Impact of public interventions from 2005-2021 in tackling smoking among teenagers in the uk

Abstract

Background: Smoking is prevalent among all ages and teenagers who develop early smoking habits are seen to suffer from negative health consequences at early stages related to cardiac and respiratory function.

Aim: The aim of the study is to examine the impact of different public interventions from 2005 to 2021 in preventing smoking among teenagers in the UK.

Methods: The secondary research or study design is to be used. The literature search to be organised for the study is to be made through electronic search. The specific platform used in framing the study are CINHAL, Medline and Cochrane Library. The inclusion criteria to be followed are articles that are written in English, published on and after 2013 fully accessible, contains primary data, evaluation reports from 2005 to present, related to teenage smoking and government intervention and framed in the UK. The exclusion criteria to be followed are articles that are not written in English, published before 2013, secondary articles, not fully accessible, contains data regarding smoking among adults and non-government strategies for smoking cessation and not containing data in the UK.

Findings: The exploration of the studies regarding prevalence of teenage smoking in UK has mentioned it to be variedly present across the UK. This is evident as in some areas it is acting as major problem but in most area within the UK the prevalence has reduced. The teenagers belong from lower socio-economic classes are found more to be involved in smoking as they do not have educated parents or service support to make them understand the adversities of smoking. Thus, due to lack of awareness they develop the action which is harmful for their health. The impact of intervention such as warning on cigarette packets, dissuasive cigarette uses and introduction of general physicians to educate regarding adversity of smoking to teenagers and adults are found to be successful in the UK in preventing teenagers to some extent to develop smoking. Moreover, the legislation and policies such as Smoke-free legislation, NHS Stop Smoking Services and Tobacco control policy in the UK are found to equally effective in preventing and reducing smoking prevalence among the teenagers.

Conclusion: The public intervention from 20005-2021 has positive impact in preventing smoking among teenagers in the UK.

Chapter 1: Introduction
Introduction

Smoking is a major health issue in the UK and other nations. Smoking is inhaling smoke from burned tobacco products like cigarettes, cigar and others. Smoking is prevalent among all ages and teenagers who develop early smoking habits are seen to suffer from negative health consequences at early stages related to cardiac and respiratory function. The UK Government mentions that regular smoking among teenagers is considered as the smoking habit in which at least one cigarette each week is smoked by individuals (ASH, 2016). In this project, the impact of intervention in tackling prevalence of smoking among teenager is to be explored. In this purpose, the research methods to be used in gathering information regarding the topic is to be discussed. Moreover, detailed literature regarding impact of intervention in tackling teenage smoking habit are to be informed in the study.

Background to the Project
Prevalence of Smoking among teenagers

The use of tobacco for smoking among the youth is a worldwide issue affecting people of different countries. Smoking is an unhealthy behaviour and its prevalence vary across nations, but it is considered as public health issue commonly in most societies (Davey and Zhao, 2020). In the UK, smoking among the teenagers is declining yet certain class of individuals are seen to remain significantly involved in the habit which makes it still an important health issue to be explored. Smoking has become one of the biggest causes of death as it has led 78,000 people on average in the UK including age groups to die from smoking each year (NHS, 2019a). In 2009, nearly 81,400 deaths are reported among adults of 35 years and above in the UK who are involved in smoking and it represented 18% of the total deaths experienced in the age group (NHS, 2010). In 2015, the number of deaths from smoking in the UK was reduced to 79,100 which is only a 2% decrease in the death rate since 2006 (NHS, 2016). In between 2016-2018, 77,600 death were reported each year as a result of smoking in the UK (NHS, 2018). This indicates that the smoking related deaths have decreased but is still present in significant number in certain nature of youth due to which it is required to be considered as an health issue to be explored.

In the UK, the history regarding smoking among adults and teenagers mentions that it is a habit which is declining, but in some groups it is still persistent which makes it still an health issue to be considered for management in such groups. This is evident as in 1974, 40% of 16-19 years of individuals, 48% of 20-24-year adults, 51% of 25-34 years adults, 52% of 35-49 years adults, 51% of 50-59-year adults and 34% of 60+ adults are found showing addiction to smoking (ASH, 2016). The number fell by 2014 where it was found that 20% of 16-19 years of individuals, 26% of 20-24-year adults, 24% of 25-34 years adults, 21% of 35-49 years adults, 19% of 50-59-year adults and 11% of 60 and above adults were involved in smoking (ASH, 2016). This indicates that smoking among teenagers as well as adults in the UK is a common problem and thought it has reduced to some extent but concerned number of people in some groups are still involved in the activity. The study by Thomeer et al. (2019) mention that development of smoking habit in the teenage years leads to its continued addiction in the adult stage. The early exposure to tobacco smoke in the teenage years causes initiation of early damage to the lungs which with time worsen and results the people to face adversities in respiratory functioning that also interferes with their everyday life activities. The smoking statistics for the past 10 years indicates that though it has decreased among teenagers, but still certain class of people are using smoking due to which it is still a problem among the teenagers. Thus, the teenage population is been focussed on the study so that the smoking issue from the age group can be entirely resolved and managed. This is to understand the intervention for them and its impact on controlling smoking among them which is a key health problem.

