Policies on a national and local level that attempt to address the issues surrounding smoking

Public health is continuously evolving, with new issues arising along with new developments concerning old issues. The first International Conference on Health Promotion was held in Ottawa in 1986. The conference aimed for action to achieve ‘Health for all’ by the year 2000 and beyond. The charter is a clear statement of action for health promotion, widely used by health promotion sectors in order to strengthen health principles and policies, later reaffirmed by the Bangkok Charter in 2005 and more recently the Tallinn Charter 2011 (World Health Organisation 2014a).
The purpose of public health is to help the population remain healthy, protecting them from threats to their health whilst trying to eliminate inequalities. It provides the information to enable everyone to make healthier informed choices regardless of circumstances to minimise the risk and impact of illness (Gov.uk 2014).
Equally, health promotion does the same but moves beyond a focus on individual behaviour towards wide ranges of social and environmental interventions (World Health Organisation 2014). The World Health Organisation originally recognised the role of the nurse in public health, this was furthered by the Nursing and Midwifery Council (NMC) requirements as laid out in the Code:
‘’Work with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community’’ (Nursing and Midwifery Council, NMC 2010).
Health however, is not easily defined other than in broad terms such as the definition by the World Health Organisation (2014) as a complete physical, mental and social well-being and not merely the absence of disease or infirmity.
This essay will be based around a public health issue affecting a population, supported by current epidemiological evidence. Epidemiology is the study of the distribution and determinants of the various forms of disease in populations, with the aim to uncover causal links between factors leading to the development of the disease from a population perspective (Rothman & Greenland 2008).
I’ve decided to discuss effects of smoking on the ageing population whilst focusing on the potential links between smoking and chronic diseases. I will discuss identified environmental and socioeconomic factors which contribute to smoking including the determinants of health, psychological factors, lifestyle choices and behaviours.
From this I will try and identify policies on a national and local level that attempt to address the issues surrounding smoking. Finally I will explore the role of the nurse in public health and health promotion.
The rationale for choosing smoking derived from my time spent on clinical placement where I cared for patients with cardiovascular disease and chronic obstructive pulmonary disease (COPD) who were also smokers. This triggered an interest in the topic of potential links between smoking and chronic diseases.
Among the five greatest risk factors for mortality, smoking is the single most preventable cause of illness and death, causing around 100,000 deaths in the UK yearly. Smokers under the age of 40 have a five times greater risk of heart attack than non-smokers. 80% of smoking deaths are attributable to lung cancer, around 80% to bronchitis and emphysema, and about 17% to heart disease. More than one quarter of all cancer deaths can be attributed to smoking. Exposure to other people’s tobacco smoke is also a cause of ill-health and it is estimated globally that 600,000 deaths a year are caused by second-hand smoke, mostly among women and children (Action on Smoking and Health 2013). It raises serious questions as to why people choose to continue to smoke in spite of these alarming statistics.
If current patterns continue, tobacco use will kill more than 8 million people per year by 2030. Up to half of the world’s 1 billion smokers will die prematurely of tobacco- related disease (WHO 2014 b). For people who already have conditions caused by smoking, such as COPD, giving up may be the most effective treatment as it can significantly reduce the rate at which the lungs deteriorate. Evidence has shown that people who stop smoking can reduce the risk of developing smoking-related diseases (British Lung Foundation 2013). Yet people continue to smoke.
The proportion of adults smoking in Great Britain has generally been declining since the health survey first included a question about smoking in 1974, from 45% to 20% in 2012. The proportion of adults smoking continued to fall between 1994 and 2007, but at much slower rates. However, from 2007 to 2012 the rate of smoking remained largely unchanged. This may suggest that current policies on a national and local level may not be having the desired effect.
While the proportion of female smokers has continued to decline over the past five years, the proportion of male smokers has changed very little (Opinions and Lifestyle Survey 2012). It would appear that initiatives are more effective amongst women leaving men disengaged and questions need to be raised in this regard.
On a local level, data from Ash (2012) shows that the economic cost of smoking to Wales is estimated at £790.66 million per year. However, it could be as high as £1.04 billion. These figures speak for themselves and are illustrative of this lethal public health issue.
