In an ideal world each of us would consistently make informed decisions in the best long-term interests of ourselves and those we love. And in an ideal world, the wise choices would always be the easy ones.
Or, if we chose to put our long-term health, wealth and happiness at risk we would accept personal responsibility for the consequences. For example, if we insisted on chain smoking, binge-drinking, drug taking or over-indulging in junk food we would arrange private health insurance, so that any health problems arising would not end up being a burden on our families and the NHS.
In practice, we don’t live in an ideal world and sometimes a government has to step in to protect the most vulnerable, especially children. However, when government does take action it risks being accused of acting like a ‘Nanny State’ – in particular in certain sections of the press. There’s even now an annual Nanny State Index, which currently ranks the UK as the worst place in Europe for smokers. So whenever I see the term being used I ask myself these questions:
1. Will the action taken save lives? From the introduction of compulsory car seat belts to the ban on smoking in public places (each opposed at the time as Nanny State-ism) the answer has nearly always been yes. And the tragedy of Grenfell Tower illustrated clearly what can happen when Health and Safety isn’t taken seriously.
2. How much real choice do people have in practice? If you live in a deprived area, with betting shops and fast food outlets on every corner, do you really have the same choices as someone living in an area with a plentiful supply of gyms and farmers’ markets?
3. Who benefits financially from ‘choices’ like smoking, alcohol, junk food and gambling? If the beneficiaries are big businesses looking to boost executive pay and shareholder returns while government is prepared to accept a loss of tax revenue in the interests of public health, I think I know which I would trust to have the public’s true interests at heart.
4. How intellectually consistent are the opponents of public health initiatives? Usually the apparent proponents of individual freedom tend to employ arguments that favour commercial interests rather than personal freedom per se. For example, how many columnists who rail against government infringing personal liberty in the UK go on to argue for the legalisation of drugs, brothels or the right to bear arms? If defending personal freedoms was their real goal, surely their arguments wouldn’t be so selective.
This doesn’t mean we should accept government proposals unquestioningly and it doesn’t mean we should adopt a puritanical ‘killjoy’ mentality, becoming in effect health fundamentalists. That's why, here at Health Action Campaign, we've been researching what options are available to food companies who want to reduce levels of sugar and salt in their products, without using artifical alternatives and without compromising the taste for consumers. And Public Health England has published research indicating that e-cigarettes are 95% less harmful than smoking.
However, it is reasonable to expect government to level the playing field, particularly for the most vulnerable. We know for instance that childhood obesity levels are twice as high in deprived areas. And people in deprived areas typically die younger and after more years of poor health.
If the choice is between saving people’s lives and protecting their health on the one hand or being accused of being a supporter of the Nanny State on the other, I know which I’d choose.
A public health crisis
Childhood obesity has risen dramatically in recent decades. It is now a major public health problem – increasing the risk of type 2 diabetes, cardiovascular disease, some cancers and possibly even dementia.
In 2016, the UK government announced a new health plan to reduce childhood obesity within the next ten years. Measures include introducing a soft drinks levy, reducing sugar in children’s products, making school food healthier and increasing children’s physical activity. These are all welcome. However, the plan has been since criticized as weak and watered down due to intense lobbying by the food and drinks industry. For example, the plan relies mainly on voluntary action rather than regulation and no limit has been placed on the TV advertising of food high in sugar, salt and fat during peak time family viewing.
Time for a whole system approach
If the UK’s Childhood Obesity Plan doesn’t go far enough, how can we reduce childhood obesity and is there any hard evidence this will work? Fortunately there are two initiatives elsewhere in Europe which have successfully reduced childhood obesity – in one case in rural towns and in the other in a major city. What they have in common is that they don’t rely on individual, ad hoc initiatives, for instance in schools. Instead they take a holistic ‘whole system’ approach. Put simply they aim to identify and address all the causes of childhood obesity and to get everyone working together to tackle the causes - parents, schools, health professionals, communities, businesses, central and local government. A whole system approach has been already shown to reverse the trend of obesity in smaller rural communities in France, as well as reducing childhood obesity by as much as 12% in just a few years in a major city in Holland.
