Certain behaviours have become labelled as ‘risky behaviours’ associated with negative health outcomes. Such behaviours include smoking, excessive use of alcohol and other recreational drugs, unsafe sex, poor diet (high fat and high sugar diet) and sedentary lifestyles. These have all been the subject of the UK national health strategies. Risky behaviours are often linked to a range of illnesses and conditions. For example, smoking is linked to lung cancer, coronary heart disease, chronic obstructive lung disease and asthma. Lifestyle risk behaviours have been associated with most of the common chronic diseases in developed countries. These conditions (e.g. diabetes, coronary heart disease and cancers) represent a significant disease burden and are very costly to manage and treat. The Coronary Heart Disease National Service Framework (NSF) (DH 2000a) highlighted the importance of tackling lifestyle behaviours as a means towards reducing the incidence of coronary heart disease. Funding for smoking cessation groups, local exercise action pilots (LEAPS) in deprived areas, a ban on advertising tobacco, and free fruit for primary school children were all introduced to support the coronary heart disease NSF.

As discussed in Chapter 10, most research into the prevention of risk factors for disease has focused on ‘downstream’ interventions that aim to affect the lifestyle and behaviour of individuals, rather than ‘upstream’ interventions such as policies that seek to influence the broader determinants of health. This has led to greater evidence for individually focused interventions than for social policy interventions. Targeting lifestyles has therefore been viewed as both an effective and an efficient strategy to promote health.

Targeting lifestyles has a long history: ‘The way in which people live and the lifestyles they adopt can have profound effects on subsequent health. Health education initiatives should continue to ensure that individuals are able to exercise informed choice when selecting the lifestyles which they adopt’ (DH 1992, p. 11). The lifestyles approach is popular because it is focused on individuals and can therefore be integrated into one-to-one contacts between practitioners and their clients. It also reinforces the popular concept of individual freedom and autonomy in lifestyle choices. However, it has also been criticized for taking behaviours out of their social context and ignoring the effect of structural constraints (such as income) and the regulatory context (e.g. banning smoking in public places) on behavioural choices. The lifestyles approach also assumes that people make rational choices based on weighing up the pros and cons of adopting a specific behaviour, and this too has been criticized for failing to take into account custom, habit, identity and the meaning of behaviours within people’s lives. Behavioural change models, such as the Stages of Change model, that assume individual autonomy and choice have been seen as unrealistic. These critiques of the behavioural change approach are discussed in greater detail in Chapter 11 of Foundations for health promotion, edn 3 (Naidoo and Wills 2009). Empowerment strategies that educate and enable people to take control over their health are discussed in Chapter 8 of this book.

The construction of certain behaviours as risky is, however, problematic. In particular, there is a gap between epidemiological and lay perceptions of risk. Epidemiological risks are scientifically calculated and presented as statistical probabilities. However, people interpret epidemiological risks within their own behavioural landscape, according to their own circumstances and priorities (Lupton 1999). For example, someone may have unsafe sex and underestimate the risks of so doing, because they want sex to be spontaneous and not negotiated, and because it is the norm amongst their peers.

Lupton (1995, p. 9) argues that risk has replaced the notion of sin. Taking risks is attributed to lack of will power and moral weakness and as a result people do not seek advice because they fear they will be ‘told off’. Research suggests that health risk behaviours should not be perceived as ‘wrong’ lifestyle choices, but as rational coping strategies adopted in the context of the demands of caring and the constraints of poverty (Graham 2003). People have very different constructions of risk, and people’s personal ‘landscapes of risk’ vary according to their social situation and status. For example, smoking is a high-risk behaviour but its risk may be downplayed and offset against its positive role, for example as a stress management and coping tool, within people’s lives. In this way, epidemiological risk factors such as smoking or poor diet may be overridden by more immediate risks and more urgent problems. The link between unhealthy lifestyles and poverty has been recognized in official government documents:

Risk perception is also influenced by role models. ‘Candidates’ for premature death who in fact lived to a ripe old age (e.g. ‘granddad smoked 40 a day and lived to 93’) and ‘victims’ who lived healthily but died prematurely (e.g. ‘my aunt never smoked, ate healthily all her life, and then died of breast cancer aged 48’) are referred to as reasons for treating epidemiological risk assessments sceptically (Davison et al 1992). In our companion book, Foundations for health promotion, the sociopsychological models of behaviour that explain health-related decision making are discussed in depth (Naidoo and Wills 2009). Lay perceptions of risk are also affected by social and cultural norms. If, for example, one’s peer group values a risky behaviour, for example binge drinking among young women, its risk is likely to be underestimated or offset against other immediate benefits, such as belonging and peer approval. Illegal behaviours are also likely to be assessed as much more risky than legal behaviours, regardless of the evidence. For example, the use of the illegal drug ecstasy is generally viewed as more risky than the use of alcohol, although alcohol represents a much more significant health risk.

Recent guidance from the National Institute for Health and Clinical Excellence (NICE) states that interventions to change behaviour can be divided into four main categories:

The educational approach is discussed in more detail in Chapter 8.

Practitioners will often need to discuss behavioural lifestyle changes with their patients or clients. This may be in the form of information, advice or a more structured and client-led examination of opportunities for change. People may reject education or advice because it runs counter to their intuitive understanding, their life experience, or the example of significant others. However, even when a message is understood and accepted, it may still not be acted upon. Being exposed to behavioural change messages that are accepted but impossible to achieve is likely to lead to loss of self-esteem and feelings of inadequacy. The alternative is to reject or deny such messages.