Smoking presents a special challenge says Ash (2012) and this is partly because men seem to have a greater disposition towards death by virtue of smoking as opposed to women. There would appear to be no clear indication as to why this is, however it may be partially linked to the fact that pregnant women are heavily targeted by anti-smoking campaigns, as illustrated by the work of MAMSS (Models for Access to Maternal Smoking Cessation Support) which at a local level is a pilot project at four of Wales’ health boards, which uses maternity staff to engage with pregnant women with the aim of encouraging them to quit. This is a vital service having regard to the alarming statistics for Wales with around 33% of women smoking at some point during their pregnancy, while the UK average is 26% (ASH 2013).
This disparity is only overshadowed by the ever increasing axiom between the health disruptions reported by those belonging to the lower class and those belonging to the upper classes. Once again, it would seem that the void between the ‘haves’ and the ‘have nots’ is clearly apparent but why should this be.
According to ASH (2013) smoking has been identified as the single biggest cause of inequality in death rates between the rich and poor in the UK. Smoking accounts for over half of the difference in risk of premature death between social classes.
It has been said that people from lower class backgrounds find their way to smoking earlier than those from elevated backgrounds, a deeper understanding of why is required before a meaningful judgment can be made.
Marmot and Wilkinson (2009) state that children from less advantaged social backgrounds are more likely to start smoking than children from more affluent backgrounds, but the difference is not great. However they state that by the time they are in their thirties, half of the more affluent young people have stopped smoking with three-quarters of those in the lowest income group carry on. This reflects work from the Royal College of Physicians (2008) who state that children living in low income households are more likely to be exposed to tobacco smoke. Not only is this in itself harmful to children’s immediate health, but parental smoking is a strong influence on the likelihood of a child becoming a smoker.
Increasing the price of smoking can be an effective means of helping smokers quit, but for smokers who do not quit, it can increase inequalities, particularly for less affluent (Marmott 2010). This reflects reality as it is clear to see that low income families would rather miss out on important amenities such as food or heating if it meant they were unable to afford their cigarettes.
Researchers have shown that much of the remaining gap in health inequalities is likely to be explained by psychological factors including a person’s individual control over their life circumstances, quality of relationships with friends and family and also their position within the social hierarchy. Progressively more research evidence suggests that societies with narrower gaps between rich and poor have better population health (ASH 2011).
Having undertaken research into why lower class people smoke more than the upper class, I’ve been met with a myriad of facts without any specific reasoning. One is therefore left to draw one’s own conclusions and these must revolve around the fact that, generally, poorer people have more time on their hands due to possible unemployment and fewer ways to fill this time. Couple this with the fact that poorer people have fewer resources at their disposal and one has a recipe for disaster on their hands. It’s clear that efforts to help low socio-economic groups quit will have long-term effects on quality of life and immediate effect on their household expenditures, which will undoubtedly improve their availability of resources.
Health outcomes such as life expectancy continue to rise in the UK due to improved social conditions, ever advancing medical and scientific knowledge along with a significantly large investment in the healthcare system (The Office for National Statistics 2014). These improvements however mask a widening gap between the health outcomes of the lower and higher social class families, meaning a child born in to a family that is well educated and affluent has a greater chance of living longer without disease or disability than a child who is not (RCN 2012).
The WHO (2014c) recognises the social determinants of health as a set of conditions in which people are born, grow up, live and work, including housing, education, financial security the environment along with healthcare systems. It states that these conditions are shaped by powerful over riding forces: economics, politics and social policy. Even though it’s now widely accepted that these determinants are responsible for substantial levels of unfair inequalities, it can be said that some health inequalities are the result of biological differences or free choice, but others are beyond the control of individuals and can be avoided.
When considering free choice this could relate to a person’s particular lifestyle or behaviour towards a perceived health risk such as smoking. Lifestyle relates to a way of living that is based on identifiable patterns of behaviour, often a matter of personal choice but determined between an individual’s characteristics and socioeconomic conditions (Naidoo & Wills 2008).
