Don’t Hold Your Breath-Changes Needed in Lung Health Education- Rachel Hill

The National Lung Health Education Program (NLHEP) is a group of professionals including doctors, respiratory therapists, and esteemed members of the American Association of Respiratory Care (AARC) who are dedicated to increasing the awareness of Chronic Obstructive Pulmonary Disease (COPD) across the spectrum of healthcare and the general population. They utilize pamphlets, speaking engagements, and documented research to help further their goal. I am going to argue that the NLHEP has failed in its goal to create a successful program of intervention and early detection of COPD in its early stages among the population at risk, and to increase awareness of COPD within the general public or among healthcare professionals. The NLHEP has also been unsuccessful in raising awareness among primary care physicians about the use of simple spirometry testing as a tool for early detection and diagnostic criteria of COPD. And focus even less on early intervention of those at risk for COPD. This is the primary method to which this institution states it uses to achieve its goals of increasing awareness, early intervention, and early diagnosis of COPD. Their goals of increasing awareness and promoting early screenings, while great ideas, are not being executed in the best possible methods.

The NLHEP campaigns have traditionally not focused on any specific population. Their target population as stated in the mission statement is “all smokers, former smokers, and people who are regularly exposed to environmental tobacco smoking or occupational exposures” as well as, “physicians, all health care professionals, patients and the public” (6). The population target is just too broad and expansive with each group requiring specific needs in order to have any form of success within each target group. Physicians require a more medical message of screening and diagnosis using statistics and peer reviewed studies. The general population message needs to focus more on awareness and risk factors. By trying to figure out the best most understandable message for each group instead of focusing on one single message that is either too elementary or too complex, they would be more successful in having more people being aware of COPD in the dimension that makes the most sense for each group. For Example: A person with no medical training does not need (or want) to know what the specific diagnostic numbers in the spirometry testing formally point to the diagnosis of COPD. Nor does a physician need someone telling them what COPD stands for and what diseases encompass COPD.

Based on Social Marketing Theory which is basically figuring out what people want and understand and tailoring the message to that target population. We can not deliver a message to physicians in the same manner as we would address the public. Physicians require a different language and tone in order to capture their attention (generally more scientific and statistical) than the general public which has little (if any) medical training and varying educational backgrounds. Not only does each group have specific requirements regarding message delivery, they also have different outlooks about lung health (2, 7). Physicians are generally ready and able to promote lung health, while the general population does not see lung health as an overt problem until symptoms arise. This is partly shown by the number of late stage diagnoses of COPD and emergency room visits for shortness of breath by the general public whom if diagnosed earlier would be better managed (8). Among people aged 45-54 years 32% had an unscheduled emergency doctor’s visit for their COPD and 27% among the same population had emergency room visits for COPD. Had these people been diagnosed earlier they would have been better managed and not needed so many emergency services. COPD is not getting diagnosed in this population who is most at risk until they exhibit such severe symptoms it warrants emergent trips to a physician or the ED. This is proof that the word about COPD is not out in public and the message is obviously not clear, people continue to remain in denial of COPD until it is too late.

People generally lack a self-efficacy around their lung health status, especially the smokers. They tend to feel that the damage is already there and they can do nothing to change it. There is a nihilistic attitude among smokers and even among healthcare workers about the status of their lungs. The NLHEP campaign messages should emphasize that behavior change can make a difference in the status of their lung health, not the nihilistic attitude that you did this to yourself now you have to deal with it. Once people start to realize that it is not too late to quit smoking or make a lifestyle change and they will still make a positive impact on their health, I think people will develop a more positive attitude towards taking control of their lung health.

Physicians tend to focus on secondary prevention (or diagnosis and cessation) and in the general population it is primary prevention that is needed specifically around the area of what COPD is and ways to prevent it (such and not smoking). There is no mention of primary interventions of COPD within the NLHEP.

