rtFootnotes]>[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/



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