Tackling teenage smoking
The development of adolescents (typically ages 12 to 18 years old) is expected to include predictable physical, social and mental milestones. Understanding adolescent development, that is how young people are changing physically, cognitively, socially, emotionally and behaviourally, is important in the design and implementation of health promotion and prevention strategies. Understanding adolescent development will aid health practitioners in selecting the content, approach, strategies and timing of the methods and programmes they implement
Biological, psychological and social development
Biological theorists argue that adolescent behaviour can be related to physiological factors that include hormone levels, inherited traits or neurological disorders (Neilsen L, 1987). This theory suggests that the adolescent’s behaviour can be explained purely by genetics, whereby unique individual genes account for the differences in each person.
On the other hand, psychological theorists focus on the development of adolescent cognitive abilities. These changes are reflected in adolescence attitudes, beliefs, motivation, personal control, self-image and self esteem (Penn GN, Bennett P, Herbert M, 1994). There are changes in information processing, decision-making and critical thinking abilities. Theories of cognitive development include that of Jean Piaget, a psychologist. Piaget theorised that adolescents evolve to become concrete operational thinkers. Rather than solving problems by trial and error, adolescents create solutions to problems by having a plan and being able to test the solution (Santrock WJ, 2004). Critical thinking skills are developed where adolescents no longer accept a hypothesis as being true but will question these assumptions.
Another contribution to the theory of cognitive development in adolescents is that of psychologist David Elkind. Elkind’s theory focused on adolescent egocentrism. He argues that adolescents find it difficult to differentiate between their own preoccupation and the thoughts of others. He uses the example of adolescent preoccupation with the way they appear to others and associates this with an imaginary audience (Coleman JC, Henry LB, 1999). They will experiment for this imaginary audience and this is driven by adolescent egocentrism. Elkind has contributed to the understanding of everyday adolescent behaviour and their thoughts of invincibility.
Adolescence is characterised by key social development and changes in social relationships where adolescents form their own identity and strive to become independent. In contrast to biological and cognitive theories, behavioural and social learning theories take environmental influences into account when examining adolescent development. These theories do not discount the importance of biological factors but recognise the impact of experience on development (Neilsen L, 1987). In Erikson’s theory, a search for identity is crucial in adolescence. He emphasised the rapid biological and social changes during this period and recognised the major decisions adolescents make (Coleman JC, Henry LB, 1999; Erikson JM, 1997).
Biological, social and psychological factors all affect the development of adolescents. No one theory can completely explain adolescent development; instead each theory has contributed to our understanding of adolescent development.
Health promotion strategies
In today’s society, the term ‘health’ is considered to be more than an individual’s physical condition. ‘Health’ incorporates an individual’s attitude towards their wellbeing – the perception of risk, diet and the environment. Focusing on biology and physical illnesses will not fully explain all matters of health. To have an overview of health needs, it is necessary and appropriate to consider psychological and social factors in addition to biological ones (Heaven PCL, 1996).
The Office of Tobacco Control (OTC) estimates that 16% of Irish people aged 12 to 17 smoke, with 28% of 16 to 17-year-olds currently smoking. Intervention in the teenage years is critical in the prevention of smoking. Irish research demonstrates that 78% of smokers start before the age of 18, with over half starting by the age of 15 (Office of Tobacco and Control, 2006).
According to the World Health Organization, tobacco is the second major cause of death in the world. It has causal links with cancer and respiratory conditions such as chronic obstructive pulmonary disease. Smoking is also considered to be a factor in other health conditions.
Adolescent cognitive development, particularly Elkind’s theory of adolescent egocentrism, helps us to understand adolescents engaging in risky health behaviour, as they have information about smoking but continue to smoke. The risk is known but they continue to engage in risky behaviour.
