The use of public health interventions in reducing addictive behaviour

Considering merging clinical and public health interventions into a single post once I've covered all the clinical interventions content, I'll see how much there is and if it's not too much then I'll redo this post to include them both. Another likely candidate for application questions, so make sure you know how to apply these in order to access top AO2 marks!

Black: AO1 - Description
Blue: AO2 - Evaluation - studies
Red: AO2 - Evaluation - evaluative points/IDAs
Purple: My notes/hints/tips

The Toxic Cycle Campaign

In 2013, Public Health England launched this campaign to remind smokers of the physical damage caused by tobacco smoking. Through television, radio and online advertising, the campaign dramatised the harms of smoking by showing how it affects the whole of the body, from the heart to the lungs, blood and brain. It aimed to increase awareness by highlighting the immediate damage done by every cigarette, focusing on the toxins in cigarette smoke polluting the blood and increasing the chance of heart attacks and strokes.

The campaign used both ‘harm’ and ‘hope’ messaging, by showing the harm caused by smoking to encourage smokers to quit, and, at the same time, providing a way for them to do so in the form of support from Smokefree. The advertising encouraged smokers to go online to find their way out of smoking, and order free support in the form of the Quit Kit, Smokefree app, text and emails. Partnership with pharmacies was a key part of the campaign strategy, and over 75% of pharmacies across England were provided with a new product – ‘Quit Cards’,  to act as a conversation starter to help  them engage with  smokers and promote the full range of Smokefree products to help them quit.

The campaign achieved a national awareness of 87%, with 84% of smokers who saw the campaign reporting that it was aimed at people like them. The messages cut through similarly well, with 68% of people agreeing that "these adverts made me think that every cigarette is harmful", 87% agreeing that "cigarettes cause heart attacks and strokes", and 30% taking action to quit smoking, by either ordering a Quit Kit, stopping smoking, or talking about it with family or friends.

During the campaign, approximately 172'000 Smokefree products were ordered, including 84'000 Quit Kits and 50'000 downloads of the Smokefree mobile app. 420'000 Quit Cards were distributed by pharmacies across England.

These figures suggest that the public health campaign was a success, and that it motivated a significant number of people to try and quit smoking, as well as raise awareness of the harmful effects of tobacco smoke on the body.

The Gamble Aware Campaign

Also known as "Bad Betty", this campaign by the Senet Group used television, radio, digital press and gambling shop window posters to highlight the warning signs of problem gambling and the benefits of staying in control, using the slogan: "When the fun stops, stop!" Aiming to prevent problem gambling, the campaign advised gamblers to only bet what they can afford, not gamble when they're angry, never chase losses, and not put gambling before their friends.

The campaign resulted in high levels of awareness, with over 1/3 of gamblers who recall the campaign saying it made them approach their gambling more responsibly, and 1/6th of people who recall the campaign being prompted to "warn other people about their gambling habits.", suggesting that it also influenced public perceptions of gambling and made people more aware of the risks. The campaign achieved an awareness of 34% in the general population, a significant percentage usually only achieved with double the levels of funding that Gamble Aware was granted.

The phrases "when the fun stops, stop" and "Bad Betty" were recited by millions following the campaign, and occupied a significant place in the consciousness of gamblers that prompted them to approach their habit with more caution.

Changes to the UK smoking laws

The 2007 public smoking ban prohibited smoking cigarettes in indoor workplaces, indoor public places, and on public transport. These laws were later amended in 2015 to prohibit smoking in a vehicle carrying children, punishable by on-the-spot fines. These law changes have resulted in significant health benefits, as well as changes in behaviour and attitudes towards smoking.

In the year following the introduction of the smokefree laws, there was a 2.4% reduction in hospital admissions for heart attacks in England, saving the NHS £8.4 million in a single year. In the same year, there was a 12.3% reduction in hospital admissions for childhood asthma cases, equivalent to 6800 admissions over the next 3 years.

The ban proved to be successful and popular, even among smokers. A YouGov survey commissioned by ASH in 2014 found that 82% of adults in the UK support the smokefree laws, including 54% of smokers.

In addition to support for the smokefree laws, people are now less willing to expose themselves to smoke in private dwellings. In 2009, 78% responders to an ASH YouGov survey did not allow smoking anywhere in their home or in enclosed areas on their property, and this had increased to 86% of respondents by 2014, suggesting that the law changes were responsible for a decrease in the social acceptability of smoking, leading to it being a less desirable behaviour among the public.

Since April 2012, it has been illegal to display tobacco products at the point of sale (POS) in large shops, and since 2015 it has been illegal to display them at any point of public sale. This was inspired by the idea that openly displaying tobacco products in shops contributed to the normalising of smoking by society, and the hope that banning this display would reduce the social acceptability of smoking.

Research shows that POS display has a direct impact on young people smoking. In 2006, 46% of UK teenagers were aware of tobacco display at POS, and those who admitted an intention to start smoking were more likely to recall brands seen at POS.

The Cochrane systematic review (2011) found that exposure to tobacco advertising and promotion, including POS displays, increases the likelihood that adolescents will develop a smoking addiction, justifying the hypothesis that POS bans decrease the prevalence of smoking.

An evaluation of the POS ban in Ireland found that it had an immediate impact on young peoples' attitudes towards smoking. The proportion of young people believing that more than 1/5th of their age group smoked decreased by 16%, and 38% of teenagers thought the law would make it easier for children not to smoke, suggesting that the bans had significant effects on the public perception of smoking and helped to de-normalise it.

A study by Cancer Research UK in 2010, just after the laws had been passed, found 73% support for the removal of POS displays, whereas a larger poll of British adults found 64% support. These results both suggest that the public is in favour of banning these displays as a way of reducing young peoples' exposure to tobacco advertising.

Issues with public health interventions

There are methodological issues in attempting to judge the effectiveness of public health campaigns. When multiple public health measures (e.g. Fit for Life, 5-a-day) are introduced within a short period of time, it is difficult to establish cause and effect as we cannot pin down which campaigns are responsible for specific changes in public behaviour, perceptions of smoking and gambling, and overall changes in health. For example, the 2.4% reduction in hospital admissions for heart attacks may not necessarily be due to the introduction of the public smoking ban, but rather due to a greater overall focus on a healthy lifestyle in the media.

We don't know how closely peoples' reported attitude changes, awareness of addiction, or planned changes in behaviour reflect their actual actions - in responses judging the effectiveness of the Toxic Cycle campaign,  people could have overestimated their own likelihood of quitting, or simply lied and reported stopping smoking for the purpose of giving a socially acceptable survey answer. Many people accessed Smokefree and NHS Stop Smoking services to attempt to quit, but this does not necessarily mean that the system was effective at helping them quit rather than just providing an incentive (30% took actions such as ordering a Quit Kit, but there is no figure for how many successfully stopped smoking.)