Question

Describe public health policies to reduce smoking levels in the community in terms of social capital. What, is anything, would you choose?

Answer 1

SOCIAL CAPITAL:-

Social capital, representing the level of social connectedness in a community, has been consistently shown to be associated with improved mental and physical health. It has been shown to deter unhealthy activities such as crime, drug use, and alcoholism. While the pathways through which social capital affects health are not fully understood, providing social support, encouraging healthy behaviors and providing improved access to goods and services probably play a role.

MEASUREMENT:-

Social capital can be defined as the degree of social connectedness in a community. The concept of social capital involves:

• Community members’ familiarity with and involvement in community affairs,
• Knowledge and trust of neighbors, and
• The extent of community members’ interactions with each other (Frank, Kavage & Litman, 2006).

SMOKING:-

Smoking is a serious public health challenge across the world. It has assumed the dimension of an epidemic resulting in enormous disability, disease, and death.

[1] The tobacco use attributed to more than 5 million preventable deaths every year globally

.[2] Further, at the present rate, the number of such deaths is expected to double by 2020. The tobacco use not only detrimental to personal health but also results in severe societal costs such as reduced productivity and health care burden, poverty of the families, and environmental damage. Ample body of evidence available to infer causal relationship between smoking and vascular diseases such as coronary heart disease, subclinical atherosclerosis and stroke, respiratory diseases such as pneumonia and chronic obstructive pulmonary disease, and cancer at ten sites.

[3] Despite the serious health risks, a considerable number of people across the world continue to smoke. It is well recognized that overall mortality rates for cigarette smokers are 60–80% higher than for nonsmokers.

[4] The degree of devastation brought to bear upon the individual and society outstrips the returns generated by tobacco production and consumption in terms of revenue and employment. As awareness of the dangers posed by tobacco spread, countries across the globe resolved to forge a campaign strategy and frame a battle plan to overcome the tobacco threat.

PUBLIC HEALTH POLICIES OR STRATEGIES FOR REDUCING SMOKING LEVELS:-

The process of smoking initiation:-

It usually takes time for an individual to become a smoker, allowing for several opportunities for tobacco control interventions that can either focus on the prevention of experimentation or progression to higher smoking levels. There are identifiable cognitions (curiosity, weakening of intention not to smoke) that predict future smoking, whether it be first experimentation or progression to a higher level of smoking experience (eg, puffer, experimenter, to occasional and then regular smoker, etc).12 13 In high-income countries such as the USA, there is good evidence that experimentation generally occurs between the ages of 10–24 years.14While some cultures have reported smoking at an earlier age, there is little evidence to suggest an uptake pattern in which never smokers start the initiation process after the age of 24 years.

HEALTH PROMOTION METHODS FOR SMOKING PREVENTION AND CESSETION:-

Peer education:-

Peer education “involves sharing of information in small groups or one to one by a peer matched either demographically or through risky behavior to the target population.The theoretical basis of peer education method can primarily be derived from behavioral theories relating to health, theory of participatory education, Information, Motivation, Behavioral skills, and Resources model and developmental theory.

Effectiveness:-

A Stop Smoking in Schools Trial (ASSIST) program assessed the effectiveness of a peer-led intervention that aimed to prevent smoking uptake in secondary schools. The study has shown that the ASSIST training program was effective in the achievement of a sustained reduction in uptake of regular smoking in adolescents for 2 years after its delivery. Furthermore, it was well received by both students and school staff.

