Nicotine, Tobacco, Cessation, and Public Policy
Margaret
Cox
Health
Management & Public Policy
Will Power, Quit
Nicotine, Tobacco, Cessation, and Public Policy
Tobacco’s Addictive Ingredient:
In examining
smoking cessation, it is important to understand the chemical dependency
brought on by the active ingredient in tobacco, nicotine. Periodic use of nicotine often leads to a
physical and mental addiction to the substance.
C10H14N2, or nicotine, is found in
tobacco leaves as a naturally occurring, poisonous, yellow alkaloid. Once nicotine enters the body, it is
distributed through the bloodstream and can cross the blood-brain barrier in
6-7 seconds.[1],[2]
Inside the brain’s structure, nicotine acts as an adrenaline stimulant for the
body by increasing the activity of the acetylcholine receptors. This causes a tobacco user to experience
symptoms like a higher activity level, elevated heart rate and respiration, as
well as blood vessel constriction, leading to an overall feeling of alertness
and well being. Nicotine also increases
the activity of the dopamine receptors, causing tobacco users to feel both
pleasure and a desire to maintain nicotine levels in the body. In this respect, tobacco is somewhat similar
to marijuana, cocaine and heroin, which also increase activity in the brain’s
dopamine receptors.
Types of American
Tobacco:
There are three
major types of tobacco produced in the
Definition of
Dependence:
Generally in
tobacco literature, dependence and addiction can be used interchangeably and
both terms are defined as being abnormally tolerant to and either psychologically
and/or physically reliant on the habit-forming substance. The behavior associated with using tobacco is
both frequent, habitual, and feels uncontrollable. According to the
DSM-IV-TR, nicotine dependence falls under the heading of substance-related
disorders, though not all daily smokers are nicotine dependent. Nicotine dependence is characterized by three
or more of the following characteristics over a twelve-month period: increased
tolerance to the drug; withdrawal symptoms in the absence of the drug; taking
larger amounts over a longer period than was intended (tolerance); a persistent
desire or unsuccessful attempts to cut down or eliminate substance use; large
amounts of time spent obtaining, using, or recovering from substance; giving up
activities due to substance use; and continued use despite knowledge of having
physical or psychological problems resulting from substance use.[4] Due to the chemical
dependence that often results from using nicotine, tobacco cessation can be
extremely difficult. The Center for
Disease Control (CDC) reported that in 2002 approximately 45.8 million adults
18 and older were current smokers with an estimated 15.4% who had stopped
smoking for more than one day in the past year in an attempt to quit.[5] Yet, it is estimated that less than 3 percent
of those who attempt to quit each year remain tobacco-free for a period of
twelve months.[6]
Definition of
Withdrawal:
Remaining
tobacco-free is a problem for many individuals due to the highly addictive
nature of tobacco’s active ingredient, nicotine. As mentioned before the effect tobacco has on
the acetylcholine receptors cases a person to feel alert and full of energy,
while the effect tobacco has on the dopamine neurotransmitters cases a person
to feel pleasure and a need to maintain nicotine in their system. Over time with repeated exposure, a decreased
responsiveness due to nicotine tolerance can cause a person to smoke more in
order to get the same desired effect, making dependence and addiction even
stronger and quitting even more difficult (as dose-response from either the
number of cigarettes consumed in a day or total years of smoking increases,
nicotine dependence increases, making cessation more difficult). Tobacco cessation can cause a person to feel
rundown, depressed, and fixated on the need for nicotine after initial termination,
with withdrawal symptoms occurring within the first twenty-four hours after
quitting. Withdrawal symptoms also
typically include feelings of irritability, restlessness, an inability to
concentrate, and an increased incidence of weight gain (as stimulants function
as an appetite suppressant, many people eat more after quitting). When people quit using tobacco, they may also
experience feelings of hostility; difficulty dealing with stress; and even
decreased psychomotor and cognitive functioning.[7] Though the physical and emotional withdrawal