People need to realize that COPD starts up to 20 years prior to symptoms. Our bodies are amazing in that they will compensate as long as they can, functioning at a lower level (of oxygen) until something happens and it just can not compensate anymore. The importance of a primary care physician being able to do a simple spirometry is that the physician is able to earlier diagnose COPD and act through early interventions (education, medication, etc…) so our bodies do not have to keep compensating. This is part of the mission behind the NLHEP however; there is no plan within the mission for reimbursement for spirometry testing. The cost of doing this test, while relatively small, would just be another added expense to the overhead unless there was a way to reimburse for the test. Currently insurances do not reimburse for spirometry screening, only spirometry as a means of diagnosing symptoms. If it were possible to conduct this simple test more often, we would be able to diagnose earlier and provide earlier intervention (1). There have been a few studies that show that when a diagnosis of COPD is coupled with intervention of smoking cessation there is a much higher rate of success quitting smoking. NLHEP encourages health care professionals to use simple spirometry to conduct prescreenings of patients, primarily those at risk, in the same way we use mammography, for early detection of COPD. This is a great idea, however, they go on to only support certain brands of spirometers fail to propose ways for physician’s offices to be reimbursed for the expense of doing the test. Because of the challenges physicians face with reimbursement for spirometry testing, only 20% of primary care offices (in the US) even have a spirometer to screen patients (4). This means that if a physician would want to screen a patient (or test a patient) they would have to send the patient out to another facility for testing, wait for the test to be scheduled, wait for the results to be read by the physician at the referral facility, wait for a copy of the test to be sent, schedule a follow up visit or follow up testing, the potential for this process to take months is not unusual. Also, the test that would be done would be a full pulmonary function test, a very time consuming and expensive test of which all portions may not be necessary to diagnose and stage COPD compared to the simple spirometry. The initial cost of a spirometer and its set up (computer software, disposable mouthpieces, and other necessary equipment) is expensive estimated at $2000 and up according to several medical device companies including medicalresources.com. Why would a physician spend the money out of pocket with no means of reimbursement? Looking closer into what the physician would want/need in order to comply with the goals of screening all patients (at least those most at risk) for COPD the two things most important to the physician is autonomy in which spirometer they feel most comfortable using. Forcing someone to use equipment they do not like or do not understand is not helpful is furthering the goal of getting this particular population to use the spirometer. The other issue is monetary. While we all would like to see as many patients screened for COPD as possible, if the physician is going to lose money on the project, they can not be expected to give their services away for free. Would you do that? The importance of financing this screening program with the insurance companies, Medicare but more importantly the private insurances and Medicaid is fundamental in the program’s success. We are aiming to identify these people with COPD in early stages, before they qualify for Medicare which is why the private insurances and Medicaid is most important.

NLHEP needs to rally with other groups to start lobbying for more reimbursement coverage for screening of COPD with simple spirometry, especially with Medicare. By working to get more coverage, more and more physicians will be able to afford to test their patients earlier and physicians will be more likely to consider having a spirometer in their office.

The NLHEP has many professional affiliates including the American Thoracic Society, American College of Physicians, American College of Allergy, Asthma, and Immunology, The National Heart, Lung and Blood Institute, and several other prestigious groups (6). Among their affiliates there are several missing key affiliates. Those would be the grassroots affiliates by using community leaders as “elite opinion”. By using these significant people (such as a clergy person, school principal, or social action leader) within their target audience groups (neighborhood, religious, or cultural communities, for example) for their message of prevention and early intervention there is a higher chance of getting the message of COPD translated within that community. This is the institutional diffusion model (7). By using the elite within the community they are able to translate behavior throughout the institution including policy changes, and social norms which in turn affects individual behavior (such as smoking) (7). A person’s attitude towards a specific behavior is based on the person’s perception of social norms associated with that behavior. This means that by getting grassroot affiliates (especially the elite) involved in helping to pass on the word of lung health chances are more likely that people in that target group would be more likely to listen.

Using combinations of Social diffusion models which focus on changing public norms and Institutional diffusion models which focus change from a higher perspective we can incorporate many different uses of grassroot community leaders (Social Network Theory, Social Marketing Theory, Diffusion of Innovations). We can change policy to effect change of individual behavior as well as using social networks to invoke behavior change (7).

