How did we reduce the smoking rate in Canada? In 1964 the US Surgeon General released a report linking cigarette smoking to cancer (Terry et al., 1964). That report was a catalyst to perhaps one of the greatest public health campaigns in Canada. “Hang tough, don’t puff” see Figure 1, was just one of many catchy slogans that was implemented to discourage people from taking up smoking; did those campaigns work? Was is changing laws prohibiting smoking in public places or changing the cigarette packaging?
Figure 1 Antismoking Campaign
Figure 1 Retrieved from: https://kids.smokingstinks.org/showcase-2013/
Complex health issues must first be understood prior to launching a public health campaign. Multilevel models of health are often used to explain a complex health issue. One such model is called the social ecological model of health (Brofenbrenner, 1977). The social ecological model of health (SEM) is a theory-based framework for understanding the dynamic interrelations among personal and environmental factors that determine behaviours. There are five nested, hierarchical levels of the SEM: individual, interpersonal, community, organizational, and policy (See Figure 2).
Figure 2 Social Ecological Model of Health
Retrieved from: https://www.pinterest.ca/pin/263038434460506282/
Within this model of health, I will explore several important factors including interprofessional approaches, various determinants of health, the structure of the Canadian health care system, vulnerable populations, and lastly chronic disease management to gain an overall understanding of smoking in Canada.
Individual and Interpersonal
Why do people start to smoke and why do they continue to smoke? Much of the research has focused on the reasons why adolescents smoke as smoking adolescents often turn into smoking adults (Diez et al., 2003). A highly cited study by Chassin et al. demonstrated that initial onset of smoking among never-smokers was more likely for subjects with more smoking friends and parents, lower levels of parental support, and friends with lower expectations for the subject’s general and academic success (Chassin, 1986). For the transition from experimental to regular smoking in girls it was more likely if their friends had more positive attitudes toward their smoking and lower expectations for their general and academic success. For boys, the transition was more likely if their friends had higher expectations for their success (Chassin, 1986).
As the forces from the psychosocial pressure and influence subsides, the pharmacological effect takes over to sustain the smoking habit. In 1988 the US Surgeon General reported that nicotine was highly addictive comparable to cocaine and heroin (US Department of Health and Human Services, 1988). Nicotine is the addictive substance contained in cigarettes. Due to the highly addictive nature of nicotine and unpleasant withdrawal symptoms the majority of the antismoking movement has been aimed at preventing individuals from taking up smoking (Pechmann & Reibling, 2000). See Figure 3.
Figure 3 Health Canada Warning – Cigarettes are highly addictive
Retrieved from http://whyquit.com/pr/052808.html
Vulnerable Populations
Smoking prevalence is higher among disadvantaged groups, and disadvantaged smokers may face higher exposure to tobacco's harms. Uptake may also be higher among those with low socioeconomic status, and quit attempts are less likely to be successful (Hiscock, 2012).
A two part series published in the Lancet examined the determinants and disease patterns and the underlying cause of health gaps in indigenous peoples (Gracey & King, 2009; King & Gracey, 2009). Gracey and King examined various determinants of health which are the range of personal, social, economic and environmental factors which determine the health status of individuals or populations. An article by Richmond (Richmond & Cook, 2016) also highlighted the gap between indigenous and non-indigenous peoples health and they advocate for a national health public policy for indigenous peoples health.
The territory of Nunavut (with a high population of indigenous people) has the highest rates of smoking in Canada, see figure 4.
Figure 4 Smoking Rates in Canada 2014 (CIHI, 2014)
Retrieved from : https://yourhealthsystem.cihi.ca/hsp/inbrief?lang=en#!/indicators/009/smoking/;mapC1;mapLevel2;/
The Canadian Health Act (Government of Canada, 1984) relies on federal spending powers to establish a Canada-wide, publicly funded health care system that bases patients’ access to health care services on need, not on the ability to pay. While the federal government establishes the national standards for health care services, the provinces and territories deliver those services. (The Council of Canadians, 2013)
Each province and territory prioritize their own strategies. Nunavut has created its own Nunavut Tobacco Reduction Framework including its own territory wide smoking quit line “Nunavut QuitLine at 1-866-3NU-QUIT” to address their unique determinants of health (“Nunavut Tobacco Reduction Framework for Action,” 2011).