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Prevalence of Smoking in teenager in local areas in the UK

The prevalence of teenage smoking in the UK as per area indicates that it is highest in the Yorkshire & Humber (8%) followed by South West and North East (7%) area. In the North West and South East UK area, 5% prevalence of teenage smoking is seen. The least prevalence of teenage smoking is seen in West Midlands, Eat of England, East Midlands and London (digital.nhs.uk, 2019). In regards to ethnicity, 5.8% of white teenagers in the UK are found to be smokers compared to others. This is evident as 3.1% of teenager of mixed ethnicity, 2.3% of teenagers who are Asian 1.5% of teenagers who are black and 3.4% of teenagers belonging from other minority communities are found to be involved in smoking (digital.nhs.uk, 2019). The statistics revealed that the white teenagers are more vulnerable and frequently involved in smoking compared to teenagers from minority communities. In the UK, in 2018, it is seen that there are 5% of teenagers who are classified as current smokers. This is reduction from 22% in 1996, 18% in 2000, 11% in 2006, 9% in 2010 and 7% in 2016 (NHS, 2010; ASH, 2016). However, it is mentioned that that 60% of regular teenage smokers find it fairly difficult to avoid smoking for a week and 74% mentioned they find it fairly difficult in avoiding smoking altogether (digital.nhs.uk, 2019). Thus, the numbers indicates that teenage smokers has reduced, but the habit is still prevalent in teenagers from certain class or social groups due to which the topic is to be further explored to understand the cause of the problem and way it can be more effectively resolved.

Cause of Smoking among Teenagers

In case of UK teenagers, few mention they involve in smoking out of curiosity. This is because teenagers wish to try and understand the taste of the tobacco used for smoking (Vazquez-Nava et al., 2017). This is evident from the study by Khalil et al. (2018) where the key aim was to determine to what extent curiosity is responsible for teenagers to develop smoking. The result developed is that 28.8% of teenagers in the study mentioned curiosity led them to try cigarettes and 19.5% of them mentioned curiosity led them to try cigars. As argued by Weitzman and Lee (2020), the prevalence of smoking among teenager is adequately influenced by advertising. This is because the advertisement leads the teenagers to develop curiosity in having the products for smoking to test it which later they fail to avoid and develop addiction towards its use. The lack of presence of enhanced education among teenagers about the health adversities related to smoking leads them to develop the habit. This is because they are unable to understand the need for avoiding smoking and may develop the habit which they later fail to cease and face negative health and well-being (Kim and White, 2018).

Policies and Strategies regarding Smoking

In the UK, various policies and strategies are present that are implemented for managing tobacco-free generation. The Tobacco Control Plan is one such policy which is developed for five years with objectives to be fulfilled by the end of the date of the policy. The objectives of the current Tobacco Control Plan for 2017-2022 include reducing the numbers of 15 years old individual who are involved in regular smoking in the UK from 8% to 3% or lesser than the percentage (Gov.uk, 2017). The other objective is to reduce smoking among adults in England to 12% or less from the current 15.5%. It is also determined in the plan that the inequality gap in delivering services regarding smoking cessation is to be reduced and the prevalence of smoking during pregnancy is to be reduced to 6% or less from the current 10.7% value (Gov.uk, 2017). Another smoking cessation policy developed by the UK government is the stated policy of 2010 to 2015 Conservative and Liberal Democrat coalition government. The action mentioned through the policy includes 18.5% or lower reduction in the prevalence of smoking among the adults, 12% or lower reduction of smoking prevalence among the adults within 15 years of age and 11% or lower reduction in smoking prevalence among the pregnant women (Gov.uk, 2015). The Children and Families (Use of Tobacco) 2014 mentions that smoking inside the care in front of teenagers and children is prohibited. This is to avoid teenagers from exposure to secondary smoke which is equally harmful to their health like active smokers (legislation.gov.uk, 2014). These policies and legislations are to be explored along with other government intervention taken by the UK government to understand to what extent and how they have affected the prevalence of smoking among teenagers in the country.

Rationale

In the UK, teenage smoking is one of the prevailing health issue and major public problem. The total population of teenagers in the UK is 7.4 million teenagers and it is estimated that nearly 207,000 teenagers initiate smoking each year in their early years (youngpeopleshealth.org.uk, 2015, NHS, 2019). This indicates small yet concerned part of the teenage population in the UK develop the habit of smoking each year. In 2014, it is reported that teenagers who are classified as regular smokers smoked nearly 31.1 cigarettes each week and the teenagers who mentioned them as occasional smokers smoked 5 cigarettes on an average each week (ASH, 2016). This indicates most of the teenagers in the UK can be considered as regular smokers as per government conditions even though few mention them are occasional smokers because they smoked more than one cigarette a week.

In the UK, it is reported that 22% of the teenagers in 2013 smoked at least one cigarette a week which was reduced to 18% teenagers in 2014 with rise to 19% teenagers in 2016 and again reduction to 16% teenagers in 2018 (NHS, 2019). This indicates a steady fluctuation and decline in the overall number of teenagers in the UK who are involved in smoking at least one cigrattes a week over the past years till the present. In 2018, out of 16% of teenagers who are considered to smoke cigarettes a week, it is was found that 2% of them were regular smokers, 3% were occasional smokers, 3% who previously used to smoke and 8% who have just tried smoking (NHS, 2018). This indicates that the number of regular smokers among the teenagers in the UK at the present in quite small even though a concerned percentage of teenagers are involved in the habit.

