The role of public health in addressing personal behaviors that influence health status has significantly expanded in the twentieth century. The use of tobacco products is one of these behaviors recognized as the most readily preventable cause of disease and death in the United States. The Surgeon General’s 2004 report1 concludes that, “Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general.” Quitting smoking is advocated as a means of improving health immediately and reducing risks of disease in the future. In this paper we address the historical development of the marketing of tobacco products and tobacco’s impact on personal health in the United States as well as practices found successful in reversing this enormous challenge to public health. Recent research and proven best practices are highlighted to demonstrate how we can reduce tobacco use in Harvestland, Missouri to ensure that all our citizens live healthy and productive lives.
The mass marketing of cigarette use began in the early twentieth century. Subsequent to the marketing strategies that evolved over time and increased tobacco use multi-fold, an increase in the prevalence of illnesses associated with smoking was detected. Lung cancer was almost unheard of in the U.S. in 1900 but is now estimated that it will take the lives of over 172,570 people in 2005.2 The cost to society can be measured many ways. Direct medical costs associated with smoking are approximately $50 billion a year. Productivity and lost earnings because of smoking-related disease and premature deaths cost an additional $50 billion a year. It is estimated that Medicare will spend $800 billion over the next 20 years caring for people with smoking-related illnesses.3 The substantial influence of tobacco companies on the behavioral patterns demonstrated in increased cigarette consumption and deaths due to tobacco use is undeniable.
Public health is based on the concept of social justice4 and, as a field, attempts to better the world for people by addressing conditions of health such as preventable diseases and environmental concerns. The tobacco industry, by contrast, has not operated within a social justice context. Instead the tobacco industry appears to be true to a system of market justice through the promotion and sales of products that people choose to purchase and consume. The tobacco industry defends its advertising and promotions as offering a product in which consumption is a matter of self-volition; it does not force individuals to purchase its product or establish an environment in which personal choice is not a factor. As the industry generates increasing sales, market share and revenues also increase resulting in tobacco leaders, advocates and investors who are pleased with personal compensation and resulting corporate income. Additionally, the U.S. as a whole benefits from over twelve billion dollars a year in tax revenue that tobacco sales generate.5 Superficially, this economic model appears to have substantial returns until consideration is given to the enormous impact on health resulting from tobacco use.
The promotion of tobacco products through unregulated mass marketing in the selling of tobacco and cigarette products cannot be endorsed by public health. Cigarettes contain nicotine which is physiologically addictive, tars and numerous toxic chemicals, leading to multiple negative effects in the body. Not all populations in our society respond to addictive substances and their marketing equally. Free choice to use the product is compromised by these characteristics.6
The social justice concept implies that when the motivation for making choices that affect health is compromised and not equal among all groups, intervention is warranted.7 This intervention could take the form of education about the hazards of tobacco in ways that will assist individuals to make healthy lifestyle choices. With such education, individuals will be empowered with greater capacity to choose what is best for their own health, and ultimately extend this benefit to the community within which they live. Programs directed at preventing the initiation and the cessation of tobacco use support the health of the entire community8 especially when they target communities’ specific needs and are woven into the community structures. Sub-populations within the community such as youth, the uneducated, poor, and mentally ill are recognized as particularly vulnerable to marketing strategies and pressures from the tobacco industry. The implementation of policies and laws restricting access are warranted in controlling tobacco product distribution to all populations including those particularly susceptible subsets. Litigation has successfully resulted in the dictate that the tobacco industry, having benefited from tobacco product sales at the expense of its customers’ health, should now compensate those states which have paid for the health care costs of their citizens who suffered the ill effects of their products. Compensation to states for health care costs, educational programs to reduce tobacco use, and the support of legislation to reduce access to tobacco are efforts they are now required to support.9 Even the established legality of tobacco sales itself comes into question as viewed through the lens of the social justice concept.