Further, the multilevel modeling showed a 22% reduction (odds ratio: 0.78 [95% confidence interval (CI): 0.64–0.96]) in the odds of being a regular smoker in an intervention school compared with a control school, with the 95% of CIs not including a null effect.Pooled results from 10 randomized controlled trials (RCTs) that used experimental smoking as the main outcome also found that peer education interventions could be marginally effective in preventing smoking uptake. Resnicow et al., reported that the programs based on peer training model produced a net change of 6% in the smoking habit relative to the 3% change brought about by other models (harm minimization, and life skills training) among the South African high school students.[8] Prince compared a six-session peer-led smoking intervention program for high school youth to the same program led by the adults. Self-efficacy was measured post- and follow-up.The significant reduction in a number of cigarettes smoked was found in both peer- and adult-led groups when compared to the control group. Furthermore, there was a continuous reduction in smoking both treatment groups at the 1-month follow-up measure.

Although the peer education has proven efficacy one must consider relevant factors before its implementation. These include selection, training, supervision, type of intervention, and the relationship between peer educators and peer educated. It is important to have the right environment and motivated peer educators for successful implementation.

Theatre in health promotion:-

For health promotion, the theater is an effective platform to create awareness and disseminate messages related to good health. The theater provides an interesting strategy as the audience is whole heartedly involved and encouraging the actor. The actor, who is integral to the dramatic narrative, explores the chosen topic as a relationship between facts and fiction. The theater method premised upon the drama theories and social cognitive theory, which recognizes the human behavior as an interaction between the individual aspects, behavior, and the context.

Effectiveness:-

Thrush et al., in their study divided 24 primary schools into 3 groups, a theater in education intervention group, a school smoking policy intervention group and a control group. The results showed that there was a weak positive effect on the boys but none of the girls in the intervention group. The theater production 2 Smart 2 Smoke and accompanying activities showed a significant impact on psychosocial risk factors for smoking among students in grades 1–3 and grades 4–6. The percentage of students who told that they would “never smoke a cigarette” increased by 10% following play intervention.

While theater could possibly be a vehicle for long-term change, it still remains to be seen if the positive results can be elicited for those concentrating on promotion of nonsmoking habit. It is important that the content is assessed on a professional level, and the intervention be made as scientific as possible.

Media advocacy:-

Media advocacy is to frame an issue well and advocate that issue using the media as a platform. Information is disseminated through the media with a view to alter public mind or change their views. Media advocacy needs to be based on the solid principles of planning. Media advocacy planning used “GOTME” approach: Goal, objective, target, message, and evaluation.

Effectiveness:-

Media advocacy was used in many health promotion interventions and it is particularly concerned with significant environmental and policy change. The Project Tobacco Reduction Using Effective Strategies and Teamwork involved the media advocacy and the retailer were rewarded with positive newspaper coverage for compiling the underage laws for selling tobacco products, whereas those who did not were “named and shamed.”The impact of the project was significant on smoking prevention. Niederdeppe et al., assessed the impact of media advocacy activities on news coverage, policy changes, and reductions in youth smoking implemented by the Florida Tobacco Control Program. They demonstrated a significant decrease in volume of program-related news coverage after the onset of media advocacy initiatives, but the ratio of coverage about students working against tobacco relative to other topics increased. Because of news coverage, there was a passage of tobacco product placement ordinances in Florida counties, but these ordinances did not significantly reduce the prevalence of smoking among the youth.

Media advocacy can be looked at as a tool in the broader policy implementation. It can help provide a platform to raise policy related issues. Further studies to see its effectiveness needs to be done. The use of media as an advocacy tool must be conceived and developed only in the context of other approaches such as community organizing, coalition building, and policy advocacy.

Community mobilization:-

Community mobilization is aimed at inducing a change of normal social norms from the utility of various intricate interventions to help raise awareness of community participants. It is brought about by teamwork, educational entertainment and the participation of other members, and groups and associations to help inspire revolutionize a change. Community mobilization is based on 3 key concepts: Social capital, empowerment, and social change.