EPODE (Ensemble Prevenons l’Obesite Des Enfants - Together Let’s prevent Childhood Obesity)
First launched in 1992 in two French communities, EPODE has since expanded to more than 500 communities worldwide. EPODE relies on a clear methodology in order to bring about results and employs a multiple stakeholder approach: both at a central level (ministries, health groups, NGOs and private partners) and at a local level in the community (political leaders, health professionals, families, teachers, local NGOs and local business community). The main four pillars of the methodology are
1) Gain formal political commitment from leaders of the key organizations, which influence policies both on national and on local level.
2) Ensure sufficient resources are available to fund both central support services and local implementation.
3) Provide social marketing, communication and support services for community practitioners.
4) Evidence-based approach to implementing and evaluating the programme.
Since 2011, EPODE International Network is additionally providing support and resources to the growing number of communities that recognized that the multi-stakeholder approach is the way to successful change.
What does a whole system approach mean for EPODE? Activities in projects based on the EPODE methodology include:
- social marketing campaigns on different topics (the importance of hydration, a balanced diet, physical activity through play, and sleep)
- the development of tools for educators to help them carry out activities
- activities for the whole community (e.g. a Vitality day – an opportunity for parents to spend a fun day with their children while being physically active).
- introduction of a “Vitality pass” in order to encourage families to participate in events supporting healthy lifestyle
- Action on fruits, a kindergarten programme where children are introduced to different types of seasonal fruit
- The installation of sport and recreational facilities in the communities
In themselves these were not necessarily new public health interventions. The difference and the key to the success of the project is that these activities did not take place in insolation, but as a combined effort, within and supported by the community, with strong support from local authorities (both political and financial). Combining these approaches gave EPODE the power to combat the many powerful forces that might otherwise encourage unhealthy diets and lifestyles.
Jongeren op Gezond Gewicht- JOGG (Young people at a Healthy Weight)
This is a Dutch movement that encourages all people in the community (city, town or a neighborhood) to make healthy eating and exercising an easy and attractive lifestyle option for young people. The JOGG foundation has been established at a national level with the aim to provide advice and training on how to successfully implement the approach in the local community. Currently, 84 municipalities around Netherlands are using it.
The main pillars that have facilitated successful implementation are similar to the EPODE methodology:
- Political and governmental support. As well as commitment and established structures at a national level, healthy weight as part of healthy lifestyle has been included in relevant policy documents and main decision-makers at a local level are personally interested in and involved in the movement. For example, the Deputy Mayor led the initiative in Amsterdam, with all-party support.
- Cooperation between the private and public sectors. Both can be included in local projects and can contribute their resources (financial, communication etc.)
- Social marketing. There is a strong focus on taking into account the user’s perspective and identifying barriers and facilitators for healthy lifestyles, and adapting the intervention to fit local target population’s needs
- Scientific support and evaluation: process and outcome evaluation are taking place in order to monitor the success of implementation and effect – and adapting the intervention accordingly
- Linking prevention and health care: overweight children are identified early through prevention activities and then taken care of in a healthcare setting
One of the most successful municipalities using this approach is Amsterdam. With almost one in five children in the city being overweight, the municipality started the Amsterdam Healthy Weight Programme in 2013. The programme is focusing on the factors most closely related to healthy weight: healthy nutrition, enough exercise and adequate sleep.
Amsterdam understands that if a change is to be made, there needs to be more than just a focus on individual factors influencing behaviour, but also on the environment. In their view, the healthy life of children is a shared responsibility for everyone who has any kind of influence on children’s environment - from parents, to neighbours and teachers in the immediate environment, and to legislators and the food and drinks industry.
Some concrete actions and interventions the city has implemented or is working on implementing include:
- Healthy primary school policies: only tap water is allowed during breaks, no more sugary beverages; and children get extra PE lessons by a trained teacher
- Education on healthy choices for parents; with special programmes to address the first 1000 days of a child’s life – encouraging young mothers to live healthily in pregnancy and offer their child a healthy lifestyle from birth
- Medical professionals trained to talk to parents about healthy choices
- Community initiatives such as healthy cooking classes with kids
- Sports clubs offering cheaper memberships to children from lower socio-economic backgrounds
- Some food companies taking attractive elements off their packaging;
- Supervision over adherence to marketing rules transferred from the food industry to an independent body.
