation, and also the reputation is seen about the effect of the success rate of smoking cessation. However, some aspects of this online initiative are not suitable for elderly people or those with low social status. In order to realize future health promotion efforts, it is necessary to construct an environment where many people can participate.
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