In regard to gender, it is seen that 16% of teenage boys and 17% of teenage girls in the UK are involved in smoking (NHS, 2019). This informs that all the gender of the teenagers is equally involved in the habit of smoking. The prevalence of smoking among teenagers are seen to increase with age. This is evident as in 2018 it is reported that 1% of 11-year-old teenagers are involved in smoking whereas 11% of the teenagers of 15 years are involved in smoking (NHS, 2019). In 2016, the rate was 1% smokers of 11 years of age and 7% regular smokers of 15 years of age (NHS, 2018). The teenage smoking prevalence by region indicates that high percentage of teenage smokers are present in the Yorkshire and Humber area (7.5%), whereas the lowest number of teenage smokers are present in London (3%) (NHS, 2018). Thus, it informs that the capital city in the UK has a lesser number of teenage smokers compared to adjacent areas.

The high smoking prevalence among teenagers in the UK is an issue because involvement in smoking at an early stage of life leads to development of deteriorated health consequences for teenagers in early years. This is evident from the report by WHO which mentions that teenage smoking leads to increase in the development of lung cancer at an early stage (WHO, 2019). This is because frequent and early exposure of the lung to harmful elements of cigarette smoke in the teenage years leads to irritation and damage of the inner lining of the lungs from the early stage which makes it vulnerable to develop cancer at early stage (NHS, 2019a). The teenage smoking among UK individuals is an issue because it leads them to show lack of enhanced physical fitness and performance at the early stage of life due to development of shortness in breathing (NHS, 2019a). This is evident as increased tobacco smoking in the early years leads to development of airway hyperresponsiveness and eosinophilia that hinders the breathing efficiency of the individuals (NHS, 2019a).

The WHO mentions that teenage smokers are three times more vulnerable than non-smokers to use alcohol, eight time more vulnerable to use marijuana and 22times more likely to involve in having cocaine (WHO, 2019). Thus, the high smoking prevalence in the UK is a key issue because the expression and continuation of the habit may lead increased teenage smokers to be involved in additional substance abuse activities that are highly harmful to their health. The teenage smoking can also be considered as a key health issue because it leads to raise the blood pressure level of the individual and affect vascular function in the body which makes them be at risk of development of heart disease in the early age (Li et al., 2017). Thus, it indicates that increased number of UK teenager smoker prevalence would indicate more deteriorated health consequences to be faced by them over the year at the early stage which would also hinder their well-being.

The prevalence of smoking among teenager in the UK has currently become an issue because increased number of certain class of teenagers are mentioning they are unable to quit the habit to develop better health (NHS, 2019). It is evident from the report of NHS which mentions that 60% of the teenage smokers in the UK who belong from por class, show stress with managing life, facing mental issues and others have mentioned smoking has become addiction for them and they are failing to cease the actions (NHS, 2019). This indicates that certain teenagers in the UK are getting addicted to the habit of smoking which is harmful to their health. In the UK, different governmental interventions are seen to be taken such as Tobacco Control Policy, Smoking Cessation Services and others to control teenage as well as adult smoking. In this project, the government interventions are to be evaluated to understand the extent of impact they have on managing teenage smoking and its harmful effect on teenagers living in the UK.

Aim

The aim of the study is to examine the impact of different public interventions from 2005 to 2021 in preventing smoking among teenagers in the UK.

Objectives
  • To identify the prevalence of smoking among teenagers in the UK
  • To assess the causes and risk factors related to smoking among teenagers in the UK
  • To evaluate the impact of different public intervention from 2005 to 2021 to prevent smoking prevalence among teenagers in the UK
  • To analyse the impact of different policies and governmental strategies from 2005- 2021 to prevent smoking prevalence among teenagers in the UK
Chapter 2: Methodology
Introduction

In this chapter, the specific methods and techniques to be used for selecting, identifying, processing and examining information regarding the research is discussed. The chapter is important to be developed as it helps to make critical analysis of data to evaluate the overall validity and reliability of the study. Moreover, well-structured research methodology helps in contextualising data within the research and ensure its high-quality execution that allows enhanced knolwdege development which supports resolving the raised questions in the study. In this context, the research design, search strategy and ethical consideration to be followed is to be discussed in the study.

Study Design

The study designs are mainly of two types which are primary study design and secondary study design. The secondary research or study design is referred to the method in which existing data from articles are summarised and collated to be used for enhancing the overall effectiveness of the study (Ploug and Holm, 2017). In contrast, the primary research or study design is the method in which direct data are collected by the researchers from the participants through interview, observation, survey and others (DeJonckheere and Vaughn, 2019). The primary research design was not to be used in this study. This is because gathering primary data involves high cost and require extensive involvement of researchers at all times to thoroughly gather and present data. Moreover, it is time-consuming and leads to gather inaccurate feedbacks which are not valid for the study leading to development of error in result presentation (Kangovi et al., 2018).

The other limitation of primary research is that it requires increased number of resources in gathering information and presentation of data. Moreover, the design requires numeric expertise from the researchers to be present at all times which may not be present among the research always during development of studies. In case the primary study is qualitative, it takes increased amount of time in interviewing participants to gather data (Kangovi et al., 2018). Therefore, the primary research design was not used in framing the research or study. A critical literature review was used in framing the study. This is because it cost-effective and less time consuming as data is easily gathered through online search which is free of cost in gathering potential articles and journals regarding the study (Beck, 2019). The other reason of using secondary design is that it helps to gather comprehensive and detailed data that are logically and experimentally proved by eminent researcher to be used in resolving the raised question in the study (Beck, 2019). It is also used because it allows adding credibility to the study because it helps in presenting data that are previously found and already proved to be effective (Beck, 2019).