- City planners exploring the possibilities of designing a ‘healthy city’ that, by design, invites all its inhabitants to move more
The effects of the coordinated efforts are already visible. Between 2012 and 2015, the percentage of overweight children (aged 2-18) fell from 21% to 18,5%, including a decline among vulnerable groups with low socio-economic status. Amsterdam now has a long-term strategy with an allocated budget to achieve their mission of a healthy weight of all children in Amsterdam by 2033, when the first generation of healthy children will become 18.
Fortunately the importance of a whole system approach is beginning to be recognized now in the UK (including the recent Go Golborne project taking place in the Royal Borough of Kensington and Chelsea, which is also based on EPODE methodology). There is still a long way to go in comparison to some other countries but this is a positive first step forward.
- If we're serious about wanting to tackle childhood obesity we need to take a whole systems approach. This means putting children’s health at the forefront - as a shared responsibility for all stakeholders. Focusing on single interventions in single settings isn't enough. We need to focus on the different causes of childhood obesity, understand how they interconnect and then take action to tackle them.
- Policians and local authorities need to realise just how serious a problem there is and put tackling childhood obesity much higher up the agenda.
- A social marketing approach can be a very useful tool. To change behaviour, interventions need to take into account the perspective of each target group and adapt the interventions to make healthy behaviour easy and accessible for them.
- Public health authorities and practitioners need to get everyone on board – working with local authorities, schools, healthcare providers, communities and families, as well as with parts of the private sector in order to make a real difference.
After 13 years of heavy smoking and many attempts to quit I finally managed to smoke my last cigarette on 19 December 2015. I have since gone over 500 days without heeding the little evil voice in my head (“Just one more!”). I am incredibly proud as quitting smoking has possibly been the hardest thing I’ve ever done in my life. But it’s possible to do it and anyone else can do it too. So let’s see what helped me chuck all my lighters in the bin and bring about the biggest health behaviour change of my life. And how this fits with behaviour change theories.
People are inherently influenced by what others around them think. This probably played a role for me too. On moving to the UK it was a bit of shock that it was ‘abnormal’ to be a smoker in my age group rather than the other way around, as in Hungary. Also some of my closest friends were giving up smoking and I genuinely envied them for being smoke free and having a healthy radiance. The constant pleas from them to quit as well as from my boyfriend and mom also influenced me. These ‘Normative Appeals’ – facing up to the fact that the normal thing to do is not to smoke and that people around me expect me to quit – were a big push to make the change.
Health Belief Model
The Health Belief Model is pretty much weighing up the costs (in this case, the awful withdrawal symptoms), and benefits (in this case, too many to list) of making the change, how likely these were to happen and how serious the consequences would be, on quite a rational level.
As far as I am concerned, completely true. The information I came across on the benefits of stopping smoking used to be quite general (along the lines of “You will be less likely to get cancer”). They made me aware that it is unhealthy to smoke and that I should quit, but they were too intangible. I wasn't prompted to actually make the effort to kick the habit and keep it up when it is hard. The same way “Smoking can kill” on the cigarette box with the horrible pictures felt too distant to apply to myself there and then, so I looked for a trendy cigarette box on e-Bay rather than quitting.
Then one day I came across a chart on what happens to your body after you smoke your last cigarette - in 20 minutes, 8 hours, 48 hours and so on. That really struck a chord. The chart stayed with me through the darkest moments of my journey. Fighting to reach the 8-hour mark to enjoy normal oxygen levels, and the 48-hour mark for the satisfaction of knowing there is no more hated nicotine in my body and to see if my taste and smell will really improve, was easier than just generally fighting for better health later on. It made my progress specific and achievable and it felt like all that suffering was worth it because it had a tangible result.
Similarly, in the first few weeks of quitting I had the opportunity to measure my carbon monoxide level by a simple breath test. It was incredibly satisfying to see the numbers on the screen showing how it was decreasing week on week and to understand how oxygen can now take over carbon monoxide’s place in my red blood cells, making it easier for my heart to work and less likely for me to give out ridiculous noises when walking up the escalator at Oxford Circus (which is really not cool for a twenty-something year old). Specific, tangible, and even (in)audible.