Social Networks are a way grassroots organizations can play a vital role in the passage of health promotional messaging. It starts out with just one person being diagnosed with COPD and they tell their family/friends to get themselves checked out before it’s too late. Those people pass it on to their friends/family and pretty soon the group gets larger and larger. People generally belong to more than one community (neighborhoods, jobs, religious, social circles). As more individual communities become more aware of COPD and testing their lungs, the faster the information gets spread. By utilizing a small amount of strategically placed resources we could have a larger influence over a larger population than by just utilizing physicians alone. The use of chain reaction techniques and grassroots organizations could also raise awareness among populations who do not always trust the medical systems. This would work very well among the younger populations (under age 50) who do not necessarily think that they are at risk for COPD. And as we stated earlier, these are the people we need to focus on. This method, although slow moving, has the potential when planned correctly to be more effective and long lasting than the traditional “because the doctor said so” methods. This method is the same as any fashion trend. One person starts a habit such as dying their hair and before we know it everyone is dying their hair. Although a juvenile comparison, the comparison fits. People want to do what is popular. So the goal would be to make testing your lungs popular.

While the NLHEP has many great ideas, their process of implementation is drastically flawed. By applying a more varied method in the way they approach the different target groups they would probably get a more effective message across. They should support a physician’s choice in equipment, not mandate only certain brands. They should also collaborate with the more influential grassroot organizations to develop better strategies to notify and involve the general population in the process of education and intervention. Until the NLHEP opens its eyes to the flaws in its prevention and intervention messages and strategies, they will continue to be unsuccessful in their attempts to decrease the number of people dying from COPD.

References
1. Diagnosis of Airflow Limitation Combined with Smoking Cessation Advice Increases Stop Smoking Rate, Gorecka, D et al. Chest 2003; 123:1916-1923
2. Global Initiative for Chronic Obstructive Lung Disease, Executive Summary 2005, www.goldcopd.org
3. Mechanisms and Management of COPD, Chest/113/4/April, 1998 Supplement
4. Office Spirometry: Key to Ventilatory Assessment. The Clinical Advisor; July/August, 2002
5. Confronting COPD in America; Schulman, Ronca, Bucuvalas, Inc. Access at www.lungusa.org
6. The Early Recognition and Management of Chronic Obstructive Pulmonary Disease, Doherty, Dennis et al, National Lung Health Education Program, http://www.nlhep.org/
7. Edberg, Essentials of Health Behavior, Sudbury, MA Jones and Bartlett 2007
8. GlaxoSmithKline. COPD in America. The Burden of COPD. 2007 http://www.copdinamerica.com/burden.html

The Strategy Behind Florida’s “Truth” Campaign: An Infirm Public Health Intervention—Meng-Yun Lin

Introduction
Smoking has been a public health concern afflicting national and international communities. In 2000, worldwide there were about 5 million deaths related to smoking, in particular between 1997-2001 there were over 435000 deaths attributable to cigarette use ([1]). Centers for Disease Control and Prevention (CDC) conducted a survey in 2006 and reported that 20.8% adults and 23.9% young adults, younger than 18 years old, are current smokers. This survey surprisingly showed that younger kids reported to be current smokers. In the same report, adults reported that they were daily smokers (71%) and smoked their first cigarette before the age of 18 years old (90%) ([2]); 60% started before age 14([3]). Researchers studying senior high school students reported that in 2001, 19% of them reported daily smoking. Studies indicate that people who start to smoke at a younger age are at higher risk for cancer, heart disease, stroke and chronic obstructive lung disease ([4]). No doubt, tobacco use is a serious public health issue as dependence begins during childhood or adolescence in the majority of tobacco users. Public health interventions should target young kids who are at risk to start smoking, to prevent and reduce the long term consequences of tobacco exposure.