symptoms tend to peak after seventy-two hours, tobacco users may continue to
experience withdrawal symptoms for months or even more than a year after
cessation due to the psychological addiction associated with nicotine. Withdrawal symptoms among cigarette smokers
are particularly intense due to the fact that nicotine enters the body most
quickly when smoked (as opposed to the dermal absorption of smokeless tobacco
and/or nicotine replacement therapy aids), with the almost instant
gratification leading to a greater physical dependency. Further, studies have estimated that about
80% of all smokers want to quit, 35% try cessation annually, but less than 5%
are successful, with the majority unable to maintain cessation for an
week. Without proper support, people are
often unable to combat the withdrawal symptoms and often start using nicotine
again within a matter of days. This is
evident when one examines the prevalent problem of nicotine in the
National and International Smoking and Production
Prevalence Rates:
Tobacco use is
the primary source of preventable fatalities in the
Costs Associated
with Smoking:
Tobacco use is
responsible for more deaths than AIDS, alcohol, motor vehicle accidents, homicide,
drug abuse, and suicide combined.[16] Tobacco use is linked to deaths due to
stroke, lung and other cancers, coronary heart disease, chronic lung disease
(Ex. emphysema), as well as other terminal conditions. These chronic illnesses cause a drain on the
individual and the healthcare system as expensive treatment may last for months
and years before a patient dies.
According to the Center for Disease Control, tobacco use causes more
than 440,000 deaths, more than 75 billion dollars in direct medical costs, and
more than 5.6 million years of potential years of life lost each year in the
Tobacco
Production
According to the
World Health Organization’s research, Brazil, China, India, Turkey, and the
United States produce over two-thirds of all tobacco crops worldwide[20]
with nearly half of the world’s tobacco growers living in China (approximately
15 million).[21] In 2003, 12.75 billion pounds of tobacco were
produced worldwide with 831 million pounds produced on the 416,000 acres in the
sixteen tobacco-producing states of the United States (on less than 57,000
farms).[22] The six major tobacco states are North
Carolina, Kentucky, Tennessee, South Carolina, Virginia, and Georgia, which
produce 90% of United States’ tobacco crop.[23] On the subject of tobacco cessation, the
tobacco industry often exploits the idea of the negative impact on tobacco
farmers to play on the emotions of voters and sway politics in their favor,
while many in the public believe that tobacco growers are given subsidies by
the United States government.[24] The government generally spends very little
of the national economy on compensation for farmers, particularly for tobacco
growers. Further, if the federal
government passed tobacco control legislation, tobacco farmers would be
somewhat adversely affected economically by the change, though not nearly to
the extent that the tobacco corporations would be affected if tobacco sales
were reduced or eliminated. At present,
tobacco cultivation, while extremely profitable for the corporations, is not
especially profitable for the farmers themselves. For each dollar spent on a pack of cigarettes
in the United States, tobacco farmers earn <$0.03, while tobacco companies
earn >$0.63.[25] This translates into many tobacco farmers
seeking supplementary part-time or even full-time employment away from the home
as 71% of all tobacco growers in the United States earn less than $20,000
annually.[26] Additionally, from 1938 until this year,
tobacco farmers in the United States were forced to work under the Federal
tobacco program’s quota system that regulated the amount of tobacco crop each
grower could produce annually in order to raise market prices nationally. With declining tobacco use in the 1990s,
tobacco quotas were lowered in 1997, further negatively impacting incomes for
tobacco farmers in the United States.[27] In October 2004, governments instituted the
Fair and Equitable Tobacco Reform in order to lower market prices by 30-40
percent, allowing demand for tobacco to increase and keeping the tobacco market
competitive both in the United States and abroad.[28] The effect this reform will have on tobacco
farmers and their economic situation has yet to be determined. Though with the annual farming incomes
averaging at about $20,000, an economic increase is predicted.