The process of imposing a system of social justice on an industry which has operated with impunity purely under market pressures since 191310 has begun. Reports from surgeons general submitted since 1964 summarize research on the health risks of tobacco use and have been a strong educational resource for communicating the health cost that tobacco has imposed.11 Public health interventions such as increased pricing, access restriction, and removal of tobacco smoke in the environment have imposed a social consciousness against tobacco sales. The Master Settlement Agreement and recent legislation have delineated the illegalities of tobacco company operating policies, further condemning their methods to market and sell a toxic product.12 The cost to society of tobacco use has not been adequately compensated by the tobacco companies and their intent to sell more tobacco remains intense as indicated by the globalization of the industry especially into China.13 However public health workers, health care providers and those responsible for the health status of the community are imposing pressures on the tobacco industry to address the social and economic costs of tobacco use. Social justice, not market justice, is challenging the industry with measured success in reducing the percentage of smokers in the U.S. from 40% in 1964 to 23% today.2 The challenge now is to further reduce smoking rates in a population that is informed about the risks of tobacco use and despite that education are nonetheless accepting the risks of the habit.
Ecological Model of Health
Sorting out what leads people to use tobacco involves assessing various risk factors they confront. This can involve the social and physical environment in which they live and the genetic endowment they carry which incorporates individual responses, disease states, and health care.14 The environment in which people live contributes to the risk factors they experience for tobacco use. This ecological model of health as it relates to the fight against tobacco use in the U.S. is illustrated by individual, interpersonal, organizational, community, and policy actions.
An example of individual action taken against tobacco is people choosing not to frequent business establishments that allow smoking on premises. Many people request that guests not smoke in their homes or vehicles. Individual actions to stop smoking were enhanced when nicotine replacement therapies (NRT) in the form of gum and patches became available over the counter in 1996. 15 The internet has served as a vehicle for wide dissemination of resources to assist in smoking cessation efforts of individuals.
Smoking cessation opportunities directed at groups have continued to grow. Telephone-based smokers’ quit lines have been established where individuals can receive counseling, support and incentives for smoking cessation.16 Successful efforts often include support from friends and relatives. Friends and family can also be very influential in reducing tobacco use through their personal policies against smoking in households, in vehicles or around children and family members. These examples of the interpersonal realm of tobacco reduction efforts demonstrate the benefits of including others and the influence of others in tobacco reduction efforts.
The Office of Environmental Health Assessment17 outlines the environmental effects of tobacco smoke including: low birth weight due to prenatal exposure, stunted childhood development, increased prevalence of acute asthma, the association of smoking with lung cancer and increased heart disease due to exposure of tobacco smoke. Organizations and employers have instituted smoking restrictions in workplaces to protect non-smokers from the effects of environmental tobacco smoke (ETS) and manage health care costs. Such restrictions also assist in changing the perceived acceptability of tobacco use by society. Smoking restrictions have been found to be effective in reducing tobacco use by motivating smokers to reduce consumption or to quit altogether.7 Extension of these restrictions to cover all indoor environments including bars and private social clubs is advocated even when faced with fears of lost revenue by the owners. Evidence exists that such policies do not result in adverse effects on business. 7
The Great American Smokeout, which began in 1977 and is sponsored by the American Cancer Society, has supported community driven activities such as worksite health fairs, events at schools and shopping malls, and examples on how to work with elected officials.18 These examples of community based approaches to smoking cessation have been widely implemented and have often led to policy changes. Examples exist where awareness of environmental tobacco smoke dangers lead to effective actions against smoking. The non-smokers’ rights movement has established a history of legislation that has made smoking “inconvenient.” Examples include: in 1974 Connecticut restricted smoking in restaurants; in 1975 Minnesota passed a clean indoor air law; in 1983 San Francisco passed laws for smoking in the workplace; and in 1989 smoking on all domestic flights was banned.19 This movement of non-smokers’ rights continues to expand. As an example Watauga Medical Center in Boone, NC has set February 14th 2006 as the day to ban all smoking on hospital property with the rationale that the environment must be healthy to support healthy people.