It is arguable whether lifestyles are a matter of choice. In addition to the constraints on choice imposed by the socio-economic context, some behaviours, for example smoking and excessive alcohol use, are addictive. People may not have all the relevant facts at hand when making behavioural choices, and access to more information may change their choices. The behaviour of significant others has an impact on lifestyles, and advertising and marketing are also significant factors determining individual behavioural choices. Recognition of the persuasive effect of mass media techniques has led health promoters and public health practitioners to adopt techniques such as social marketing to try to achieve healthy lifestyle changes (see Chapter 8 for further discussion of this topic).

Individually focused educational and persuasive approaches have been used to try to change many behaviours. In addition, many other approaches have been used, including legislation and regulation, policy formation and implementation (discussed in more detail in Chapter 4), and community development. The following sections examine a range of strategies addressing smoking, diet, exercise, alcohol and drug use, and sexual health. Within each section, the contribution of this behaviour to ill health is first outlined, followed by a discussion of approaches used in practice and evidence as to their effectiveness.

Although the detrimental effects of smoking on health have been known for half a century, smoking remains a common habit that significantly affects the health of the population, both in the UK and worldwide.

Smoking has been identified as one of the greatest causes of the health divide between the rich and the poor. Due to its expense, smoking also has a significant financial impact on low-income households, and money spent on cigarettes may lead to shortages in essential items such as food, heating and clothing.

The evidence relating to the harmful health effects of tobacco has been well documented for over half a century dating back to Doll and Hill’s (1950) original work, published in the British Medical Journal in 1950, which demonstrated the link between smoking and lung cancer. The 1963 Report by the Royal College of Physicians, which led to the setting up of the pressure group ASH (Action on Smoking and Health) and the Froggatt Report on passive smoking published in 1988, summarized the available evidence and made the case for stronger controls on smoking in public places and the advertising and promotion of tobacco. The government finally acted on this evidence base and in 1998 published the White Paper Smoking Kills (DH 1998).

Smoking is a global health issue affecting all countries. The WHO global burden of disease study (Ezzati et al 2002) found that in developed countries tobacco is the leading cause of disability adjusted life years (DALYs), and tobacco remains a significant cause of disability and a major health risk factor in developing countries. The WHO recognized the global impact of tobacco and negotiated the Framework Convention on Tobacco Control (WHO 2003), its first global health treaty. The Framework Convention is a legal instrument based on evidence that is intended to be incorporated in law and implemented in different countries.

Recent years have seen a raft of smoke-free legislation in the UK:

• 2003 Advertising of tobacco banned except limited advertising at the point of sale

• 2003 Tobacco sponsorship of domestic sporting events banned

• 2005 Tobacco sponsorship of international sporting events banned

• 2007 Sale of tobacco products to under 18-year-olds banned

• 2007 Smoking in virtually all enclosed public places and workplaces banned

• 2008 Mandatory written and pictorial health warnings on all tobacco products.

The European Union banned all tobacco advertising and sponsorship in 2008. Smoke-free legislation has been supported by an increasing percentage of the population – 81% in 2008 compared to 51% in 2004 (http://ash.org.uk/files/documents/ASH_119.pdf).

WHO reports that the most cost-effective option in all countries is taxation on tobacco products, followed by comprehensive bans on advertising tobacco. Together, it is calculated that these two measures could reduce the global burden of tobacco by 60%. In countries such as the UK, where these two measures are already in place, additional measures such as education and smoking cessation interventions become cost-effective.

Tobacco use is unique in that its effects are unequivocally negative, both for the immediate user and for others exposed to tobacco smoke. Strategies to reduce tobacco use are correspondingly well advanced and multi-pronged, including legislation to ban tobacco advertising and promoting access to nicotine replacement drugs on prescription. The American social marketing youth campaign ‘Truth’, with its message that ‘tobacco will control you’, recognizes the pervasive influence of the tobacco industry and the addictive nature of tobacco. The WHO Framework Convention demonstrates the potential for global strategies to change unhealthy behaviours. A range of strategies is necessary because the addictive nature of tobacco means that education and advice alone are insufficient. However, the use of complementary strategies at different levels (individual, community, national, global) has been shown to be effective in reducing tobacco use.

Diet is a crucial factor contributing to health. Malnutrition and underweight is a problem for the developing world, and the Millennium Development Goal 1 is to reduce by 50% the number of people who suffer from hunger. Nine hundred and forty-seven million people in the developing world are undernourished, leading to a failure to grow and thrive and an increased likelihood of becoming ill and dying prematurely (Bread for the World 2009). In 2006, about 9.7 million children died before the age of 5 years. Four-fifths of deaths occurred in sub-Saharan Africa and South Asia, the two regions where people suffer most from hunger and malnutrition (UNICEF 2008).

Although obesity is a problem in developed rather than developing countries, it is the poorest members of society who are most likely to be obese and suffer related ill health and premature death. Substantial evidence shows how poverty affects food choice:

Figure 11.1 shows how diet is determined by a number of different interweaving factors. Simply improving knowledge about healthy foods does not necessarily lead to changes in consumption. Such foods need to be accessible and available and people need the skills and confidence to prepare these foods. The UK government has recognized the negative impact of fast food outlets on the nation’s diet, and in a recent strategy document stipulates that local authorities can and should use existing planning powers to control the number and location of fast food outlets in their local areas, especially in relation to parks and schools (HM Government 2008).