Tobacco farming
is extremely labor-intensive and involves the use of costly products such as
fertilizers and pesticides (often sold to growers by tobacco companies at the
onset of the season).[29] It is estimated that approximately 250 labor
hours are required to bring each acre of harvested tobacco to consumers in
developed countries (each acre yields approximately 2,000 lb. of tobacco at
harvest) and 400-500 labor hours are needed in underdeveloped countries.[30] Additionally, illness and injuries are quite
common in farming, particularly in tobacco cultivation. Aside from exposures to pesticides, another
common chemical occupational hazard among growers and tobacco handlers is Green
Tobacco Sickness (GTS). People pick up
this illness through the dermal absorption of nicotine caused by skin contact
with wet tobacco leaves or tobacco plant contact with wet clothing, causing
individuals to become stricken with symptoms such as nausea, feebleness,
cramps, migraines, faintness, and variability in blood pressure and pulse.[31]
To illustrate the
injuries and medical costs associated with tobacco workers and growers,
Struttman et al. (2002) conducted an eight-year evaluation of Kentucky farmers
where tobacco, particularly burley tobacco, is the leading cash crop for the
state.[32] Burley tobacco farms tend to possess fewer
acres, as the growing process for burley tobacco is less mechanized than other
types of tobacco or other types of agricultural harvesting and the geography of
the localities producing burley tobacco restrict farm acreage as they are
amidst hilly terrain.[33] Burley tobacco harvesting comprises multiple
stages, including tasks such as tobacco spearing and hanging tobacco plants
from barn tiers for drying. The
investigators excluded incidences of Green Tobacco Sickness in their research,
but included all other types of injuries in their analysis in order to obtain a
final count of 674 injuries and an estimated total hospital cost of $273,387
(not including medical providers’ costs, rehabilitation fees, etc.). Individually, the average cost per laborer
was $403 with more than one quarter of all injured individuals lacking
insurance coverage on any kind and 17% of individuals covered by Medicare and
Medicaid. The cost analysis also omits
the expenditures associated with lost work time and wages paid to substitute
laborers. Further, the researchers even
alluded to the idea that 674 might be a conservative number of injuries, as
underreporting by hospital staff appeared to have occurred during some years of
the study. But, among injuries reported,
the most common injuries involved falls, piercing/cuttings, overexertion, and
agricultural machinery. These types of
injury are not as common in traditional agriculture, as tobacco farming tend to
employ less mechanization and more manual labor.
With all of the
agricultural expenditures, illness, injury, and minimal profits, tobacco
farming, though more profitable than other agricultural endeavors, is not as
lucrative as the tobacco companies make it seem. Further, though the tobacco companies speak
of the economic hurt tobacco farmers would incur if tobacco control legislation
were passed, among the tobacco-producing counties in the United States,
approximately half of these regions gain 1% or less of their net income from
tobacco farming.[34]
Research
examining farming alternatives has been conducted in the flue-cured tobacco
farming industry. Flue-cured tobacco
farming is more mechanized, has higher acreage, and generates more revenue than
burley tobacco farming.[35] In an effort to examine alternative
agricultural opportunities for flue-cured tobacco growers, Purcell et al.
(2003) conducted a case study in Pittsylvania County, Virginia using 1997 data
(a time period before the tobacco quotas were lowered among farmers nationwide
due to reduced tobacco consumption).[36] The investigators utilized Geographic
Information Systems (GIS) and Linear Programming (LP) in order to analyze
approximately 7,900 acres in the region for crop and livestock
alternatives. Researchers assessed the
baseline net revenue for various scenarios of farming options and found that
with a 50 percent cut in tobacco quota, Pittsylvania tobacco farmers were
subject to a minimum 16.9% baseline net revenue loss. So, though tobacco farming is not extremely
profitable, it generates more revenue than traditional agriculture growing and
livestock alternatives. Therefore, in
evaluating tobacco control legislation, the economic effect on tobacco growers
should be considered.
