Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Sunday, December 9, 2007

The Tobacco Free Initiative: A Flawed Global Public Health Intervention – Bukola Sowunmi

The Vienna Convention for the Protection of the ozone layer was created to reduce the use if chlorofluorocarbons which are responsible for depleting the ozone layer. This protocol reduced the total worldwide consumption of chlorofluorocarbons from about 1.1 million tonnes in 1986 to 160 000 tonnes in 1996. This protocol was regarded as the perfect example for using international legislature in solving global environmental and health problems (1). It was drastically reducing the depletion of the ozone layer and preventing an increase in the amount of skin related diseases and global warming. One of the present global health concerns is the consumption of tobacco and its related illnesses. There does not seem to be a reduction in the amount of tobacco smoking on a global scale. The Framework Convention on Tobacco Control (FCTC) was developed in 1993 by the World Health Organization in response to the globalization of the tobacco epidemic (2). The Tobacco Free Initiative (TFI) is the project that is responsible for ensuring that the FCTC achieves its objectives. Unlike the Vienna Convention for the protection of the Ozone layer, the Framework for tobacco control would be unsuccessful because it fails to address the sociological aspects of the human existence.

Theory of Reasoned Action

The theory of reasoned action can be used to analyze and explain the reason for which the TFI would not be able to accomplish the objectives of the FCTC. The theory of reasoned action focuses on a person’s attitude toward a particular behavior and the subjective norms which they associate with that behavior. In TRA, intention is the best way to predict behavior. The attitude and subjective norms typically determine the intention of the individual to perform the behavior (3). The attitude explains what the individual thinks about the outcome of smoking. The TFI and FCTC have failed to take into consideration the subjective norms that play a role in the theory of reasoned action. The framework does not consider the somewhat primitive cultures of the world. Tobacco smoking has been present since ancient times. Villages and communities cultivate tobacco plantations. It has run in some families for hundreds of years. The TFI does not solve the problem of an instance in which a tobacco farmer would refuse to give up a family tradition of 200 years.

Tobacco is an integral part of some cultures and tribes. This could be in the form of smoking, chewing, cultivation, or cosmetic. The first major step in the production of a cigarette is its cultivation. Families make a living out of planting tobacco. The legislation of the FCTC concerning the control of tobacco cultivation cannot be implemented in all countries. First, there are 168 countries that are members and have signed the treaty (2). There are many more countries that have not signed the treaty. In addition, countries that have signed this treaty are not obliged to follow the measures of the treaty. The countries which have not signed it may or may not have their own tobacco laws. An addition of FCTC tobacco laws to a country’s already existing could create confusion and undermine effective laws that would actually curb the tobacco epidemic.

A country that is not signed to the FCTC and does not have or implement its tobacco laws is going to continue to add to the problem of world wide tobacco consumption. Countries which are not signed to the FCTC treaty and also, have and enforce their tobacco laws are countries which would be effective at controlling tobacco consumption. However, their effort could prove to be futile because tobacco is produced worldwide. It is grown in one part of the world, processed in another part of the world and sold in the general world market.

Second, all countries cannot enforce the laws effectively. Developed countries would normally be able to enforce laws to a reasonable extent but developing countries would not be able to enforce those laws. A developing country which cannot enforce traffic laws would not have any capacity to enforce tobacco laws. Tobacco control in a developing country would not be a priority when the majority of the population is poverty stricken. Other issues such as corruption, economic failure and ravaging diseases like malaria and AIDS would be of greater concern (9). In addressing the subjective norms and the actual smoking of cigarettes, an individual is usually bound by the norms of the society. In some parts of India, the use of tobacco is common in the form of chewing and smoking bidi (4). It is part of some Indian cultures. For an individual who grows up in an Indian village where smoking bidi is the norm, that individual may feel a strong attachment to the culture and smoke the tobacco regardless of the attitude. That individual may see it as compulsory to smoke the bidi because of family members. In a study on condom use in Ghana, it was discovered that respondents who intended on using condoms and those who had no such intentions were equally as motivated to comply with the wishes of their referents; family, sexual partners, doctors or close friends (5). In the cultural use of tobacco, those who have a positive attitude and those who do not have a positive attitude towards the use of tobacco may want to comply with their cultural norms of tobacco smoking or tobacco cultivation. The motivation to comply with cultural norms plays a major role in the subjective norm that leads to intention to smoke tobacco. The FCTC and TFI have not developed an efficient means of controlling tobacco use from this perspective.