Community mobilization efforts took on new life after the Master Settlement Agreement was reached in 1998. Schools, businesses, community leaders, hospitals, community organizations, clergy, private physicians, and many more community members began to organize and establish anti-tobacco movements that continue today. Communities all across the United States have established efforts to build the capacity (such as through the allocation of funding) to respond to community needs to decrease secondhand smoke exposure, reduce access of youth to tobacco, provide cessation resources, counter the influences of pro-tobacco lobbies and support policies to prevent and control tobacco use. For example, the health department in California funds 25 local community projects to 1) increase the number of smoke-free areas; 2) reduce the availability of tobacco products; 3) counter pro-tobacco influences through sponsorship, marketing, and promotional activities, and; 4) promote cessation. These projects also focus on populations that have higher rates of smoking, such as African Americans, Native Americans, Lesbian, Gay, Bisexual, and Transgender populations, Korean males, White males, and 18-29 year olds.20
One of the most substantial policy related initiatives against tobacco has been the push for advertising bans to remove misleading information and images provided by tobacco companies. “Countries which have restricted or banned tobacco advertising have experienced greater than projected declines in tobacco use, leading governments and health organizations to conclude that advertising bans are an effective means of reducing smoking.”21 For example, smoking rates in Canada declined an average of 1.35% per year prior to significant policy interventions, 2.08% per year when tobacco taxes were increasing, and 3.60% per year following the introduction of an advertising ban and other regulatory measures in conjunction with higher taxes.21 Policy initiatives to raise the excise tax on tobacco products are recognized as effective.
Health warnings on tobacco packages
Health warnings are required to be included on all tobacco products. Although it is questionable if such warnings are effective, the federal government passed the Federal Cigarette Labeling and Advertising Act of 1965, requiring all tobacco products to have the following on one side of its package panel: “Caution: Cigarette Smoking May Be Hazardous to Your Health.” The warning has changed several times in an attempt to make the message clearer. In addition to packages advertisements must also contain warning in regards to the smokers’ health, and health consequences during pregnancy.22
Core Functions and Essential Services
Assessment is vital to determine the impact of smoking on health23 and is a first step in managing the problem. Epidemiological studies have been completed which developed a body of evidence for a causal relationship of tobacco use to lung cancer. For most of the twentieth century, tobacco companies were able to deny tobacco’s risk for causing lung cancer due to the lack of prospective randomized trials. But it was the painstaking and detailed research that showed the strength, consistency, specificity and coherence of the numerous retrospective trials that linked tobacco to lung cancer. A direct link was finally discovered when benzopyrene (a chemical in tobacco) was found to cause the same mutations in the p53 gene that causes lung cancer. 24
Once health problems and effective interventions are properly assessed, programs can be developed and implemented. Effective programs fall into two categories: cessation and prevention. Cessation programs include developing dedicated “quit lines,” and providing access to Wellbutrin, nicotine patches, and other nicotine replacement therapies (or NRTs). Prevention programs involve other parts of the community. Many school boards have collaborated with public health to include “No Smoking” policies on school property that applies to everyone at all times.25 Legal policies include increasing excise taxes to increase the overall cost of cigarettes as well as regulations restricting access to tobacco. Partnerships with organizations such as the American Lung Association have been influential in increasing policies to educate the public.
Assurance is the third core function of public health and elements of it are present throughout the processes of Assessment and Policy Development. Studies are constantly monitored by public health specialists and social scientists to ensure accuracy. One study addressed the effectiveness of nicotine patches versus placebo. Of those using a placebo, 5% were smoke free in 1 year, and of those using a nicotine patch, 15% were smoke free in 1 year.26 Another study examined the effectiveness of Wellbutrin. For individuals only using Wellbutrin, 30% were tobacco free in 1 year versus those using Wellbutrin plus a nicotine patch, 35% were tobacco free in 1 year. The addition of the nicotine patch was not found to be statistically significant over using Wellbutrin by itself.27 Studies have also been conducted to evaluate the effectiveness of physician intervention. Of the patients who received no support other than being told to quit smoking by their physician, only 1-2% were tobacco free in 1 year.28 In short one can deduce that any form of intervention has at least a slight impact on smoking cessation.
By working with the government, we also utilize assurance to develop and enforce rules and regulations regarding smoking. Educating the health care work force is another way to assure effectiveness and accuracy of policies under development. The interplay between all essential services provides assurance that all avenues are covered and “no stone is left unturned.”