In an economic
analysis of tobacco farming, Altman et al. estimated that the total number of
jobs lost in the South would be approximately 36,500 should tobacco use be
eliminated in the United States.[37] However, Altman went on to mention that
economic safeguards could be implemented to control for the adverse economic
impact in the South. He proposed that
state and/or federal governments could raise tobacco excise taxes and allocate
increased revenue for tobacco-reliant regions, particularly for tobacco
harvesters. The allotted funds could be
used to help farmers diversify their land or to aid conversion into alternative
ventures altogether. This would
safeguard harvesters from job loss while encouraging them to become less
dependent on tobacco profits. It would
also protect growers from the financial risk associated from attempting
ventures into new enterprises and offset the financial burden of start-up
costs. Additionally, Altman points out
that some governments in tobacco-producing states (particularly Virginia and
Kentucky) tender low-interest loans for small businesses (such as tobacco
farms) interested in diversifying.
Tobacco
Corporations and Marketing Campaigns
As mentioned
previously, tobacco companies in the United States earn more than sixty cents
for each pack of cigarettes sold, a higher profit margin than farmers,
government taxes, and retailers combined.
Philip Morris, a United States tobacco corporation noted for the
Marlboro brand name, is the world’s leading tobacco company, holding 16.4% of
the global market and with net earnings of 47 billion US dollars in 1999 alone.[38] Other leading tobacco corporations selling
tobacco in the transnational market include: the United Kingdom’s British
American Tobacco (BAT) with 15.4% of the global market, Japan Tobacco
International (JTI) with 7.2% of the market, Germany’s Reemsta with 2.6% of the
market, and Spain’s Altadis with 1.9% of the market.[39] In order to maintain high net earnings,
tobacco companies utilize massive advertising campaigns in an effort to attract
new consumers, particularly younger consumers.
In the United
States in 1970, tobacco companies spent 361 million dollars on advertising,
while in 1993 tobacco companies spent six billion dollars.[40] Though the United States government banned
televised marketing in 1994, tobacco advertising expenditures remain high. Tobacco companies continue to advertise using
promotional allowances, special offers/gifts, coupons, in-store advertising,
entertainment, magazines/newspapers, specialty item distribution, sporting
events, direct mail, free samples, outdoor marketing (e.g. outside convenience
stores), public transport, and the internet for a total marketing campaign cost
of approximately 9,660,950,000 dollars (about $200 per smoker or $0.46 per pack
of cigarettes) in the year 2000 alone.[41] In fact, as the number of smokers and total
cigarette consumption has been declining, the tobacco industry continues to
spend more money each year on advertising.[42]
As mentioned
previously, tobacco companies also benefit from their marketing campaign as it
attracts potential consumers, particularly adolescents. In a study of 2,518 California adolescents in
1999, Pierce et al. (2002) found two primary social persuasions that were
significant forecasters of adolescent smoking were peer pressure and
receptiveness to tobacco corporate marketing campaigns.[43]
Though adolescents with more-authoritative parents tended to smoke less than
adolescents with less-authoritative parents, having friends who smoke and
interest in advertising were still the chief determinants of adolescent
experimentation with tobacco. Tobacco
consumption among adolescents is also influenced by the cost of cigarettes (the
cheaper it is, the more teens will try/continue smoking) and tobacco company
promotions (i.e. clothing and other paraphernalia), another type of marketing
often employed by the tobacco industry.[44]
Tobacco
advertisements are also found in discreet fashion in films and on television,
both through brand appearance and tobacco consumption. It could be argued that children and are a
major target of this type of advertising as one review of 50 G-rated animated films
found 76 characters using tobacco products for a total duration of 45 minutes.[45]
Another study has found that 90 percent of films reviewed for various age
groups have incidences of cigarette consumption.[46] Researchers have also found that children and
adolescents observing cigarette smoking and brand exposure in movies is a
potential risk factor for introduction to tobacco use (the findings were
statistically significant, even when controlling for peer pressure, personality
traits, and parental influence).[47] One study has also noted that the fictitious
cigarette smoking represented in film does not mimic reality of smoking. In movies, smokers are depicted as
influential, wealthy, romantic, and cool, with the addictive nature of nicotine
seldom symbolized, while the reality that the majority of smokers have a lower
socioeconomic status is hidden.[48]
Tobacco Cessation
and Healthy People 2010 (www.healthypeople.gov)
Healthy People
2010 is a Center for Disease Control program that establishes a holistic set of
national health objectives in an effort to measure health improvement over the
decade. Healthy People was established
in 1979 with “Healthy People: The Surgeon General’s Report on Health Promotion
and Disease Prevention”. The goal of the
Healthy People program is to remove disparities from the health care system
while improving quality and years of healthy life among Americans. Healthy People have identified 28 health
focuses, 467 specific objectives, and ten leading health indicators (major national
health issues) for the current decade.