This could relate to youngsters with their lay perception on the health risks of smoking, being naïve to the fact that they could be putting themselves at risk of developing chronic illness in the future. They may not perceive it as important to them at that point in their lives, or may even disbelieve such outcomes. The worrying fact is that’s it’s clear that the number of life-years gained is tiny in comparison to the number of life-years lost as a result of smoking.
Behaviour is another factor to consider. This is simply a way a person behaves and their attitude towards that behaviour. There are several theories and models that explain the smoking behaviour of young adults. Take Ajzen’s (1991) Theory of Planned Behaviour which encompasses beliefs that attitude toward behaviour, social norms, and perceived behavioural control, together shape an individual’s behavioural intentions and behaviours. Thus meaning young adults may be more likely to smoke if their family members and peers do as they will perceive the behaviour as normally accepted. Adults on the other hand would have different reasoning. They may not be ready to stop smoking, or may feel that if they did they would be isolated from their group norm. Smoking may also be a negative coping mechanism for them and relieves stress and anxiety therefore their potential motivation to change will be affected.
In contrast to that, a report by the Royal College of Physicians (2010) showed that most people do not smoke out of choice, but because they are addicted to the nicotine, and the association of feeling less stressed and anxious is just a temporarily relief from the unpleasant symptoms of nicotine withdrawal.
Research has shown that the risk of chronic disease is greatest among those who smoke the most cigarettes, over the longest period of time, having started at the youngest age (Cancer Research UK 2014). This is why we need to make certain that policies at all levels recognise and address recent evidence suggesting a wider responsibility for creating a healthier, better educated population.
The WHO is the directing and coordinating authority for health within the United Nations system. It is responsible for providing worldwide guidance in the field of health, shaping the health agenda, setting global standards, expressing evidence-based policy options and monitoring and assessing health trends (WHO 2014d). With regards to the public health issue being discussed the WHO devised a Framework Convention for Tobacco Control (FCTC) which came in to force in 2005. It is the WHO’s most important tobacco control tool and a milestone in the promotion of public health. Later, in 2008 six new measures were introduced to up-scale the implementation of provisions of the WHO’s FCTC. These were to monitor tobacco use and prevention policies, protect people from tobacco use, offer help to quit, warn about the dangers, enforce bans on tobacco advertising, promotion and sponsorship and raise taxes on tobacco (WHO 2014 e).These are influenced at a Marco level giving international perspectives, driving forward National and local campaigns and initiatives.
Through research, several policies and campaigns have been identified in order to help promote health and reduce smoking. The Welsh Governments ‘Fairer Outcomes for All’ (2011) states that the annual economic cost of dealing with the consequences of inequalities in health in Wales due to additional illness, productivity losses, loss of taxes and higher welfare payments is estimated between £3.2 and £4 billion.
Welsh Government created a new strategic framework for better health with ‘Our Healthy Future’. It focuses on supporting change to healthier behaviour and improving the economic, social and physical environments we experience by setting the foundation for the Government’s ambition for public health. It identifies six action areas with ten priority outcomes (WG 2009).
One of which is to reduce the level of smoking which led to the Tobacco Control Action Plan which sets the direction in Wales for partnerships and collaboration to reduce tobacco harm and prevalence of adult smoking to under 16 per cent by 2020. The plan consists of four identified action areas; promote leadership in tobacco control, reduce the uptake of smoking, especially amongst children and young people, reduce smoking prevalence levels and exposure to second-hand smoke (Griffiths 2012).
The number of young people smoking has been steadily decreasing since 1998. The Health Behaviour in School Aged Children survey found that 11% of males and 16% of females aged between 15-16 smoked weekly, among 13-14 year olds these figures were 3% and 6%. To help reduce these figures, Public Health Wales is providing an Assist programme to around 45 and 60 secondary schools in each academic year where influential pupils from Year 8 are trained to support their peers not to start smoking and encourage who have already started to try to give up. The percentage of pupils smoking was lower in schools receiving the Assist programme, with evidence from the programme showing that smoking has decreased in young people (WG 2014). The Assist programme may hopefully be of interest to a larger number of schools in the future – prevention is clearly better than cure.