Understanding adolescent development and cognition, as observed by Piaget, will aid with planning health promotion because there are considerations regarding the level of the decision making and negotiating capabilities of adolescents. Consideration is given to how we communicate with adolescents; programmes need to be appropriate to the adolescent’s level of development. The health promotion strategy should be interactive and integrative. Using an accessible and attractive method, such as the internet, produced good results (Norman CD et al, 2008).
Understanding the social aspect of adolescent development can contribute to the evolution of health promotion strategies. Studies have shown that school-based programmes for preventing smoking can be somewhat effective. One systematic review by Thomas and Perera (2006) concluded that there is insufficient evidence that information alone is effective.
It is important to consider the adolescent’s environment. Is the adolescent in an environment where parents and peers smoke? Smoking is positively associated with having friends or relatives that smoke (Muula AS et al, 2008). Consequently, health promotion interventions may prove more effective if they are also family based (Thomas RE et al, 2007; Kelishadi R et al, 2004). To show further long-term effects, local health promotion programmes should be comprehensive and include school-based, family and community programmes (Aten CB, Gotlieb EM, 2006). Adolescents smoke because their peers do. Consequently, peer-led intervention can be incorporated into local health promotion programmes.
The evidence clearly supports a multi-model preventive strategy including adolescents, their peers, family and the community. However, there is a need for further studies providing high quality evidence of multi-model programmes that include community interventions (Ariza C et al, 2008).
It seems logical that if adolescents cannot purchase cigarettes we should see a lower number who smoke. The deterrent for retailers selling cigarettes to minors includes fines and suspensions. This has been shown to reduce the number of retailers willing to sell cigarettes to adolescents (Stead LF, Lancaster T, 2005).
The mass media is often used to deliver preventive health messages. One review conducted to determine the effectiveness of mass media campaigns concluded that there was some evidence to support such operations as being effective in preventing the uptake of smoking in young people. However, the overall evidence is not compelling. From at total of 63 studies, only six were accepted. These six studies used a controlled trial design and two concluded that the mass media was effective and these had a strong theoretical basis (Sowden AJ, 198). Nevertheless, we cannot disregard the mass media in health promotion strategies, as it can assist in keeping non-smoking adolescents from starting to smoke. This would be a primary goal in local health promotion strategies (Edelman C, Mandle C, 2006).
A collaborative opportunity
Physical appearance is important to adolescents and they are particularly concerned about their teeth (Heaven PCL, 1996). Understanding this can facilitate planning in health promotion strategies. Smoking has an adverse effect on the teeth. Studies have shown that there is an association between smoking and periodontal disease. Smokers have 2.7 times greater probability of getting periodontal disease than non-smokers (Calsina G et al, 2002). Teeth can be lost through gum disease and it has been established that smoking is a risk factor for periodontal disease and tooth loss (Albandar JM et al, 2000; Do LG et al, 2008; Tomar SL, Asma S, 2007). As smoking is a risk factor for many diseases and it influences teeth and gum health, this could be an opportunity for a collaborative health promotion strategy (Haber J, 1994).
There is a need for multi-modal local health promotion strategies but a multi-disciplinary approach can also be advantageous. All healthcare professionals have similar goals regarding the prevention and cessation of smoking. However, oral health is marginalised because it is not considered to be life threatening and consequently oral health promotion programmes are developed in isolation from other initiatives (Watt RG, 2005).
Opportunities can be created to link the mouth with the rest of the body in health promotion, particularly as appearance is important to adolescents. A collaborative effort will also have implications for health promotion resources, since savings may be made by having joint, rather than separate, public health initiatives.
Biological, psychological and social elements all influence the development of adolescents. Understanding all of these factors will lead to a more progressive approach for local health promotion strategies. It takes into consideration the broader socio-environmental factors that will affect individual choice. People make decisions within a broad social context and are influenced by many factors. Understanding the various development issues requires recognition of the Government’s legislation and initiatives, the family, the community, peers and the mass media’s role in health promotion strategies.