"Truth" campaign: a counter-marketing, anti-tobacco media program
In 1997, the Tobacco Industry and the state of Florida reached a settlement of 11.3 billion dollars and 200 million dollars per year to reduce smoking among kids. ([5],[6]). The program made it possible to markedly expand tobacco control programs in the states and provided for the creation of a new foundation, American Legacy Foundation, whose primary purpose is to combat tobacco use in the United States. Florida hired Crispin Porter & Bogusky as their advertising agency to take the lead on the Florida’s youth anti-tobacco project. The agency was charged with creating a series of social marketing interventions incorporating mass media advertisement and web based education sites. This campaign was eventually called the “Truth campaign.” In 1998, a study indicated the percentage of youth tobacco users declined by 7.4 percentage points in middle school and 4.8 percentage points in high school. The "truth" campaign has been well received by public and reduced smoker among youths. The only negative reaction to the campaign has been, predictably, from the tobacco industry ([7]).


It seems that the “Truth campaign” is much successful in youth smoker control, however, considering the context of behavior theories it is an inform public health intervention. In this paper, first, I will look at the modified social marketing theory that the “Truth” campaign uses and focus on the flaws of the anti-tobacco campaign. In my view, the unconventional youth marketing theory is flawed because it neglects to consider the individual factors and environmental effect, rather than just looking at the group level factors. Second, behavior is part of a continuous interactive cycle that includes individuals and their physical and culture environment. I will contemplate the program based on social cognitive theory (SCT) (9-15). Final, I will also argue that the Florida’s “Truth Campaign” should be a model across the nation to decrease smoking among kids ([8]) and discuss how media tobacco control programs use Social Marketing Theory ([9],[10]).


"Truth" campaign lacks tools to promote self- efficacy
Florida’s “truth” campaign is not valid because it does not take into account individual factors for example self-efficacy, self-control and behavioral capability. According to the SCT ([11],[12],[13],[14]), changing behavior includes the following: individual characteristics, environmental factors and reciprocal determinism. Especially, individual factors similar to an internal engine switch and further activate the behavior of quitting smoking or keeping from smoking. For example, self-efficacy as the representative of confidence decides whether kids can shift their behavior to healthier one. And behavior capability meaning the knowledge or skill related to change behavior determines if one can accomplish changing process. Here, I generalize the above-mentioned elements as self-efficacy, teenagers’ ability of devoting themselves to changing behavior. Only when teenagers possess internal impetus can they possibly achieve the action of changing behavior. However, youths at the stage of developing personality usually have lower willpower and lack of self-efficacy. Therefore, it is more difficult for teenagers to make up their mind of changing behavior and to maintain changed behavior.


SCT is based on self-efficacy, and assumes that people have the belief that they could perform a behavior. In the anti-tobacco campaign, even though the ads are very impressive and successfully attract teenagers’ attention, self-efficacy can not be given to students through the ad campaign, therefore reducing their ability to make behavioral changes. In other words advertising succeeds in awaking kids to the “truth”, the death toll of smoking, it does not result in devoting to quit smoking or keeping from cigarette. After all, knowing is one thing and doing is another thing. Elisia L. Cohen ., 2007, conducted a study looking at televised anti-smoking ads to discourage adult and teenagers from smoking, and this study reported that the ads focused on people’s attitudes on smoking([15]). The study also reported that the ads mentioned the benefits of not smoking 61% of the time, while barriers to smoking were mentions 17% of the time. This advertisement campaign demonstrates how anti-smoking campaigns emphasize on the consequences of smoking more that the concept of self-efficacy.


The SCT also states that people need three things to maintain self-efficacy: expectations and expectancies, self-control and emotional coping ability. The people’s expectation about what will happen after changed behavior and if the expect outcome is rewarded. The level of strong will in terms of making the change. Their ability to deal with the emotions involved in the behavior change. To completely change behavior, maintaining self-efficacy plays a crucial role in sustaining changed behavior (11, 12). Campaigns like the “Truth” campaign may get teenagers attention; however teenagers with lower self-esteem may have a more difficult time to change smoking behaviors. And teenagers with low self esteem may have inadequate behavioral and emotional skills to quiet smoking and give up the wayside while suffering from emotional strikes involved in changing step. Finally youth’s behaviors often shift between positive and negative behaviors, making television ads anti-smoking campaigns ineffective.