Effectiveness:-

A systematic review by Secker-Walker et al., of community interventions to reduce the prevalence of smoking shows the effectiveness of community-based health promotion initiatives. A favorable outcome was suggested as a significant change in smoking behavior, being either lower prevalence, reduced cigarette consumption per capita or an increase in smoking cessation rate. Of the studies, 23 (62%) suggested at least one favorable outcome with relation to smoking change, whilst 14 studies (38%), showed no marked difference. Where the community was the unit of assignment and analysis, 5 of the 8 studies (62.5%) reported a positive change in smoking behavior. In the remaining studies, where the individual was the unit of analysis, hence with a reduced significance level, 18 out of 29 studies (62%) showed at least one favorable outcome with relation to smoking behavioral outcome. This systematic review concluded that community health promotion methods were more effective than other methods of smoking prevention.

Community mobilization methods are essential in the field of health promotion. Empowering communities to bring about change in their own social domains is not only more sustainable but however, is also extremely effective.

Social marketing:-

Kotler and Zaltman coined the term “social marketing” using it in an article evaluating the application of commercial marketing principles. The social marketing is the systematic application of principles and techniques of marketing to create, communicate, and deliver value in order to influence a target audience to achieve specific behavioral goals, for social good.It is best described as a behavioral approach that helps to create a long-term sustainable impact upon the choices of people. Social marketing draws on and incorporates the use of behavioral theory.

Effectiveness:-

Despite many challenges, the evidence for the effectiveness of social marketing interventions does exist and is growing. The project 16 incorporates social marketing method for reducing both illegal sales of tobacco and youth tobacco use showed a significant effect on lowering the smoking prevalence. In a review by Gordon et al., 18 out of 21 studies examined short-term impact (up to 1-year) of social marketing intervention on smoking prevention. Thirteen studies demonstrated the significant positive effects.The Sunderland project was based on social marketing strategy for increasing the uptake of smoking cessation services and quit rate among pregnant women in Sunderland. The intervention primarily includes the design and pretesting of new marketing/information material and consumer friendly cessation support. There was a significant impact of project and there was a 10-fold increase in the smoking quitting or setting a date for quitting smoking among pregnant women as compared to neighboring primary-care trusts which did not apply similar social marketing approach.

A meta-analysis of the efficacy of SMS text message interventions for smoking cessation showed that smoking quit rates for the text messaging intervention group were 35% higher compared to the control group quits rates. Results also suggest that SMS text messaging may be a promising way to improve smoking cessation outcomes.[24]

The social marketing interventions should always be adapted according to local needs and contexts. There is a need for integrating specific vertical and horizontal interventions with social marketing to make it more sustainable and effective.

Motivational interviewing:-

Motivational interviewing (MI) defined as a client-centered, directive approach to stimulate the positive behavior change and resolve ambivalence. The important guiding principles of MI are expressing empathy, supporting self-efficacy, developing discrepancy and rolling with resistance. It primarily derived from social psychology, cognitive dissonance, self-efficacy, and empathic processes. Various forms of MI are Motivational Enhancement Therapy, Brief MI (BMI), and telephone consultation.

Effectiveness:-

MI has been used successfully for smoking cessation. Glasgow et al., demonstrated the effectiveness of a BMI-based intervention given by clinical staff versus advice to quit smoking among 1154 women attending planned-parenthood clinics. There were a higher 7-day abstinence rates in the MI intervention group at 6 weeks (10.2% vs. 6.9%). The MI intervention group showed a significant reduction in a number of cigarettes smoked at both 6 weeks and 6 months. The relatively brief training of staffs for MI and low rate of completion for follow-up telephone calls were a limitation of this study. Valanis et al., found a significant impact of MI intervention for women attending prenatal clinics on self-reported quitting rates both during pregnancy and 6–12 months after delivery. In another study, 536 smokers from 21 clinical practices were randomized to receive either MI or brief advice to quit smoking from their general practitioner showed a significant effect on smoking cessation. Meta-analysis of MI versus brief advice or usual care yielded a modest but significant increase in quitting. Subgroup analyzes demonstrated that the MI intervention was more effective when administered by primary-care physicians and by counselors, and when it was conducted in longer sessions (more than 20 min per session). Recently conducted systematic review of RCTs in which MI used for smoking cessation showed that MI versus brief advice or usual care yielded a modest but significant increase in quitting (risk ratio: 1.26; 95% CI: 1.16–1.36; 28 studies; n = 16,803).[30]

MI appears to have broad application to behavioral medicine. Although the initial outcome studies have produced mixed results, MI appears to have potential efficacy. Further research studies required to address the numerous questions regarding how MI works in different conditions and individuals and which health professionals are best able to deliver MI with fidelity.