Literature Search

The literature search to be organised for the study is to be made through electronic search. This is because literature searching through electronic or online mode helps in faster way of collating relevant data through the use of specific keywords (Nasrabad, 2018). It is considered to be less costly and needs little amount of time for organising it which allows relevant articles and journals to be easily collected needed for presentation of valid data in the study (Nasrabad, 2018). Moreover, the gathering of data through electronic search helps to avoid facing any physical barriers which are faced with gathering data from the books as they are found in limited number and present widely dispersed. The error of margin in the electronic data search is limited as specific keywords are present to narrow the search (Nasrabad, 2018).

Search Engines

The specific platform used in framing the study are CINHAL, Medline and Cochrane Library. The use of CINHAL is made because it contains high-quality and wide variety of top nursing and allied healthcare literature regarding various topics which are published and supported by the National League for Nursing and the American Nurses Association (ebsco.com, 2019). Thus, accessing data from such platform ensures gathering error-free and credible information for specific topic to be explored. Medline is to be used because it contains wide data of biomedical studies and life sciences (NLM, 2020).

Keywords and Boolean operators

The keywords to be used in the study are “teenage smoking”, “young smokers”, “government intervention”, “UK government”, “smoking policy” and others. The keywords are important as they help in putting specific and important variables that ensure narrowing down the search to gather potential articles and journals within limited time of the study. The Boolean operators And and OR are to be used in connecting key terms for framing the search. In meeting the specified objective, key terms from each of them mentioned are to be considered and included in the identified search platform by connecting them with Boolean operators in framing a meaningful search.

Inclusion and Exclusion Criteria

In research, inclusion criteria are the characteristics which are essential and important part of the research and needs to be involved in the study because it enhances collection of relevant and related data for the research topic (Luchenski et al., 2018). The exclusion criteria are the characteristics part of the study that are needed to be avoided from inclusion in the research because it would result in error in the study and diversion of information from the key focus of the study (Kruse et al., 2017). The inclusion criteria to be followed are articles that are written in English, published on and after 2013 fully accessible, contains primary data, evaluation reports from 2005 to present, related to teenage smoking and government intervention and framed in the UK. The exclusion criteria to be followed are articles that are not written in English, published before 2013, secondary articles, not fully accessible, contains data regarding smoking among adults and non-government strategies for smoking cessation and not containing data in the UK.

The articles which contain data regarding facts present in the UK are to be included and other excluded as the study is set in the UK and the relevant data from the country are able top provide credible results for presentation in the study. The articles which are not written in English is considered for exclusion because the facts written in other language could not be understood by the researcher who belong from the UK where the key language understood is English. The articles written in English are to be included as they contain data presented in language which is easily understood by the researchers who belong from UK where English is the key language been commonly spoken and understood. Thus, the facts present in the articles in English can be effectively analysed by the researchers to develop an enriched study.

The policy statement, legislation and strategies presented by the UK government regarding smoking from 2005 to present are to be included as it would help in evaluating wide activity of the government and the effectiveness of the steps taken by them in managing smoking among the teenagers. The articles published on and after 2013 are considered for using as they have presence of valid data that are currently approved by enhanced research by the researchers. The articles published before 2013 are to be avoided and excluded because they contain backdated results and facts that are currently ignored or changed due to the advanced research results and framework been developed. The governmental reports are to be included apart from articles in the study because they are required to be evaluated to understand their level of impact in smoking management among teenagers that is the key focus of the topic and related data are not adequately present in the articles only.

The secondary articles are excluded from the study because they includes data that may be manipulated by the beliefs and thinking of the researchers while its presentation in the specific studies from other previous studies. Moreover, secondary articles contain backdated data that on inclusion in the study may led to raise error and therefore not included in the current research. The articles that are focussed on teenage smoking are to be included and other excluded as it the teenage smokers are the populated targeted in the study.

PRISMA Framework
PRISMA Framework
Ethical Considerations

The ethical considerations in the study is been followed to avoid illegal actions to be taken and moral strategies are followed to effectively perform the study. In this context, the plagiarism of the facts is to be avoided. Therefore, the gathered data from existing articles and government reports are to be paraphrased and referenced effectively. The integrity in the study is to be ensured as ethical consideration because it mentions the study is been honestly and meaningfully performed. The integrity of the study is to be maintained by honestly presenting all the gathered facts from existing studies without manipulating them through personal vies and beliefs. The dignity of the authors is to be valued by avoiding to manipulated and falsify the facts presented by them while including them in the study. The ethical concern that may be raised in the study is case study sharing of patients with details from the government reports while referring them in the study. The concern is to be avoided by using the anonymous name of the patients and avoiding disclosing any personal data of the person whose case study is been presented. The permission from the government authorities is to be duly taken to use any government data which is restricted by them to be implemented in research.

Summary

The methodology section summarises that electronic search methods is to be used in gathered secondary data in developing the literature review. The search of the articles for gathering data is to be performed by considering the inclusion and exclusion criteria along with the use of keywords. The ethical considerations are to be effectively maintained to ensure moral values and legal obligations are supported in the study.

Chapter 3: Literature Review
Introduction

In this chapter, a detailed exploration of the facts based on the identified research objectives is to be presented. In this regard, each of the objective formed in the study is to be used as a heading in explaining the facts. The most important facts are to be shared and analysed in trying to answer the raised research questions and problem in the study.

Findings
Theme 1: Identify the prevalence of smoking among teenagers in the UK

The prevalence of smoking among teenagers in the UK is required to be understood to determine the extent to which the problem is present in the UK. In this context, the study by Laverty et al. (2019) is been explored that had the key aim to explain the smoking uptake among UK children through analysis of the UK Millennium Cohort Study. The study mentioned that 16% of the 13-14 years aged individuals in the UK were ever smokers in the time they reached their early teenage years. The application of these estimated statistics to national data mentioned that 228,136 who are in their early teens are every smoker. Among them, 2.8% of the early teenagers are current smokers in the UK which equates to 39,653 people who are in their early teenage years.