"Truth" campaign does not emphasize environment factors
This program is ineffective because it regards the young tobacco users as a relatively independent group and ignores the external content in that teenagers live in. Social Cognitive Theory also tells us that individuals social and physical environmental factors play an important role to change behavior. For example, the behavior of other people and the consequences of that behavior cause vicarious learning. Different circumstances in which the anti-smoking communicate may make viewers product distinct perceptions concerning tobacco. In addition, negative or positive reinforcements among live environment give teens various responses to cigarette (9-15). In the program targeted on young people, gender, geography and family’s tobacco use are all critical factors implicating in the intervention outcome. On the other hand, I think temperate education or persuasion is insufficient to reduce youth tobacco prevalence and hence a rigid legislation may be a more active and dominated kind of intervention.
Teenagers that have parents and other family members that smoke are more likely to have access to cigarettes and are at high risk to start smoking at a young age. In a study that compared teenagers with parents that smoked with teenagers that didn’t have parents that smoked reported that the Truth campaign was more effective in preventing smoking among youths that didn’t have parents who smoked ([16]). In other words, in a tobacco-using environment, kids are more likely to access cigarette and it is harder to keep them from smoking. It is clear that access to cigarettes in a home environment and parents that smoke are role models that offset the goal of the Truth campaign. Anti-smoking campaigns should not only target teenagers’ peers, but also include family, because they can also have a strong influence on their smoking behaviors.


Policy changes are an effective way to effect the way that Anti-tobacco campaigns are focused on education or persuasion interventions ([17],[18],[19],[20]). At first, with high public visibility and strong public support, “truth” campaign is somehow significantly successful. Many short-term surveys indicated the teen smoking prevalence rate dropped from 23.3% to 20.9%. Nevertheless, in 1999, the state legislature cut the program’s funding from $70.5 million to $38.7 million, and the Bush administration dismantled the program’s administrative structure ([21]). These changes effected the implementation of the “Truth” campaign, as not only limited the funding support but also weakened the political support for this campaign. Public Health interventions would be more stable if intervention programs were pushed through legislation and became enacted bills. This would allow interventions to become established to be more effective to change behavior. Because smoking prevalence is preventable through precluding potential smoker, legislating will be a powerful intervention. Lack of legislation to control tobacco use resulted in dramatic rise in tobacco consumption in India, the third largest grower of tobacco in the world ([22]). It is more economical to prevent a problem in advance rather then to deal with the puzzle while it developed.


"Truth" campaign risks overestimated the efficacy of marketing
The Truth campaign is too optimistic in having a social marketing media campaign address teenagers issues to effectively change their smoking behavior. In this campaign, social marketing theory sees behavior change a selling product to teenagers. Every year, new public health mass media campaigns are launched attempting to change health behavior and improve health outcomes. Recent years, these campaigns enter a crowded media environment filled with messages from competing limited sources ([23]). With limited government funding, state funded agencies and organizations also have limited resources and political support from legislators to help with funding resources.


Due to the widespread communication, “truth campaign” produced a substantial impact reducing cigarette consumption and stimulating the development of policies to eliminate environmental tobacco exposure. Research looking at teenagers smoking attitudes report that they perceive the serious consequences of smoking from anti-tobacco ads regardless of their sex and ethnicity ([24]). However, such achievements do not therefore lead to the reduction of smoking initiation and smoker population among adolescents in a long term frame. As I mentioned before, if there were state legislation supporting anti-tobacco campaigns it would give them the stability to have long term impacts on the reduction of teenagers smoking rates ([25],[26]) .


The past studies designed to estimate the outcome of “truth” campaign revealed controversial results: some reports showed ads had created a great decrease in teen smoking ([27]) as other studies claimed there were no apparent effect ([28]). The differences in measurement of public health media program might contribute to the effect of differences observed. However, even existing positive outcome the conclusions regarding effectiveness is limited and exclusive. For instance, adolescents who live in tobacco producing regions appear to be less responsive to anti-industry ads than their counterparts in non-tobacco producing regions ([29]). Also, although the anti-smoking campaign had an effect on both sexes, less of an effect was required to influence young women than young men and the effect of ads on young men continued to be weakened ([30]). In addition, study found industry sponsored anti-smoking ads do more to promote corporate image than to prevent youth smoking ([31]). Between traditional marketing-brand cigarette ads, the counter- conventional anti-smoking campaign marketing public health issue seems not as helpful for youth as we expecting.


