In 1986, the Ottawa Charter defined health promotion as

the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realise aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasising social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being.

Promoting health can be undertaken in many ways and in many settings. Health promotion can focus on intervention at the individual level, through health education initiatives and provision of support to encourage behaviour change. This support necessarily also involves changes at a wider environmental level. Whole populations may be the focus of promotional interventions such as local or national campaigns and programmes, as well as legislative interventions including taxation. Health promotion is delivered through the actions of a range of organisations; local and national government, health services, schools and businesses, and through community groups. These actions can be organised at a number of geographical levels, from neighbourhood to national level.

The Ottawa Charter identified five areas of health promotion activity (Figure 34a); Figure 34b shows how these areas can be applied to tobacco control. Other models of health promotion have been developed, including the community development approach, which has led to the Healthy Cities movement, developed by the WHO, which

seeks to promote comprehensive and systematic policy and planning for health and emphasises

• the need to address inequality in health and urban poverty
  
• the needs of vulnerable groups
  
• participatory governance
  
• the social, economic and environmental determinants of health.

A health promotion programme should be based on the assessment of need and evidence of the effectiveness of what is proposed. Otherwise, where there is an important health need but a lack of evidence, a decision needs to be made about whether there is a good theoretical rationale for expecting the programme to influence practice. A programme should have a stated aim with specific objectives and involve implementation of one or more well-defined, evidence-based interventions, delivered to a specified target population in a particular setting, with clearly defined outcomes. Specifying outcomes needs to include both immediate and longer-term outcomes; the ultimate aim of a tobacco control programme may be to reduce tobacco-related illness and death, but it takes a long time for changes in these diseases to become apparent. This lengthy timeframe makes it difficult to attribute any changes to a specific time-limited intervention. Short-term outcomes can, however, also be defined, including self-reported measures of behaviour change, although less reliable than objectively measured outcomes. On the other hand, process measures, such as the numbers of posters displayed or programme participants in a given time period, may be valuable to indicate that a programme was carried out as intended, but give no indication of whether any health or behaviour change occurred as a result of the activity.