In comparison, the study by Hopkinson et al. (2014), aimed to determine the prevalence of smoking uptake by teenager based on different areas in the UK. It revealed that 3.7 million teenagers who are 11-15 years of age are involved in smoking. It is also mentioned that an estimated 463 teenagers in England, 55 teenagers in Scotland, 19 in Northern Ireland and 30 in Wales from the mentioned figure are teenagers who are involved in regular smoking actions. As per other areas, it is mentioned that 10 teenagers in the UK initiate to smoking each week from a population of 8200 teenagers. In Birmingham, 9 teenagers initiate to smoke daily and in London 67 teenager initiate to smoke daily from a population of 458,000 people.

The study by Laverty et al. (2019) to meet the aim gathered data from a birth cohort study in the UK who are born between 2000-2002. It led the selection of 11,872 early teenagers to take part in the study. In comparison, the study by Hopkinson et al. (2014), performed annual survey in secondary schools in England. In the process, 219 schools are surveyed in the year of 2011. The cohort studies are used to target specific group of individuals who are essential to be included in the study and helps in evaluating the incidence of the disease among the exposure group in enhanced manner (Wijmenga and Zhernakova, 2018). However, the disadvantage faced in the article with using cohort study is that it is lead the researchers take increased amount of time and money in gathering the data (Laverty et al., 2019). In comparison, the study by Hopkinson et al. (2014) used survey method which are cost-effective and less time-consuming. It led the researchers in the article to gather data within limited time and less expenditure to formulate the study.

The limitation faced in the study by Laverty et al. (2019) is that the measures taken to gather data regarding the prevalence of smoking among teenagers and its cause in the UK were self-reported. Thus, the self-reported data may have led to the inaccurate gathering of facts as it may have been manipulated by the personal beliefs and thinking of the participants. In comparison, the study by Hopkinson et al. (2014) mentioned that though a large sample of participants are included in the study, yet the analysis is made dependent on the age group and sex of participants regarding which the categorisation of the sample size was very small. Moreover, the other limitation is that the data is gathered in a public manner which is rounded that may lead to duplication of data collection.

In both the studies, the local smoking rate among teenagers in the UK remains unidentified which led to create hindrance in understanding which locality in the UK are most vulnerable to teenage smoking prevalence. Thus, the prevalence of teenage smoking in one of the local areas in the UK that are Blackpool is been explored in relation to national average. This is because it is one the key local areas in the UK which mention to have high average of teenage smokers. In Blackpool, 4.3% teenagers of 11-15 years of age regularly involved in smoking whereas 11.6% in age group of 15 years and 19.1% in age group of 16-17 years were mentioned to be involved in regular smoking (blackpooljsna.org.uk, 2020). In comparison, in England, it is seen that 3.1% of teenagers of 11-15 5 years, 8.7% of teenagers of 15 years and 14.8% of teenagers of 16-17 years are involved in smoking (blackpooljsna.org.uk, 2020). In the Blackpool area, marked differences are faced regarding smoking prevalence among teenagers in deprived areas and affluent areas present in the borough. It is evident as 7.7% teenagers are found to be smoking in the Park compared to 19% in the Bloomfield area in the Blackpool. Moreover, at 16-17 years of age, 30.6% of the teenagers are mentioned to be smoker in comparison to 12.4% teenagers living in Park borough (blackpooljsna.org.uk, 2020). The data gathered from the study is governmental report which has been made by surveying the people of the locality. The limitation of the report compared to previous two studies is that it did not followed effective experimental research methodology in gathering data.

Theme 2: Assessing the causes and risk factors related to smoking among teenagers in the UK

The causes and risk factors responsible for teenage smoking in the UK is to be explored to understand the reason which are responsible in developing the health issues and for which effective intervention are implemented. In this regard, the study by Taylor-Robinson et al. (2017) is been explored which aimed to inform the socio-economic factors responsible for teenage smoking. The study identified that nearly 2.7% of the children they surveyed developed smoking at the age of 11 years which continued in their teenage years. The study mentioned that teenagers are six times more likely to involve in tobacco smoking at early age who have mothers with no effective educational qualification compare to those who have mother with degree-level educational qualification. Moreover, the presence of adult smokers in the same room also instigates teenage smoking. In comparison, the exploration of report by ASH (2018) mentioned that parental and sibling smoking has key impact on the smoking prevalence among teenagers. It is evident as teenagers who have mothers and siblings who smoke are mentioned to be three times more likely involved in the activity. The national survey reports also mention that cause of teenage smoking includes influence of peers and friends, lower socio-economic status, exposure to increased tobacco marketing, deception of smoking in the entertainment industry and others.

The study by Taylor-Robinson et al. (2017) used the UK Millennium Cohort study design in fulfilling the mentioned aim in the study. The use of the specific design was beneficial as it led to identify the original cause of the raised problem that is teenage smoking prevalence in the UK. The study included data from 9,609 participants in developing related information and the logistic regression was used in statistical analysis of the results. This acted as strength for the study as larger sample size helped in better analysis of results and generalisation of findings. The limitation of the study was that the information gathered for analysis was self-reported due to which the accuracy of the gathered data cannot be ensured. In contrast, to identify the causes of smoking in teenagers a national survey reported by ASH (2018) was analysed. The report does not mention the total number of people surveyed in the UK to present the information and no detailed statistical information was present to inform way the data are gathered and presented. Thus, the limitation of the study is lack of rationale behind the research methods used in the study.