Mass media campaigns:-

Mass media campaigns are widely used to expose the population to messages through television, radio, and newspapers. Such campaigns can produce positive or negative changes in health-related behavior in populations and is a useful method for raising an issue and encouraging debate. The mass media campaign approach based on the theories of the social influences or social learning theory.

Effectiveness:-

It has been suggested that the mass media is particularly appropriate for delivering antismoking messages to young people because they are more exposed to the media. In the interventional review of studies for assessing smoking behavior by Brinn et al., investigated the effect of a mass media prevention effort directed at young people <25 years using a parallel group RCT or controlled clinical trial design. Three studies were associated with a reduction in smoking outcomes. One study found a statistically significant decrease in smoking uptake by girls (with net increase of 8.6% in Intervention County vs. 12.4% in the control) and a nonsignificant trend in boys at 3-year follow-up (6.8–10.5%). In an another study, impact compared between school based programs with mass media and school based intervention alone, showed a significant effect of combined intervention as compared to school alone. The results reported in all seven studies tended to be based on outcome data relating to a sub-sample of participants rather than on the basis of allocation to groups. Evaluation of effectiveness on the basis of data provided by those participants available at follow-up is likely to be biased.

Bala et al., assessed the effectiveness of mass media interventions in reducing smoking among the adults through systematic review has shown that the comprehensive tobacco control programs which include the mass media campaigns can be effective in changing smoking behavior in adults. The intensity and duration of campaigns may influence effectiveness.

Mass media campaigns should be included as a key component of approaches to improve population health behavior. Careful planning and testing with target audiences is crucial. Emphasis should be placed on the involvement of small groups of representative samples at whom the campaign is directed. Such groups can also be involved in message development.

Setting based approach:-

The emergence of the settings approach has been attributed to the Ottawa Charter's assertion that, “health is created and lived by people within the settings of their everyday life; where they learn, work, play, and love.”Settings for health are defined as “the place for social context in which the people engage in daily activities in which environmental organizational and personal factors interact to affect health and wellbeing.” A settings approach is built upon the principles of health promotion, in a holistic manner, and as a process of enabling people to increase control over, and to improve their health.

Effectiveness:-

The workplace has potential as a setting through which the large groups of people can be reached to encourage the smoking cessation. Cahill et al., conducted an interventional review of 51 studies covering 53 interventions. They found 37 studies of workplace interventions aimed at individual workers, covering group therapy, individual counseling, self-help materials, nicotine replacement therapy, and social support. Group programs, individual counseling, and nicotine replacement therapy increased cessation rates in comparison to no treatment or minimal intervention controls. Self-help materials were less effective. They also found 16 studies testing interventions applied to the workplace as a whole and found the settings based approach is more effective than other interventions. But overall, there was a lack of evidence that comprehensive programs reduced the prevalence of smoking. Incentive schemes increased the attempts to stop smoking though there was less evidence that they increased the rate of actual quitting. They failed to detect an effect of comprehensive programs in reducing the prevalence of smoking.

The better understanding of health promoting setting among various actors, politicians, and well as workers is essential for the efficient implementation of setting based health promotion methods. There is a need to understand the implementation process and the importance of carrying out systematic evaluations for sustainable, healthy settings.

These above are some of the public health policies and health promotion methods to reduce smoking levels in society,and smoking is bad for both the person who smokes and to the persons near to him.so its better to be away from smoking.