Each of the 10 Essential Services (ES) of Public Health plays a vital role in successfully reducing tobacco use; no one essential service is more important than another. Monitoring the health status of the community (ES1) and measuring the level of damage caused by tobacco use both in health and mortality (ES2) are the initial steps in assessment. Disseminating information about the size of the problem and its impact on health (ES3) has been seen in many media campaigns - such as the Florida youth media campaign that had success in reducing tobacco use by up to 40%.29 Partnerships with organizations such as the American Lung Association and the American Cancer Society have proven valuable in informing the public about the negative health consequences of tobacco use and exposure to ETS. Such partnerships are useful in establishing and implementing programs to prevent the initiation of smoking and assist those who choose to quit (ES4). The Community Guide 8 is an excellent informational resource for communities desiring to initiate programs. Finally, media campaigns spread the message and encourage communities to mobilize.
Those policies and programs that have been selected as being effective in reducing tobacco use must be supported, once implemented, with informed personnel and budgets so that community health efforts are sustained (ES5). Regulations and laws limiting access and exposure to environmental smoke must be enforced for the health and safety of the community (ES6). Laws requiring warning labels and especially those regulating advertising must be constantly enforced to be effective.
People who are attempting to quit smoking need significant support, encouragement and access to affordable health services staffed by competent personnel (ES7 & ES8). The availability of dedicated quit lines which can provide a smoker support networks is one type of program shown to be effective.8 Access to Wellbutrin, nicotine patches, and other NRTs has also been found effective.8 The Community Guide stresses that the reduction in cost for these NRTs is a huge motivator to participate in smoking cessation programs, so adequate funding for such medications is essential for adequate impact on tobacco cessation efforts. The involvement of a health care provider with whom the client can meet with regularly is key to a smoker’s success in cessation programs.8 Most patients believe that their physician knows what is best for their health, and are more likely to listen to a physician and take a health threat more seriously than they would through a public service announcement.
As with every public health intervention those programs established to reduce tobacco use and exposure need to be evaluated for their effectiveness (ES9). Whether they are accessible and accomplish the goals of the program must be measured within the context of each community. This information then plays a role in investigating new solutions for managing tobacco’s enormous impact on the health of people (ES10). All core functions and essential services of public health are involved with meeting this challenge. Each service functions interdependently and all are necessary to effectively combat the complex challenges created by tobacco sales, consumption and addiction.
Evidence Based Guidelines
Communities have limited resources to invest in public health therefore decisions must be made to maximize the effectiveness of every program. These limited resources must cover all aspects of program development, implementation, evaluation and sustainability including the cost of training, personnel, program activities, operating expenses and materials. Choosing programs that are known to be effective in reducing tobacco use will maximize efficient use of money and justify further investment. With current research clarifying the outcomes of many types of tobacco intervention programs, there is strong rationale for a community with limited money to invest in a program with known effectiveness. The Community Guide is a resource that summarizes the current research on program outcomes including economic efficiency. It provides guidelines for evaluating each step in a program, assessing which problems should be addressed, and defining resources in the community that can be utilized for support. It also advises communities on analyzing the financial basis for supporting programs. Among those programs shown to be effective in communities are those that address changing high-risk behaviors and target specific diseases, injuries, impairments and environmental and ecosystem challenges. By investing in programs with known effectiveness, communities will have a more persuasive argument for future funding from local sources, granting agencies and legislators.
Tobacco is the leading cause of preventable illness and death in the U.S. and even after four decades of educational efforts, establishment of anti-smoking policies and challenges to the tobacco industry, all designed to reverse this trend, smoking and its health consequences are still widespread. Despite knowing that cigarette smoking is unhealthy many smokers do not or cannot quit. We live in communities in which youth continue to initiate smoking. Exposure to environmental tobacco smoke remains a problem. Programs must be established that increase youth knowledge and change attitudes and behaviors in order to prevent smoking initiation and direct the entire population away from the habit. Measures listed in the Community Guide and other resources that have a proven history of success should be the focus of communities in their efforts to reduce tobacco use, prevent its initiation and eliminate environmental exposure. These measures recommend increasing the unit price for tobacco products, establishing media campaigns combined with other interventions, and restricting minors’ access to tobacco products through policies, laws and regulations.
The causes of tobacco dependence are multi-factorial and steps taken should approach the problem from a variety of angles. The Community Guide provides a summary of evidence-based community-wide interventions that are cost effective and have successful implementation results.
There are three key areas to target: reducing the number of people who start smoking, decreasing the number of current smokers and reducing environmental exposure to tobacco smoke. Each step proposed below targets one or more of these areas.