Community and the Interprofessional Approach
Family doctors, nurse practitioners, family health teams, and hospitals in communities have all banding together offering programs and support to assist with smoking cessation. This approach to smoking cessation is interprofessional offering services from social workers, councilors, dietitians and more. Nicotine replacement therapy (NRT) along with counselling is proven to be useful in helping individuals quit (Silagy, Mant, Fowler, & Lancaster, 2004). Many provinces and territories currently offer subsidies or free NRT. In addition, there is a national website to support individual who wish to give up smoking linking them to various supports in their local community www.smokershelpline.ca.
Chronic Disease and Defining Health
COPD is a chronic and progressive condition characterized by gradual airway obstruction, shortness of breath, cough and sputum production. Smoking is the principal underlying cause of COPD and is responsible for about 80% of deaths from COPD (Rehm et al., 2006).
Among Canadians with COPD, 45 % reported their overall health as “fair or poor” and 33% reported their health as “somewhat worse r much worse” than a year ago. (Canadian Community Health Survey, 2010)
How do Canadians define health? The World Health Organization (WHO) describes health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1948). Huber challenges the current 1948 definition of health by stating that health should include the ability to adapt and to self-manage ones chronic conditions (Huber et al., 2011).
There are various organizations that provide support and adaptation strategies to individuals living with chronic diseases such as COPD. The lung association is an national organization providing support groups and a hotline for patients diagnosed with COPD (“The Lung Association,” n.d.).
Policy and Culture Change
Since the 1964 Surgeons General’s report linking smoking to lung cancer many countries have jumped into action by changing their smoking policies. Prior to that report the culture in Canada toward smoking was very different. Physicians were advertising cigarettes and you could smoke anywhere you wished, including in the House of Commons, see figure 5.
Our society has gradually shifted over time to be one that makes it challenging to start and maintain smoking. Health care providers such as myself have a professional identity to uphold which promotes healthy behaviours and discourages unhealthy behaviours. As such I continue to ask every smoking patient if they would like information and/or assistance with smoking cessation.
Figure 5 Advertisement Physicians Recommending Cigarettes
There have been numerous policy changes on the federal, provincial, and municipal levels that have assisted to drive the smoking rate down and shift attitudes towards smoking. Collectively these policies have increase taxation of smoking, increase age of purchase, mandatory health warnings on tobacco products, marketing and sponsorship restrictions, supporting those who wish to quit, and banning smoking in public places, see figure 6. All these strategies are in line with the World Health Organization Framework Convention on Tobacco Control (WHO Framework on Tobacco Control, 2003).
In 2008 the WHO introduced a package of six evidence-based tobacco control demand reduction measures that are proven to reduce tobacco use. These measures are known as the MPOWER package and refer to M: Monitoring tobacco use and prevention policies; P: Protect people from tobacco smoke; O: Offering help to quite tobacco use; W: Warning about the danger of tobacco; E: Enforcing bans on tobacco advertising, promotion and sponsorship and R: Raising taxes on tobacco (MPOWER: Six policies to reverse the tobacco epidemic, 2008).
Figure 6 Cartoon reflecting the culture shift in smoking
Future
Smoking remains a leading cause preventable death and disease in Canada (CIHI, 2018). Although we have reduced the overall smoking rate we still have a long way to go to reduce the smoking rate to even lower levels and reduce the health gap between smoking rates of indigenous and non-indigenous Canadians, see figure 7.
Figure 7 Infographic Smoking Rates in Canada 2014
Retrieved from : https://yourhealthsystem.cihi.ca/hsp/inbrief?lang=en#!/indicators/009/smoking/;mapC1;mapLevel2;/
There are also new challenges with smoking including the increase in electronic cigarette use and the upcoming legalization of cannabis. Electronic cigarettes also known as e-cigarettes or vaping contain the addictive chemical nicotine. Many policies makers are catching up to enforce similar restrictions on e-cigarettes to traditional cigarettes however there still remains much work to be done regarding the marketing and availability of these products (Grana, Benowitz, & Glantz, 2014). The legalization of cannabis in Canada is currently slated for August 2018. All levels of government are currently working to ensure this change is safe for all Canadians through public awareness campaigns around its use, highlighting impaired driving, and the creation of policies surrounding cannabis use (Government of Canada, 2017).
Using the social ecological model of health, I have highlighted all the levels on which smoking behaviour has been influenced. I have also explored other variables including determinants of health, the structure of the Canadian health care system, vulnerable populations, interprofessionalism, and chronic disease management to further explain how health systems work and to provide an overall understanding of smoking in Canada.
References
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