Tobacco use is classified as a one of the public health issues and there
are 27 objectives related to tobacco exposure in non-smokers, current tobacco
use, smoking cessation, advertising, tobacco use in the workplace, and
governmental tobacco control legislation.
Healthy People 2010 includes the following specific objectives: to
decrease cigarette consumption among adults to 12 percent, to decrease current
cigarette use among adolescents to 16 percent, to increase the average age
adolescents try smoking from 12 years to 14 years, and to increase smoking
cessation attempts among adults (to 75 percent) and adolescents (to 84
percent). Though federal tax still
collects $0.11 per tobacco dollar[49]
and though tobacco companies continue to spend millions of dollars on campaign
contributions for the United States government and on lobbying in Congress,[50]
the federal government is starting to take a more active role on the issue of
tobacco cessation through the implementation of programs like Healthy People
2010.
Transtheoretical
Model of Change
Prochaska,
DiClemente, and Norcross[51]
(1992) originally proposed the Transtheoretical Model of Change to describe an
individual’s attempt to quit smoking (the theory has now been applied to a
variety of problematic behaviors). Stage
one is the Precontemplation stage
when the individual is not sincerely considering the idea of suspending tobacco
use at any point in the future. This is
the least active stage and individuals are frequently either unaware or
“underaware” of their nicotine addiction or the harm it is causing them at this
point. Stage two is Contemplation when the individual realizes they have a problem and
is now considering an attempt to terminate their smoking habit. Though they are thinking about quitting, they
have not yet committed themselves or resolved to try at this point. Stage three is Preparation when the individual intends to try to quit in the next
month and has attempted to quit in the past year, though unsuccessfully. At this time, a person may modify their
behavior by reducing cigarette consumption, though smoking is not entirely
eliminated at this point. Stage four is Action when the individual has made
behavioral changes, has committed him/herself to attempting cessation, and
abstains from smoking for a period of one day to six months. Stage five is Maintenance when an individual continues to abstain from smoking
and is making an effort to avoid relapse from the time period of six months or
longer. At this point, an individual is
continuing in their prior efforts and expanding behavioral changes. Additionally, individuals may or may not
experience or advance through all of the stages. Some people skip stages when attempting
tobacco cessation.
Research has
demonstrated that the leading predictor of a successful cessation attempt for
individuals using the Transtheoretical Model is a person’s readiness to change.[52] Though a person may have intentions of
quitting, they may not be prepared for the behavioral modifications necessary
for tobacco cessation. Prochaska et al.
(1992) reason that while 50-60 percent of smokers are in the Precontemplation
stage, 30-40 percent of smokers are in the Contemplation stage, and only 10-15
percent of smokers have advanced to the Action stage.[53]
Primary Health
Care Professionals and Cognitive/Behavioral Interventions
Russell et al.
(1979) conducted an early study of smoking cessation and medical intervention
in the United Kingdom with more than 2,000 current smokers participating in the
research project.[54] Subjects visiting their general practitioner
for regular consultation were randomized to one of three intervention groups or
a nonintervention control group. The
three intervention groups were: participants given a smoking questionnaire
given prior to their appointment, participants given a one to two minute
smoking cessation guidance, and participants given both a one to two minute
smoking cessation guidance and leaflet containing instructions on how to quit. Smoking cessation was evaluated after one year
had elapsed. While 0.3% in the control
group had quit, 1.6% in the questionnaire group had quit, 3.3% in the guidance
group had quit, and five percent of individuals given instruction and the
leaflet were no longer smoking. These
findings demonstrate that medical intervention, no matter how brief, may have a
statistically significant effect on prompting individuals to make a successful
attempt at smoking cessation.