In comparison, the study by Conner et al. (2018) aimed to determine whether use of e-cigarettes has influence on causing increased cigarette smoking among teenagers in the UK. The study used cross-sectional survey in executing the research and recruited 2836 teenagers from 200 schools in England. The use of the specific research design is strength of the study as it helped to determine the burden of teenage smoking due to e-cigarette use as a cause. The results revealed that on comparison of baseline data, the use of e-cigarettes does act in initiating and escalating cigarette use among the UK teenagers. However, follow-up studies are further required with larger sample size to prove the fact. The limitation faced in the study is that cause-effect relationship cannot be proved, and it presented hindered sensitivity analysis. Moreover, the validity of the measurement

Theme 3: Impact of different public intervention available from 2005 to 2021 to prevent smoking prevalence among teenagers in the UK

In controlling increased prevalence of smoking among teenagers in the UK, different public interventions are taken by the government and local authorities. The impact on them in controlled the problem is to be focused to determine it extent of usefulness. The study by Moodie et al. (2019) aimed to identify the impact of introduction of dissuasive cigarettes among adults and teenagers in the UK to reduce cigarette smoking among them. The study revealed that two dissuasive cigarettes that is one with warning and another green cigarette were found to be significantly less favoured by teenager and adults in the UK who are smokers or non-smokers. The study expressed significant relation of lower affinity to smoke cigarettes among the smokers with use of dissuasive cigarettes. In contrast, the study by Moodie et al. (2020), aimed to explore the impact of intervention of putting warning signs on standardised cigarette packets, risk of smoking and others on the smoking awareness and cessation. The study revealed that in comparison to never smokers, the current smokers show likeliness of noticing the warning signs on cigarette packets ((AOR (95%CI) = 2.76 (2.10, 3.63)), closely read them (AOR(95%CI) = 2.16 (1.51, 3.10)) and considerably think regarding the health risk they are creating for themselves due to smoking (AOR(95%CI) = 1.92 (1.38, 2.68)) which leads them to think regarding cessation of smoking (AOR(95%CI) = 1.90 (1.30, 2.77)).

The study by Moodie et al. (2019) to gather the information performed cross-sectional survey where 997 individuals of 16-24 years of age are included from the UK. The age range shows that both teenagers (11-18years of age) and adults (above 19 years of age) are included in the study. Thus, the study fails to specifically inform the impact of the intervention taken on preventing teenage smoking. The limitation of the study is that dissuasive cigarettes are not widely present in the market place and way the teenager smokers are going to avoid smoking with its introduction over long period of time is also cannot be identified from the study. The focus on the teenager and online panel makes it difficult for the results to be generalised. In similar, the study by Moodie et al. (2020) also used cross-sectional online survey method in collecting data from two regions of England. This indicates both the studies used similar research methodology in gathering information. The limitation of the study that no insight into the different responses received from two places in England was shared. Further, like the previous study, the online way of gathering data created hindrance in generalisation of the results because the responses gathered from the population cannot be narrowed down to implemented on larger population.

In the study by Szatkowski and Aveyard (2016), the aim is to be determine the impact of new recommendation for smoking cessation in regard to 2012 Quality and Outcomes Framework (QOF) revision. The study mentioned that on following the recommendation mentioned in the framework, 19.6% of the participants in the study mentioned to have ceased smoking compared to intervention executed 8 years beforehand. Moreover, referral of teenagers to Stop Smoking Services in the UK increased by 38.8% with the introduction of 2012 Quality and Outcomes Framework (QOF). Thus, it can be seen that paying general physicians to intervene through the framework for all smokers acted to support them in cessation of smoking but no changes in the pharmacotherapy initiated for smoking cessation are identified. The study by Szatkowski and Aveyard (2016) used quantitative design to perform the research and it recorded monthly rate of delivery of smoking cessation advices in the NHS Stop Smoking Services and smoking cessation medication. In the study, 3.3 million patients are included who are teenagers and adults. The strength of the study is large sample size that helped in representing entire UK population and supported generalisation of results. However, the limitation of the study is that it did not mentioned the range of advice and payments were responsible for initiating better smoking cessation among teenagers and adults.

Theme 4: Impact of policies and governmental strategies from 2005- 2021 to prevent smoking prevalence among teenagers in the UK

The UK government has implemented several policies and strategies from 2005to 2021 to prevent smoking prevalence among teenagers and others. The interventions are focussed among all age groups in equal manner to avoid promotion of early smoking. The study by Bauld et al. (2016) aimed to determine the impact of NHS Stop Smoking Services for one year. The prospective study included 3057 individuals who are teenagers and adults from nine areas in the England those initiated to quit smoking from March 2012-2013 through the NHS Stop Smoking Services. The results informed that 7.7% of the participants expressed lower carbon monoxide validity at the end of 52 weeks indicating they effectively responded to the smoking cessation services to lower the worsened impact of smoking habit. The participants in the program was seen to show increased smoking cessation who were provided group support compared to one-to-one in cessation of smoking. In the study, it was that 1 in 13 people who set a cessation data through the program achieved it by the end of the year. The results further inform that 18,000 deaths among teenagers and adult smokers could be avoided with the use and implementation of the program within the year. However, varied impact was seen among different participants. The limitation faced in the study is that it is observation study due to which the confounder remained unmeasured and causality was maintained non-cautiously.