Conclusion
The Florida’s “truth” campaign uses a variety of scenarios to address the death toll caused by cigarette using, during 1998. The campaign ads use fear and humors tactics to attract teenagers’ attention ([32]), however anti-smoking TV media campaigns are unlikely to be effective, and could have negative unintended consequences. It is crucial to prevention of risk behavior before it becomes embedded in an individual's life ([33]), therefore recent anti-smoking programs principally targeted on young adults. A public health intervention such as the true campaign simple through advertising its idea of anti-smoking, however, is not sufficient. First, anti-Smoking ad campaigns should further focus on the complexity of the behavior the intervention is trying to change. These include individual and social factors. Intervention should not only targets on teenagers but consider them with their parents, families, and communities as a whole. Second, we should reduce the chance of letting kids expose to a smoking-use environment. Forbid smoking around children in daily life as ban against smoking in public places such as schools and hospitals. Increase cigarette taxes according to the growing tobacco consumption and strictly forbid young adults purchasing cigarette through legislating. Third, give adolescents the ability of choosing healthier behavior by establishing their self-efficacy. Set physician counseling to introduce smoking cessation and help children quit smoking. As many teenagers regard smoking as an emblem of independence like adults , through public education teach them anti-smoking is even a mature and cool behavior and giving up smoking is as easy as engaging in. The more extensively a behavior is embedded, the more difficult it is to alter such behavior. Relative levels of embeddedness of the risk behavior and its entanglement with other nonrisky behavior evolve and change throughout one's life course. Without controlling the trend of young smoking population, it would reverse the decline in whole smoking prevalence seen in the past several decades.