Presently,
tobacco cessation programs tend to vary in length of program (ranging from one
day to ongoing treatment unspecified in duration) and in type of program
(whether it utilizes multiple types of support, contains multiple steps, or are
single-faceted interventions). In a
United States Public Health Report reviewing more than 6,000 research articles
and abstracts from the Journal of the American Medical Association (2000),
various smoking cessation treatment methods relating to clinical practices were
evaluated.[55] The issue of the dose-response relationship
between level of nicotine dependence and length of cessation counseling was
mentioned as cigarette consumption varies among tobacco users and has a
potential effect on successful cessation.
However, the authors noted that in some cases a brief intervention may
be successful. Practical counseling and
social support offered during and/or outside of treatment were reported to be
particularly valuable methods for increasing smoking cessation success rates
among individuals. Further, the importance
of the availability of cost-effective treatment and health insurance coverage
for such programs was highlighted, as many smokers are of a lower socioeconomic
status. Of particular mention was the “5
As” strategy, a program to aid individuals seeking smoking cessation. This strategy recommends that patients are
systematically ASKed whether they use tobacco in order to identify smokers;
that identified smokers be ADVISEd to quit; that health care professionals ASSESS
whether identified smokers wants to quit; that a health care professionals
ASSIST identified smokers who want to quit; and that health care workers
ARRANGE follow-up sessions for identified smokers who want to quit.[56]
Nicotine
Replacement Therapy and Pharmacological Cessation Treatments
Due to the
addictive nature of nicotine, smoking cessation is extremely difficult and
relapse is common among individuals who attempt to quit. As withdrawal symptoms can be difficult to
endure among nicotine-dependent individuals, nicotine replacement methods and
pharmacological aids are often employed to support individuals attempting to
quit smoking. However, it is recommended
that individuals should first attempt cessation independent of any nicotine
replacement therapy method or pharmacological aid.[57] Nicotine replacement methods deliver lower
nicotine levels to the body than derived from smoking without the carcinogenic
effects of tobacco. NRT methods are
neither toxic nor addictive or habit-forming[58]
and are often available over the counter.
As previously mentioned, cigarette smoking delivers nicotine to the body
in 6-7 seconds, while nicotine replacement therapy is not absorbed as
quickly. Nicotine replacement products
are intended to be and most effective when used as an adjunct to treatment rather
than a replacement for other cessation programs or counseling.[59]
Nicotine
replacement methods include: Nicotine
gum, the Nicotine transdermal patch, the
Nicotine nasal spray, the Nicotine inhaler, and the Nicotine sublingual tablet. In a meta-analysis of 53 nicotine
replacement therapy (NRT) studies (17,703 participants) findings suggested that
NRT 6-12 month cessation rates are twice as high (15-25%) with an odds ratio of
1.71 (95% CI=1.56-1.87) than when compared to control study participants who are
attempting cessation independent of any nicotine replacement method. [60] The current NRT products have demonstrated
similar efficacy in use, although little research has been conducted to compare
the different nicotine replacement methods to each other. This is particularly important considering
that the various nicotine replacement methods have different effects on the
body. While nicotine gum, nicotine nasal
spray, and nicotine inhalers are administered through self-dosing when the
individual is “craving” nicotine and absorbed by the body within minutes, the
nicotine transdermal patch is adhered to the body in the morning and functions
by administering an extended release of nicotine to the individual over the
course of a day. These products are offered
in varying doses and can be dispensed to individuals based upon the degree of
nicotine dependence. Though intended for
short-term use and to be weaned steadily as the degree of nicotine dependence
diminishes, some individuals do employ nicotine replacement methods for
extended periods of time. Nicotine
replacement methods are sometimes combined to combat withdrawal symptoms for an
individual attempting cessation (i.e. nicotine gum used in conjunction with the
nicotine transdermal patch).[61]
For some individuals,
pharmacological treatment is employed, as some prescription medications have
been found to be effective in the off-label use of aiding smoking
cessation. These medications are
sometimes prescribed in addition to NRT methods, although they can be
administered independent of NRT methods.