Another tangible benefit was not handing over an eye-watering amount of money to tobacco companies. I made the promise to myself that if I make it to the 3-week mark I will buy a gift to my mom and dad, something they would really like but they would not buy for themselves. My mom got a nice summer dress and my dad a couple of nice handkerchiefs and a note that they are the tangible evidence for me having quit smoking for good. They were over the moon, which made me feel extremely good too.
Seeing my progress through the time milestones and decreasing carbon monoxide levels was also very important, especially when I needed convincing stuff to tell myself during strong urges. The belief that you can do it, which is called self-efficacy, is a powerful motivator to make a start on quitting and to keep it up when it hurts the most. Why bother if you are unlikely to reap the benefits?
As time progressed this belief just got stronger and stronger as I saw my carbon monoxide levels decreasing and I was clocking in time milestones with the same joy as collecting coins when travelling through Mushroom Kingdom with Super Mario in the 1990s. It is also one of the main principles of Cognitive Behavioural Therapy (CBT) that you need positive thoughts and interpretations to replace the negatives that are holding you back.
After each ‘first’ risk situation I survived without lighting a cigarette – the first morning, the first time someone offered me a cigarette, the first argument, the first time I was exhausted, the first time meeting up with smoking friends (I did skip many social events just to avoid this!), the first article written (I had the habit of smoking after each section), the first time drinking alcohol, the first conversation with someone smoking a cigarette right in front of me - it helped me feel even more convinced that this time I will make it.
Also, I had lots of positive case studies around me to encourage me including my closest friends, who had successfully quit before I did. This, combined with thinking that lighting a cigarette would flush all the efforts and suffering I went through down the toilet, being unable to reap the benefits of my arduous effort, kept me going.
‘Cues to action’ theory
Research from Health Action Campaign shows that people with less motivation to change their behaviour sometimes experience trigger points in their lives when they are more likely to make changes. These can include getting married, having children, or a loved one developing serious health problems. These events can serve as a cue to action. In my case I had just finished university, had started my career and was in a serious relationship with a view to potentially have children in a few years’ time. So I felt settled and I was planning to quit at some point. My cue to action was a leaflet advising that my workplace was launching a free stop smoking clinic through the NHS. This was my time.
The weekly sessions gave structure to my attempt to quit, and suddenly it mattered because having signed up I was accountable to my counsellor, and I was expected to quit there and then by her, the people around me and indeed myself (hello Normative Belief!). My awesome counsellor also kept telling me I would make it because I was approaching it in such a determined way and I believed her (hello Self-efficacy!). She provided the carbon monoxide device and took my levels every week to show my progress, so I had something positive to focus on (hello Cognitive Behavioural Therapy!) and I was seeing very tangibly how I was already reaping the benefits (hello Health Belief Model!).
People tend to favour immediately enjoying something as opposed to long term benefits. This isn’t a friend to people trying to stop smoking. When you are having a strong urge to smoke, and the little evil voice in your head is throwing a tantrum shouting “Just one more!”, it is extremely difficult for your brain to come to terms with the thought that “I know I could ease this horrible feeling very simply but I won’t do it because I am working towards long-term benefits.” However, if you know this, it is easier to counteract it. I measured how long the urge pikes lasted, so I knew that most of the time I just needed to survive a couple of minutes and I would be fine. Yes, it did happen a few times that I was literally staring at a clock for 2 minutes, and it worked.
And there is a trick too. Luckily, we are also more motivated by the prospect of losing something we already value than by possible future gain. In my case, by smoking a cigarette I would have been risking losing my 24/48/72/96/1000 hours clocked which I was very proud of. I was risking losing my finally healthy carbon monoxide levels. I was risking losing my sense of achievement and people’s recognition of my efforts. I was risking the right to loudly declare that I don’t smoke anymore when offered a cigarette. I was risking losing all ‘my firsts’ I survived without a cigarette. Most of all, I was risking losing the belief that I am ever able to quit smoking, after all those attempts when I didn’t manage. So start counting now!
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