REFERENCES
[1] Centers for Disease Control and Prevention. Annual Deaths Attributable to Cigarette Smoking—United States, 1997–2001. http://www.cdc.gov/tobacco/data_statistics/tables/health/attrdths.htm
[2] US Department of Health and Human Services. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center to Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1994
[3] Epps RP, Manley MW. A physician’s guide to preventing tobacco use during childhood and adolescence. Pediatrics 1991; 88:140–144.
[4] Davis JW, Shelton L, Watanabe IS, Arnold J. Passive smoking affects endothelium and platelets. Arch Intern Med 1989; 149:386–389.
[5] Jeffrey Hicks. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.
[6] Bauer UE, Johoson TM, Hopkins RS, et al. Changes in youth cigarette use and intentions following implementation of a tobacco control program. JAMA 2000; 284:723-728.
[7] C Healton. Who's afraid of the truth? American Journal of Public Health 2001; 91:554-558.
[8] Zucker D, Hopkins RS, Sly DF, Urich J, Kershaw JM, Solari S. Florida's "truth" campaign: a counter-marketing, anti-tobacco media campaign. J Public Health Manag Pract. 2000;6(3):1-6.
[9] Philip Kotler, Gerald Zaltman. Social Marketing: An Approach to Planned Social Change. Journal of Marketing 1971; 35(3): 3-12.
[10] Lefebvre, R. Craig; Flora, June A. Social Marketing and Public Health Intervention. Health Education Quarterly 1988;15(3): 299-315.
[11] Mark Edberg. Social, Culture, and Environmental Theories (PartI) (pp 51-64). In: Mark Edberg, ed. Essentials of Health Behavior. Sudbury, MA: Junes and Bartlett, 2007.
[12] Bandura, A. Social cognitive theory. Annals of child development 1989; 6:1-60.
[13] Bandura, A. Social cognitive theory of self-regulation. Organizational behavior and human decision processes 1991; 50:248-287.
[14] Bandura, A. Human agency in social cognitive theory. American Psychologist 1981; 44:1175-1184.
[15] Elisia L. Cohen . Original: Anti-Smoking Media Campaign Messages: Theory and Practice. Health Communication 2007; 22(2), 91-102.
[16] David F. Sly, Richard S. Hopkins, Edward Trapido, ScD, Sarah Ray. Influence of a Counteradvertising Media Campaign on Initiation of Smoking: The Florida “truth” Campaign. American Journal of Public Health 2001; 91(2): 233-238.
[17] Chin R. Benne KD. General strategies for effective change in human systems. In Bennis W et al. (eds.): The planning of Change (3rd edition), pp. 22-45. New York: Holt, Rinehart and Winston, 1976
[18] Rosenblatt M. should our judicial system and legislatures protect infants and children from second-hand tobacco smoke? Children’s Legal Right Journal 2005; 25:37-50
[19] Siegel M. Education and persuasion versus coercion as public health approaches. The Rest of the Story: Tobacco News Analysis and Commentary (blog). May 4, 2006.
[20] Siegel M. Making it unlawful to smoke around children could have detrimental effect on children’s health, especially among disadvantaged populations. The Rest of the Story: Tobacco News Analysis and Commentary (blog). May 22, 2006.
[21] Michael S. Givel, Stanton A. Glantz. Failure to Defend a Successful State Tobacco Control Program: Policy Lessons From Florida American. Journal of Public Health 2000; 90(5): 762-767.
[22] Riti Shimkhada, John W. Peabody. Tobacco control in India. Bull World Health Organ 2003; 81(1): 48-52.
[23] Whitney Randolph, K. Viswanath. Lessons Learned from Public Health Mass Media Campaigns: Marketing Health in a Crowded Media World. Annual Review of Public Health 2004; 25: 419-437.
[24] L Biener. Anti-tobacco advertisements by Massachusetts and Philip Morris: what teenagers think. Tobacco Control 2002; 11:43-46.
[25] Michael Siegel & Lois Biener. Evaluating the Impact of Statewide Anti-Tobacco Campaigns: The Massachusetts and California Tobacco Control Programs. Journal of Social Issues 1997; 53(1):147-168.
[26] Michael Siegel. THE EFFECTIVENESS OF STATE-LEVEL TOBACCO CONTROL INTERVENTIONS: A Review of Program Implementation and Behavioral Outcomes. Annual Review of Public Health 2002; 23: 45-71.
[27] Matthew C. Farrelly, Kevin C. Davis, M. Lyndon Haviland, Peter Messeri, and Cheryl G. Healton. Evidence of a Dose–Response Relationship Between “truth”Anti-smoking Ads and Youth Smoking Prevalence. American Journal of Public Health 2005; 95(3): 425-431.
[28] Matthew C. Farrelly, Cheryl G. Healton, Kevin C. Davis, Peter Messeri, James C. Hersey, and M. Lyndon Haviland. Getting to the Truth: Evaluating National Tobacco Countermarketing Campaigns. American Journal of Public Health 2002; 92(6):901-907.
[29] J F Thrasher, J Niederdeppe, M C Farrelly, K C Davis, K M Ribisl and M L Haviland. The impact of anti-tobacco industry prevention messages in tobacco producing regions: evidence from the US truth® campaign. Tobacco Control 2004;13:283-288
[30] David F. Sly, Richard S. Hopkins, Edward Trapido and Sarah Ray. Influence of a Counteradvertising Media Campaign on Initiation of Smoking: The Florida “truth” Campaign. American Journal of Public Health 2001; 91(2): 233-238.
[31] L Henriksen, A L Dauphinee, Y Wang and S P Fortmann. Industry sponsored anti-smoking ads and adolescent reactance: test of a boomerang effect. Tobacco Control 2006; 15:13-18.
[32] Cheryl Healton. Who’s Afraid of the Truth? American Journal of Public Health 2001; 91(4): 554-558.
[33] Melanie Booth-Butterfield . Embedded Health Behaviors From Adolescence to Adulthood: The Impact of Tobacco. Health Communication 2003; 15(2):171-184.

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.