Commonly used as antidepressants,
Buproprion (Wellbutrin), Doxepin, Desipramine, and Nortriptyline, exhibit evidence that they may increase smoking
abstinence in moderate to heavy smoking individuals.[62] Clonidine,
an Alpha2-adregenergic agonist (often used to manage
hypertension), is sometimes prescribed to curb withdrawal symptoms in
individuals unable to tolerate other pharmacological aids and nicotine
replacement methods. Although, Clonidine
is administered as a final option due to side effects like dry mouth, sedation,
and dizziness.[63] Other pharmacological treatment methods have
been evaluated as aids to tobacco cessation and yielded inconclusive results,
including medications such as appetite suppressants, benzodiazepines,
beta-blockers, buspirone, caffeine/ephedrine, cimetidine, dextrose tablets,
lobeline, moclobemide, and SSRIs.[64]
Successful
Tobacco Cessation Studies and Program Implementation
While some
tobacco cessation programs exist relatively independently, other programs are
part of a holistic public health initiative.
The North Karelia Project is an example of a region’s all-encompassing
health initiative.[65],[66] The North Karelia project began
in 1972 as an effort to reduce the high rates of cardiovascular diseases in the
community. Local representatives,
national experts, and World Health Organization officials implemented a
campaign to urge citizens modify their diet and quit smoking in order to avoid
cardiovascular diseases. This region was
one of the first localities to ban smoking in public places and even
popularized smoking cessation using national broadcasts and “quit and win”
competitions. Cholesterol-lowering
promotions were also popular and government assistance prompted many dairy
farmers to convert their farms to berry production. Though the project was originally intended to
last for five years, it went on until 1997, twenty years after it’s original
stop date.
A similar
initiative has been developed in Victoria, Australia. VicHealth has identified a number of priority
health issues in the region, mainly: healthy eating, built environment,
inequalities, mental health and well-being, physical activity, substance
misuse, sun protection, and tobacco control.[67] This organization has been instrumental in
developing programs like: “the walking school bus”, an “out of school hours
sports program”, “arts for health program”, and many other pro-health safety
behavior programs. The VicHealth Centre
for Tobacco Control is an extension of VicHealth and works in conjunction with
Quit Victoria in an effort to reduce tobacco rates among the 19.2% of
Australian adults who currently smoke in Victoria.[68] Together, the VicHealth Centre for Tobacco
Control and Quit Victoria are working to educate Victorians about the adverse
effects of smoking, the negative impact of marketing campaigns, the benefits of
committing to a smoking cessation program, the positive impact of promoting
tobacco control legislation removing smoking from sporting venues, dining areas,
and other public places, and efforts to keep youth from attempting to
smoke. Their website promotes smoking
cessation with a mascot (Will Power), a song, a quit calendar, and smoking
cessation research and literature.
In a 1993 to 1996
smoking cessation program implemented in 20 primary care clinics in
Pennsylvania, primary care nurses recruited 1,695 patients.[69] The study was sponsored by a health
maintenance organization (HMO). Patients
with an HMO (that supported nicotine replacement therapy) were compared to
those without an HMO. After a one-year
enrollment period that included scheduled smoking cessation counseling visits,
patients with an HMO self-reported quitting at a rate of 30.5 percent compared
to those without an HMO who reported cessation at a 20.9 percent quit. Those without an HMO were less likely to
maintain smoking cessation counseling visits.