In the UK, smoking-free in public places is one of the key policies introduced in England in 2007 (smokefreeengland.co.uk, 2007). The impact of the legislation on smoking reduction among teenagers in school environment is determined by the study of Katikireddi et al. (2016). The study mentioned that on implementing Smoke-free legislation in the public places in the UK, 4.3% reduction in regular smoking prevalence among the teenage girls is seen. Moreover, 1.5% reduction per annum in the regular smoking prevalence among the teenagers is seen with the implementation of the legislation. Among 13 years of age teenage girls, the implementation of the legislation created 2.8% reduction in regular smoking. However, non-significant reduction in the smoking prevalence among the teenage boys is seen with the implementation of legislation. The study to gather the results used the method of survey in gathering information about regular smoking among teenagers from 13-15 years of age in the UK. The limitation faced in the study is that it does allow to determine the causality between changes in smoking habits of teenagers and smoke-free legislation and it only present demonstration of association between the two variables. The other limitation is that long-term impact of the legislation is not evaluated.

In the UK, through the Tobacco Control Policy, the legal age of smoking was increased to 18 years from 16 years between 2006 and 2008 (gov.uk, 2017). The study by Anyanwu et al. (2020) aimed to identify the impact of Tobacco control policy in the UK on cessation of smoking among the teenagers. For this purpose, the study included 14,992 people who were 11-15 years and 74, 960 person-years of longitudinal data of them were studied. The results revealed that the implementation of the policy led to reduce smoking initiation among teenagers (change in legal age odds ratio [OR]: 0.67; 95% confidence interval [CI]: 0.55 to 0.81; smoke-free legislation OR: 0.68; 95% CI: 0.56 to 0.82) along with narrowing down of socio-economic inequalities that promoted teenage smoking was also to be achieved. The change in the legal age led to change of smoking habit to occasional from regular among many individuals along with reduction smoking cessation was seen. The limitation faced in the study is that potential mechanism was not implemented how the smoking cessation among teenager vary with different implementation of tobacco control policy.

Chapter 4: Conclusion and Recommendations
Introduction

In this chapter, the ideas presented all over the topic are to be summarised and presented with a strong final analysis. The chapter is going to restate the problem and reason behind been it to be explored. Moreover, arguments and findings presented in the study also to be summarised in this chapter.

Summary of Findings

The summarisation of findings indicates that each of the themes framed effectively presented data that meet all the objectives in the study. This is evident as the first theme mentioned prevalence of smoking among teenagers in the UK. In explaining the information two key articles Laverty et al. (2019) and Hopkinson et al. (2014) were used and a government report was analysed to present further detailed data. The findings from the studies by Laverty et al. (2019) and Hopkinson et al. (2014) indicated that while the first focussed in gathering data through cohort study design, the later focused on using survey design to gather data. In the study Laverty et al. (2019), 16% of teenagers (13-14 years) in the UK were mentioned to be involved in regular smoking. However, the figures presented were not compared with data from previous year to mention to what extent of increase or decrease in the prevalence of teenage smoking was experienced. In contrast to Laverty et al. (2019) who holistically focused to mention teenage prevalence of smoking in the UK, the study by Hopkinson et al. (2014) tried to identify way the smoking prevalence among teenagers are distributed in different nations within the UK. The study revealed that more teenagers in England were greatly involved in smoking compared to Northern Ireland, Scotland and Wales. The exploration of local areas in the UK regarding teenage smoking prevalence indicated that Blackpool borough has one of the worst teenage smoking prevalence compared to national average in England (blackpooljsna.org.uk, 2020). Thus, the studies indicated that teenage smoking prevalence in varyingly distributed in different areas within the UK.

The next theme in relation with the second objective tried to highlight the causes of smoking prevalence among teenagers in the UK. In the aspect, the study by Taylor-Robinson et al. (2017) is explored which is performed by following Cohort study design and Conner et al. (2018) which presented information by following cross-sectional survey design. The study by Taylor-Robinson et al. (2017) highlighted education of the mothers to be reason behind smoking among teenagers. This is evident as mothers are the key parents who look after their children to educate and support them in developing habits. The lack of education of the mothers makes them unable to guide the children and teenagers about the adversity of smoking, in turn, making the teenagers develop the activity. The report by ASH (2018) highlighted that cause of teenage smoking is influence from parents, peer support, low socio-economic condition and others. This is evident as presence of parents who smokes makes the teenager develop the activity by watching them without realising the way it would negatively impact their health (Scalici and Schulz, 2017). Moreover, peer support provides easy access to tobacco availability in social condition irrespective age and the teenagers involve in smoking to socialise with them (Robalino and Macy, 2018). The teenagers belonging from lower socio-economic condition are seen to involve in smoking out of stress regarding social situation and deteriorated education that does not inform them about the adversities to faced with smoking habit (Budin et al., 2018).

The intervention made in the UK to prevent teenage smoking is introduction of warning on cigarette packets, dissuasive cigarette uses and introduction of general physicians to educate regarding adversity of smoking to teenagers and adults as identified from the studies of Moodie et al. (2019), Moodie et al. (2020) and Szatkowski and Aveyard (2016). Each of these studies mentioned that use of interventions were effective on controlling, lowering and preventing smoking among teenagers and adults to some extent. The issue involved with the studies is that none of them perfectly focussed on only teenager which was key target population in the study to inform the way the intervention impact in regarding smoking preventing and rather focussed on both adults and teenagers. The dissuasive cigarettes were effective in lowering smoking prevalence among teenagers may be because they are unattractive, resulted them to be unwanted from use by the teenagers. The warning on cigarette was effective on teenage smoking prevention and reduction of prevalence to some extent because it makes the teenagers understand the harmful effects to be faced with smoking, in turn, making them cease the activity to retain healthy condition and well-being (Evans et al., 2017). In study by Szatkowski and Aveyard (2016), paying of the general physician to aware teenager regarding smoking adversities was effective to reduce smoking habits in them.