As previously discussed, and identified in the Tobacco Control Plan, there is strong evidence to support the contention that second-hand smoke poses serious health risks for non-smokers. Welsh Government has supported this with its renewed campaign ‘Fresh Start Wales’ launched in 2012 following the great success of the smoking ban in public places in 2007. Its aim is to raise awareness and reduce the impact of second-hand smoke on children in cars, the environment and families. Results from the Welsh Health Survey suggest that the number of adults and young children being exposed to second-hand smoke has reduced (WG 2014 a).
On a local level, similar initiatives are being implemented for Wales and across all the local health boards. Stop Smoking Wales, is funded by the Welsh Government and delivered on part of Public Health Wales where it forms a central element of the National Tobacco Control programme. Stop Smoking Wales is a specialist health service providing smoking cessation support to people who want to quit. Its other provision is to provide brief Intervention training for individuals who regularly come into contact with people who smoke (Public Health Wales 2013). Alongside that, Stop Smoking Wales launched a mass media smoking cessation campaign in October. ‘Stoptober’ was a 28 day challenge to remain smoke free. Evidence shows that smokers are five times more likely to stay smoke-free if they successfully make it through the first four weeks which is an astonishing difference. Figures for 2013 show that over 160,000 people in Wales and England quite smoking for Stoptober. The target for the overall campaign was men aged 25 to 54 as according to the Welsh Health Survey they presented with the highest amount of smokers (Stop Smoking Wales 2013).
Stop Smoking Wales offers a seven week treatment programme based on the withdrawal oriented treatment model. It provides weekly appointments and expert behavioural support in groups or one to one with follow ups at four and twelve months (Stop Smoking Wales 2013).
The National Institute for Health and Clinical Excellence recommends that by combining their efforts, smoking cessation services should aim to treat five per cent of smokers each year. During 2012/2013 Stop Smoking Wales alone treated 1.1 per cent of the smoking population (Stop Smoking Wales Annual Report 2013).
It’s evident that the local campaigns are attracting attention, but some figures have shown slight declines in outcomes over recent years. In order to develop a greater understanding of people’s behaviour and perception of these services and the importance of educating them in order for them to make an informed choice, one might need to consider the role of the nurse in public health and promotion.
Nurses need to play an active role in the promotion of health, protection from harm and the prevention of ill-health. Their contribution is to the delivery of the health policy objectives of all governments across the UK in vital (RCN 2012).
The NMC (2008) highlights the role to
“Work with others to protect and promote the health and well-being of those in your care, their families and carers, and the wider community”
Health promotion is focused on three different perspectives. They are primary, which is directed at preventing ill health from arising in the first place. Secondary, which involves healthy people with or without an acute illness who partake in health risk behaviours, the aim here is to prevent ill health or chronic ill health from occurring. Thirdly there is tertiary, directed at people with chronic illness focusing to reduce the impact of the disease and promote the quality of life through active rehabilitation (Department of Health 2010).
For the purpose of the health issue being discussed, one would conclude that a combination of both primary and secondary would seem most effective. The biggest preventative measure in primary health promotion would be to educate in schools to target children before they even attempt to smoke. We know this already exists with the Assist programme run by Public Health Wales which reflects one the recommendations set out by NICE in that Anti-smoking activities should be delivered as part of personal, social, health and economic (PHSE) and other activities related to Healthy Schools (NICE 2010). As previously researched, younger people do not often consider health warnings as relevant to them to it is imperative to educate them in order to prevent.
Secondary promotion as a role would be the smoking cessation programmes and relevant campaigns such as ‘Stoptober’ run by public health Wales. The nurse may advise, provide self-help materials or refer for more intensive support through engaging with other health care professional as appropriate. Utilising group or one to one behavioural therapy has also proven effective as recognised by NICE 2010. Being able to relay this message across as a nurse without being forceful, giving the patient all the relevant information for them to make an informed decision on whether or not to quit smoking is vital. As once on the cessation programme for four weeks Stop smoking Wales 2013 states the chances of them relapsing significantly reduces.
Through researching health promotion approaches such as the medical, educational, pastoral and social change model one would conclude that there are aspects in them all that would be useful in aiding smoking cessation. However the educational and pastoral approach could be effective in the role of the nurse for this topic.

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