Social Learning Theory

Learning occurs in the everyday life of humans. Learned behavior could be good or bad or both. Social Learning Theory was formulated on the theory of learning by observation (6). This social learning occurs through close contact, imitation of superiors, understanding of concepts, and role model behavior (7). Smoking is an easily learned behavior. This is one of the major reasons why smoking is rampant in the world today. The FCTC and TFI are meant to reduce the global consumption of tobacco thus eliminating its adverse effects. The prevalence of smoking in developed countries has declined due to research based control. On the other hand, developing countries that have fewer resources have been experiencing a higher prevalence of smoking. Smoking prevalence is shifting from more to less developed countries (8). The less developed countries are in close contact with developed countries and there is an imitation of ‘superiors.’ Smoking is declining in the western world but it is still prevalent enough to be learned by other parts of the world.

Tobacco adverts are very much controlled in the developed world. There are more anti-campaign adverts on television than there are smoking adverts. Using the social learning theory, the media is a major reason why the efforts of the WHO at curbing global tobacco consumption would be futile especially in the developing countries. Developing countries have more exposure to western culture through magazines, the internet, and satellite television. Most of these countries do not have a way of controlling the media. The WHO does not have control over the media of poorer countries. The tobacco adverts in developing countries are some of the flashiest adverts on the networks. A Caucasian male dressed in a white suit stands by the window of a lavishly furnished high rise condo and stares at the world in front of him. In front of him lies a lot of other shiny high rise buildings. There is a grand piano beside him. On top of it lies his pack of menthol cigarettes with one cigarette sticking out. These types of adverts are eye catching and they do have a lot of air time on the TV networks of developing countries. They portray a life of success. An individual in this region of the world looks at that adverts and dreams of himself in that high rise Manhattan apartment. He definitely cannot afford that apartment, the suit and the piano, but he can surely afford to walk down to a road side store and buy one thing that he saw in the advert – the cigarettes. The urban pop culture of the western world, especially the United States would appeal to teenagers in the developing world. Through satellite TV, teenagers in the third world can watch celebrities smoke in movies and in real life, they can watch their favorite artists smoke in their cadillacs. They may not be able to afford their jewelry and cars, but they can learn their behavior by talking like them, walking like them, and smoking like them. The media is a major avenue through which smoking is learned. Imitation through the western media is definitely accounting for the rise in smoking in developing countries. The FCTC cannot effectively reduce the prevalence of global smoking without solving this issue. Even though smoking is declining in the western world it is still existent and it may never decline to the levels where it would not be imitated by the populations of the developing world who want to live like their counterpart in the developed countries. In contemporary society, smoking is seen as a violation of healthful behavior, and also, good and acceptable behavior (10). Within the developed regions of the world, smoking among teenager is a deviant behavior that makes them look “cool” is some particular situations. The social learning theory is a model that can be used to understand the strategy which can be used to curb the smoking of tobacco. Even if the FCTC succeeds in controlling the supply and demand of tobacco, it would not curtail the learning of the behavior. If there is a scarce supply of tobacco, which is very unlikely, the scarcity would make deviant teenagers look “cooler” amongst their peers.

Self-Efficacy

Some individuals believe that they cannot get through the day without smoking. I usually tell some of my friends who smoke, “you are killing your lungs, you’ll die soon,” and they would not bat an eyelid. They have a low self efficacy. Self efficacy is the belief that one has the capabilities to execute the courses of actions required to manage prospective situations (10). The factor analysis of 16 items scale showed that mood changes, relaxation, stress and self image are four essential factors that increased smoking urge in a population (14). Self efficacy is the strongest predictor in the process of trying to quit tobacco smoking (14).