In the final theme, the impact of government policies and strategies implemented in UK regarding smoking prevention were identified. The study by Bauld et al. (2016) focused to mention the effect of NHS Stop Smoking Services among the individuals. The study mentioned that it was effective in reducing worsened impact of smoking among teenagers as well as adults by making them quit cigarettes and maintaining the action in continued manner. The study by Katikireddi et al. (2016) focussed to mention the impact of Smoke-free legislation according which smoking in public places are to be avoided regarding smoking prevention. It also mentioned to show success in reducing smoking activity among female teenagers. However, no reduction in smoking prevalence was reported among male teenagers, indicating its failure to prevent smoking among young men through the legislation. In contrast, the study by Anyanwu et al. (2020) evaluated the impact of Tobacco Control policy on smoking prevention among teenagers in the UK. It mentioned to show success in reducing smoking prevalence among teenagers on increasing legal age of smoking. This is because many teenagers were barred from availing access to tobacco in free manner, in turn, making them to quit the habit.

Conclusion

The above discussion leads to conclude that smoking among teenager though have reduced exponentially over the past years in the UK, yet it has been existing problem among teenager based on social class and others. In some areas such as Blackpool, the prevalence of teenage smoking is high due to which effective actions regarding the problem is required to be discussed. This is because teenage smoking is found to cause individuals develop health complications from early age such as respiratory issues, cardiac problem and others. It interferes with their enhanced ability to live life with better health and well-being. The teenage smoking is to be holistically resolved because smoking habit at the early stage creates enhanced basis for addiction towards tobacco with extents to later life of the people. Thus, focusing on understand the cause of the problem and intervention which could impact on preventing the problem is essential.

The exploration of the studies regarding prevalence of teenage smoking in the UK has mentioned it to be variedly present across the UK. This is evident as in some areas it is acting as major problem but in most area within the UK the prevalence has reduced. The teenagers belong from lower socio-economic classes are found more to be involved in smoking as they do not have educated parents or service support to make them understand the adversities of smoking. Thus, due to lack of awareness they develop the action which is harmful for their health. The impact of intervention such as warning on cigarette packets, dissuasive cigarette uses and introduction of general physicians to educate regarding adversity of smoking to teenagers and adults are found to be successful in the UK in preventing teenagers to some extent to develop smoking. Moreover, the legislation and policies such as Smoke-free legislation, NHS Stop Smoking Services and Tobacco control policy in the UK are found to equally effective in preventing and reducing smoking prevalence among the teenagers. This is because they have created rules which are hard to be avoided along with awareness regarding smoking for the teenagers to be able to avoid in the action of smoking.

Recommendations

The recommendation are as follows:

Smoking prevention awareness: The recommendation in respect to teenage smoking prevention is that increased awareness regarding adversities of smoking among the teenagers are to be created through better healthcare campaigns. This is because it would aware teenagers with supportive evidence to minutely understand the impact of smoking on their body and the need to avoid it. The awareness campaigns are recommended because it would help to reach wider areas to many teenagers in supporting them to get educated regarding adversities of smoking to make them eventually quite the activity and support others to cease the actions too.

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Anti-smoking services: The anti-smoking services are recommended to be freely available to teenagers in school and locality. The services are required to include one-to-one as well as group counselling session to educate teenagers regarding the way to overcome smoking actions and its need. The services also required develop presence of actions that can identify and provide support to potential teenagers in local areas to avoid smoking. The services required to include information regarding use of medication and nicotine patch by the teenager who are highly addicted to smoking to help them to effectively quite the habits to lead a better life.

Educate parents of the teenagers: The other recommendation is that the parents of the teenagers are to be widely educated through evidence regarding the adversity of smoking for them as well as for their children. This is because it is been already identified that parents who smoke and are uneducated about adversities of smoking are seen to have children who are involved in smoking at early stage. It is evident as the children get influenced by the actions of the parents to some extent. Therefore, educating parents to avoid smoking and supporting their children in teenager year to avoid the action would be effective in controlling and preventing increased prevalence of teenager smoking.

Strict implementation of laws: It is recommended that existing laws for smoking among the teenagers are to be strictly implemented so that they can be able to holistically jhelp teenagers avoided from the actions. This is because if the laws have been effectively implemented, teenage smoking incidence would not have still be prevailing in UK which is to some extent in concerned number for few teenagers of certain areas and classes. The strict implication of laws ensure creates better obligation and restriction to avoid certain action which in case of teenagers smoking prevention in the UK is currently needed.

Critical Reflection on Methodology

The critical reflection on methodology informs that use of secondary research design in framing the study has been disadvantageous to some extent. This is because it may have led to inform the data from existing studies through influence of the beliefs and perceptions of the researchers who evaluated and analysed them for presentation. Moreover, there has been chances due to use of them methods where accurate data as needed as per the study topic was not available (Tarrant, 2017). This is evident as few studies include impact of intervention for smoking among teenager and adults in the UK even though the current study focussed on teenager only. Therefore, such condition may have led to some form of basis in presentation of information in the study. The use of secondary research also did not allow to gather direct data regarding the topic from participants and made researchers in the study rely on existing studies which are backdated to some extent to be included.

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