The first step is for the state of Missouri to increase the excise tax for tobacco in an effort to discourage new smokers and reduce the amount of use by current smokers. Presently Missouri ranks 48th in the nation in amount of tax collected per pack of cigarettes at only 17 cents per pack. 30 The data gathered from tax increases shows that an increase of 10% in the price of a pack of cigarettes would decrease the number of adolescents who smoke by 3.7% and the amount that adults smoke by 4.1%7. So in Missouri, with over 1.5 million smokers (using more than 630 million packs of cigarettes per year), raising the excise tax from 17 cents to the national median of 70 cents would potentially reduce the amount of cigarettes used per smoker by an average of 17 packs per person or a total of 25 million packs per year statewide while at the same time raising $330 million per year in revenue.
The second step targets the work environment. Banning smoking in the workplace has several benefits. In addition to reducing environmental tobacco exposure, experience from other states shows that this measure is also effective in reducing the number of smokers. Costs include administration and enforcement of the ban and which would average approximately $800 per quitter.31
Educating businesses about the cost effectiveness of smoking cessation campaigns is an effective method for encouraging initiation of smoking bans. Although businesses will have to invest some money to start these campaigns, after five years, on average, they receive between $5 and $6.50 in return for each dollar invested.32 The money saved comes from increased worker productivity, decreased days missed due to sickness and direct health care cost savings. Experience from restaurants has shown no detrimental effect on service establishments. Businesses can support their workers by giving time off for counseling sessions and education and utilizing health insurance that provides for smoking cessation benefits.
Encouraging health insurance companies to invest in smoking cessation materials and services for patients can result in cost savings for them as well. However, despite demonstrated evidence of cost savings, most insurance companies do not provide counseling, Wellbutrin or nicotine patches for patients. A smoking cessation program that includes Wellbutrin and nicotine patches has been shown to increase the one year success rate of smoking cessation from about 5% in those who try to quit on their own to over 30-35% in those who use counseling with Wellbutrin and nicotine patches.33 Providing these medications can contribute significantly to the success rate.
Targeting youth is an important facet of a program. With more than 30% of children in grades 9-12 using tobacco products in Missouri, and almost all adult smokers having have started before the age of 18, this is a very important population toward which to target anti-smoking campaigns. An anti-smoking curriculum that involves instruction by trained educators that is reinforced by health care providers throughout students’ education experience must be a part of any community anti smoking campaign. Monitoring and researching effective methods for program development and relying on best practice theory will sharpen programs and enhance cost effectiveness.
In addition to youth as a high risk population for tobacco use, minority groups are also at higher risk for becoming regular smokers. In Missouri, Native Americans and Hispanics have a smoking rate that is higher than the general population.34 It is important in any community-wide smoking cessation effort to ensure that no ethnic, gender, or minority group is excluded and that programs are designed to target these populations specifically.
To ensure that the message of tobacco cessation occurs in multiple environments including work, school and sub-population settings, a concerted media campaign can be designed and launched. Media campaigns which use brief messages repeated over a long time period through a variety of media mediums such as billboards, print media, television and radio are an effective component of efforts to reduce the number of new smokers and increase the number of those who quit. This reinforces messages that people hear at work, school and in the community setting. Likewise it counteracts media campaigns launched by tobacco companies which continue to target youth and minority populations.
A concerted effort to reduce and eliminate tobacco use needs to be a top priority for Missouri because tobacco related diseases are the number one cause of preventable illness and death in the state. With social justice being a core principle, public health needs to defend the health of those most vulnerable to the targeted marketing strategies of the tobacco industry including children, the uneducated, the mentally ill and minority groups. Reducing tobacco use will require a constant monitoring of current use practices, their impact on health and success rates. A coordinated effort that includes government, businesses and public education is essential. Guaranteed access to proven methods of smoking cessation utilizing medications and counseling must be established. Prevention also requires educating our youth in the development of skills that change attitudes and behaviors in order to stop the multi-generational nature of tobacco use and its life long consequences. Utilizing research in effective methods of reducing tobacco related illness and death we can reverse the trends that result from the dangerous threat of tobacco to our community’s health. With more than 10,000 residents in Missouri dying each year from smoking related diseases, doing nothing is not an option.
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