The FCTC framework wants to reduce the amount of tobacco in a world in which a great number of people live in cities and work long hours. Individuals who work long hours have an increased risk of smoking and a one-third of young smokers reported that they first smoked at work (14). Smokers have different psychological profiles and subtypes that need different types of information and intervention to be inspired to quit smoking (14). The FCTC framework has not put into consideration a method to cater for all these different psychological needs. An effort to do this may not be very feasible. According to a study carried out on smoking habits in Kuwaiti adults, different smokers need different public health messages and program interventions (14). An intervention that works for a group of individuals may not work for another group of individuals. This could be as a result of some other external factors. Income and education are factors that play a role in self efficacy. Individuals with low income experience more hardships and stress. They have an increased urge to smoke. Individuals with lower levels of education are more likely to smoke because they are less receptive to smoking interventions that is targeted at them. They may not be able to understand the information that comes with such interventions. Self efficacy is an imperative factor in the change of adverse health behaviors (14). The FCTC framework does not properly account for self efficacy mainly because it has not tackled the factors that tend to reduce self efficacy in individuals trying to quit smoking. The FCTC framework has to address socioeconomic factors and the stress filled world in which we live in. Stress would always be a part of our society and the FCTC framework does not have a plan to eliminate stress. It neither has any alternatives that are enticing enough to make smokers quit. When the FCTC and TFI have a plan in place, it would only be effective in a proportion of the population since different messages and strategies are required for people with different psychological needs.

Conclusion

The main objective of the FCTC is to protect the present and future generation from the devastating consequences of tobacco through information, strong political commitment, international cooperation, comprehensive multisectoral measures, and technical and financial assistance; along with an emphasis on the supply and demand (12). The protective factors of smoking especially in teenager includes individual influences (which includes refusal self efficacy), social relationship influences, and environmental and cultural contexts (13). Tobacco would always be present in our society. The objectives and principles of the FCTC are strong measures and strategies but the entire approach is flawed because they are not approaching it from the correct perspective. A global campaign on tobacco would not yield positive results because of the enormous diversity and the different social factors that cut across the different populations of the world.

References

1. Sarma KM. Protection of the Ozone Layer – A Success Story of UNEP. Linkage Journal 1996; Vol. 3 No 3.
2. The WHO FCTC: A Global Health Treaty. (
http://www.who.int/tobacco/framework/en/).
3. Poss JE. Developing a New Model for Cross-Cultural Research: Synthesizing the Health Belief Model and the Theory of Reasoned Action. Advances in Nursing Science 2001; 23(4): 1-15.
4. Dikshit RP, Kanhere S. Tobacco Habits and Risk of Lung, Oropharyngeal and Oral Cavity Cancer: A Population-Based Case-Control Study in Bhopal, India. International Journal of Epidemiology 2000; 29: 609-614.
5. Bosompra K. Determinants of Condom Use Intentions of University Students in Ghana: An Application of the Theory of Reasoned Action. Social Science & Medicine 2001; 52: 1057-1069.
6. Edberg M. Social, Cultural, and Environmental Theories (Part I) (pp 52-62). In: Edberg, M. Essentials of Health Behavior. 2007.
7. Wikipedia. Social Learning Theory. Wikimedia Foundation Inc. (
http://en.wikipedia.org/wiki/Social_learning_theory).
8. Lando HA, et al. The Landscape in Global Tobacco Control Research: A Guide to Gaining a Foothold. American Journal of Public Health 2005; 95(6): 939-945.
9. Warner KE. The Role of Research in International Tobacco Control. American Journal of Public Health 2005; 95(6): 976-984.
10. Akers RL, Gang L. A Longitudinal Test of Social Learning Theory: Adolescent Smoking. Journal of Drug Issues 1996; 26(2): 317-343.
11. Wikipedia. Self-Efficacy. Wikimedia Foundation Inc. (
http://en.wikipedia.org/wiki/Self-efficacy).
12. WHO. WHO Framework Convention on Tobacco Control: World Health Organization 2003; pp 1-15.
13. Chang F et al. Social Influences and Self-Efficacy as Predictors of Youth Smoking Initiation and Cessation: a 3-year longitudinal study of vocational schools in Taiwan: Addiction 2006: 1645-1655.
14. Badr HE, Moody PM. Self-Efficacy: A Predictor for Smoking Cessation Contemplators in Kuwaiti Adults. International Journal of Behavioral Medicine 2005; 4:273-277.






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1 Comments:

  • At December 14, 2007 at 6:28 AM , Anonymous Jaffy said...

    These are powerful arguments. I especially like the way you explained the second one- about social learning theory.

     

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