This study supports the theory that smoking cessation rates increase
with a cost-effective therapy and that quitting is more successful when cessation
attempts combine counseling and nicotine replacement therapy.
There are special
interest groups that need to be considered on the subject of smoking
cessation. Smoking tends to be higher
among mental health patients, as dual diagnosis common within this
population. Yet, although this theory
has been repeatedly reinforced, little research has been conducted on the
subject smoking cessation programs within mental health populations.
Tobacco Control
Legislation
Legislation has
historically had a direct and indirect effect on tobacco cessation. As it was previously mentioned, federal
excise taxes could serve as a potential funding source for tobacco
growers. However the implementation of
additional taxes, smoking bans, and advertising tobacco control legislation
could all have an indirect effect on cigarette consumption as well.
The effects of
second-hand smoke (or environmental tobacco smoke) and the move towards indoor
smoking bans (or clean air indoor policy) are a strong initiative currently being
debated in many cities and states nationwide.
While California, Florida, Massachusetts, New York, and Vermont have all
adopted anti-smoking legislation within bars and restaurants in an effort to
make more workplaces smoke-free, cities in thirty states have followed suit[70]
with most clean indoor air policies being implemented through self-enforcement.[71] While the arguments in favor of smoking
restrictions in public places and workplaces lie in the harmful effects of
environmental tobacco smoke, smoking restrictions also tend to have an indirect
effect on smoking prevalence and daily cigarette consumption.[72] This may be particularly true for current
smokers who are in the contemplation stage, as it may influence them to move
into the preparation and/or the action stage.[73] An additional benefit to more public smoking
restrictions is the removal of further social influences for onset in
adolescents.[74] So, while Clean Air Indoor Policies may limit
the amount environmental tobacco smoke in public, it may also influence smoking
prevalence, cigarette consumption, and onset within the general
population.
Further research
has indicated that other tobacco control factors tend to decrease smoking
prevalence rates in adolescents. It has
been suggested that a tobacco price or tax increase of ten percent could
potentially reduce tobacco consumption anywhere from three to six percent
within the general population, especially among adolescents who where higher
tobacco prices have led to dramatically decreased tobacco sales in the past.[75] Additionally, though laws exist restricting
the sale of cigarettes to minors, enforcement of these laws has been weak.[76] By restricting access, adolescent onset and
prevalence rates could decrease. As
previously mentioned, research has demonstrated that children and adolescents
are influenced (if not, targeted) by the marketing campaigns of the tobacco
industry. So, obviously by further
restricting the ability of tobacco companies to market to the general public,
onset rates in adolescents could be reduced.[77]
Tobacco
Information and Cessation Resources
1. About Smoking: http://www.quitsmoking.about.com/
2. Agency for Healthcare Research and Quality: http://www.ahrq.gov/consumer/index.html#smoking
3. American Cancer Society: http://www.cancer.org/docroot/PED/ped_10.asp
4. American Legacy Foundation: http://www.americanlegacy.org/
5. American Lung Association: http://www.lungusa.org/
6. Center for Disease Control and Prevention (TIPS): http://www.cdc.gov/tobacco/
7. Center for Tobacco Cessation: http://www.ctcinfo.org/
8. Circle of Friends (for women): http://www.join-the-circle.org/
9. Clean Break Online: http://www.cleanbreak.com/
10. Great Start (for pregnant women): http://www.americanlegacy.org/greatstart/
11. Healthy Living-TLC (The Last Cigarette): http://www.bcbsmo.com/healt_links/healthyliving/TLC.shtml
12. National Cancer Institute Smokefree Site: http://smokefree.gov/
13. National Institute of Drug Abuse: http://www.nida.nih.gov/
14. North American Quitline Consortium: http://www.naquitline.org/
15. QuitNet: http://www.quitnet.com/
16. Stand Ohio (for adolescents): http://www.standohio.org/index.asp
17. Treatobacco.net: http://www.treatobacco.net/home/home.cfm
18. World Health Initiative, Tobacco Free Initiative: http://www.who.int/tobacco/en/