Question

use the ecological model to design a community program to discourage smoking amongst teenagers

Answer 1

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 Generals 2004 report 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 tobaccos 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.
Social Justice
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. 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. 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 justice 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. 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.  
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. 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 community 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. 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 1913 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. 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. 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. 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. 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. 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. 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 Assessment 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. 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. 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.
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. 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.
Core Functions and Essential Services
Assessment is vital to determine the impact of smoking on health 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 tobaccos 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.
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. 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. 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. 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. 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%. 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 smokers 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