With adolescents, providing information alone is not enough. Therefore, strategies should be developed to take the broader social and environmental factors into consideration. Collaborative efforts may also be useful and save valuable resources in health promotion strategies.
Albandar JM, Steckfus CF, Adesanya MR, Winn DM (2000) Cigar, pipe and cigarette smoking as risk factors for periodontal disease and tooth loss. J Periodontol 71(12): 1874-81
Ariza C et al (2008) Longitudinal effects of the European smoking prevention framework approach (ESFA) project in Spanish adolescents. European Journal of Public Health 18(5): 491-497
Aten CB, Gotlieb EM (eds) (2006) Caring for adolescent patients. 2nd ed. Illinois: American Academy of Pediatrics
Calsina G, Ramon JM, Echeverria JJ (2002) Effects of smoking on periodontal tissue. J Clin Periodontol 29(8): 771-6
Coleman JC, Henry LB (eds) (1999) The nature of adolescents. 3rd ed. London: Routledge
Do LG, Slade DG, Roberts-Thomson KF, Sanders AE (2008) Smoking – attributable periodontal disease in the Australian population. J Clin Periodontol 35(5): 398-404
Edelman C, Mandle C (eds) (2006) Health promotion through the life-span. 6th ed. Philadelphia: Elsevier Mosby
Erikson JM (1997) The life cycle completed by Erik H Erikson. New York: WW Norton and Company
Haber J (1994) Smoking is a major risk factor for periodontitis. Curr Opin Periodontol 12-18
Heaven PCL (1996) Adolescent health: the role of individual differences. London: Routledge
Kelishadi R et al (2004) Smoking, adolescents and health: Isfahan healthy heart programme – heart health promotion from childhood. Asia Pac J Public Health 16(1): 15-22
Muula AS, Siziya S, Rudatsikira E (2008) Cigarette smoking and associated factors among in school adolescents in Jamaica: comparison of the Global Youth Tobacco Surveys 2000 and 2006. BMC Research Notes 1: 55
Neilsen L (ed) (1987) Adolescence: a contemporary view. 3rd ed. Orlando: Harcourt Brace College Publishers
Norman CD, Maley O, Li X, Skinner HA (2008) Using the internet to assist smoking prevention and cessation in schools: a randomised, control trial. Health Psychol 27(6): 799-810
Office of Tobacco Control TNS mrbi (2006) Children, youth and tobacco: behaviour, perceptions and public attitude
Penny GN, Bennett P, Herbert M (1994) Health psychology: a life-span perspective. Switzerland: Harwood Academic Publishers
Santrock JW (ed) (2004) Life-span development. 9th ed. New York: McGraw-Hill
Sowden AJ (1998) Mass media interventions for preventing smoking in young people. Cochrane Database of Systematic Reviews. Issue 4. Art. No.: CD001006. DOI:10.1002/ 14651858.CD001006
Stead LF, Lancaster T (2005) Interventions for preventing tobacco sales to minors. Cochrane Database of Systematic Reviews. Issue 1. Art. No.: CD001497. DOI:10.1002/14651858.CD001497.pub2
Thomas RE, Perera R (2006) School-based programmes for preventing smoking. Cochrane Database of Systematic Reviews. Issue 3. Art. No.: CD001293. DOI:10.1002/14651858.CD001293.pub2
Thomas RE, Baker P, Lorenzetti D (2007) Family-based programmes for preventing smoking by children and adolescents. Cochrane Database of Systematic Reviews. Issue 1. Art. No:CD004493. DOI: 1002/14651858.CD004493.pub.2
Tomar SL, Asma S (2007) Smoking – attributable periodontal disease in the United States: findings from NHANES III. National health and nutrition examination survey. J Periodontol 71(5): 743-51
Watt RG (2005) Strategies and approaches in oral disease prevention. Bulletin of the World Health Organization. 83(9)
World Health Organization (2009) Tobacco free initiative programme and projects. Switzerland