Imagine for a moment that a sick bigot published an ad insulting blacks, Jews or homosexuals. We might debate the scope and limits of the first amendment and the freedom of individuals to say what they please, so long as they please the lynch mobs.
But what if the government ran it?
Nazi Germany in the thirties? No, America in the nineties. The only difference is that the group out of favor today is smokers. Anyone who dismisses the comparison has not been reading the news. Smokers are banned from universities, libraries, most places of business and the halls of government. They have been denied employment and fired from their jobs for smoking at home. They have been fined and thrown in jail. And the anti-smoking campaign is just getting warmed up: what lies ten years ahead?
There are two fundamental problems here. First, there seems to be a general acceptance that a majority can do anything it likes to a minority. If you are unconcerned or even happy about the present plight of puffers, you should remember that in one respect or another everyone belongs to some minority and that one day, your turn will come.
Second, and more seriously, our government, which was elected to serve (not rule!) us, is now in the business of bashing the politically incorrect. That phrase, once used humorously, is now starting to acquire the sinister tone that it carries in China. Once we allow the state the power to coerce "correct" behavior, it is only a matter of time, given present trends, before we are all clad neck to toe in severe black garments and addressing each other as "thee".
But some states (notably California and Massachussets, with others sure to follow) have a special indignity reserved for smokers: They must pay for their own persecution. In California, an additional 25 cents per pack tax on cigarettes was passed in 1988 to be used for cancer research, 5%; wetlands(!), 5%; indigent medical care, 40%; and "education" - read anti-smoker campaign - 50%. If you have no problem with that, try switching minority groups and see how well it sits. What about 5% for sickle-cell anemia research and 50% for an anti-black campaign, to be funded entirely by taxing blacks?
The argument that this is being done "for smokers' own good" is demeaning: our bodies are not government property. The argument that smokers cost society money is specious: about one third of us considerately die before cashing in on social security. The argument that smoke is harmful to others is nothing but a subterfuge: the risk of second-hand smoke exposure has been so outrageously distorted that it amounts to an outright lie.
For over twenty years I have watched the growing persecution of a minority with discrimination, harrassment, demeaning propaganda, unfair taxes and laws that fly in the face of our country's constitution. This has been made possible by smokers who are, by and large, apathetic and apolitical. The time is long overdue for smokers to stand up for their rights: to become aware of the issues, armed with facts and willing to work to restore their freedom, their dignity and their rightful place in society.
Secondhand Smoke: The Big Lie
The principal ammunition used in the war on smokers consists of these claims:
All of these falsehoods depend for their general acceptance on the credibility of those disseminating them and upon the inability of the typical listener to perform simple sanity checks using common sense and arithmetic. The simplest is this. It takes 20 years or more for damage to manifest itself in a smoker. ETS is hundreds of times more dilute than mainstream smoke. Non smokers would have to live with ETS for upwards of 2,000 years to incur the same damage. Here's another. Smoke from charcoal contains many of the same components as those most feared in tobacco smoke (carbon monoxide, formaldehyde, carcinogens and so forth). A ten pound bag of charcoal produces as much smoke (and harmful chemicals) as 160 packs of cigarettes. Are you going to quit barbecuing? Probably not. Yet the slightest whiff of tobacco smoke gives many anti-smokers apoplectic fits. Are they being hysterical? Read on and decide for yourself.
CancerThe reason science enjoys such weight and credibility is that it has generally been structured so as to encourage a wide scrutiny of methods, data and findings, peer review and a healthy debate from all viewpoints. In the end, faulty data and fanciful theories are laid to rest, and truth emerges the winner. Usually.
Scientists, like everyone else, are subject to personal bias. They can set out to prove a pet theory, they can ignore data which contradicts a favored hypothesis, and they can read into data facts which simply aren't there. In addition, and perhaps more importantly, their employers can be biased. Employers can put pressure on researchers or even research firms to validate a preordained position or to produce a desired result. Not that they really have to, since it is much easier to hire or retain investigators who agree with them to begin with. And even that is not necessary, since the employer gets to write conclusions and recommendations. Scientists who dissent can effectively be buried simply by not publishing what they have to say.
In an open and honest world, all of this would amount to little, since all sides would have their say and we could count on disinterested observers to wade through the fancy and glean the facts. In the case of secondhand smoke, however, it is near impossible to find anyone who is both disinterested and of sufficient standing to be heard. What we have instead is a war of credibility over conflicting interpretations of biased reports. What we have is politics.
On one side are anti-smokers and the EPA. On the other, smokers and the tobacco companies. At this moment, the antis and the EPA clearly have the upper hand, enjoying as they do a credibility which is just as clearly undeserved. No one is surprised that the tobacco companies have a financial agenda. The same people, on the other hand, express astonishment at the suggestion that the government might actually have a political agenda. Or at the fact that the government, too, is an employer, with more power than most to select and pressure the scientists it employs and to bury the ones that dissent. Nowhere is this power more abused than on the subject of ETS. Last year's EPA report on ETS, the cornerstone of the anti-smokers' arguments, is worse than just bad science.
It is corrupt.
Corrupt science has two salient characteristics. First, instead of starting with a hypothesis and data and deriving from that a conclusion, it does just the opposite: starting with a desired conclusion, it then selects data in order to support the hypothesis. Second, it stifles dissent by excluding dissenters from the process of review and by using ad hominem arguments to question their character and motives. The EPA is guilty on both counts.
Of the 30 studies on spousal smoking referred to in the EPA report, only 6 found any statistically significant association between ETS and cancer in nonsmokers married to smokers, and none found a strong relative risk. The studies actually used by the EPA were limited to 11 studies done in the United States. Using the EPA's own Guidelines for Carcenogenic Risk Assessment, none of these showed a statistically significant risk. These guidelines call for a 95% Confidence Interval. By lowering it to 90%, only one of the 11 studies showed a statistically significant risk. More importantly, the two largest and most recent studies, one of which was partially funded by the National Cancer Institute, were omitted from consideration altogether. Had these two been included, no statistically significant risk would have been found even after lowering the Confidence Interval to 90%. Even after violating its own guidelines, in other words, the EPA could still show no statistically significant risk without selecting data to fit its hypothesis. This cooked data is the EPA's only basis for declaring ETS to be a "Group A" carcinogen. ("Group A", incidentally, does not mean "extra deadly". It simply means "human".)
The EPA's studies on ETS operate under a "zero threshold" hypothesis, or the assumption that if huge quantities of something are dangerous, then microscopic quantities are dangerous also. The data they used, however, fails to bear this out: virtually all of the studies used either found no risk at all or a risk so weak that it would not be considered significant if applied to other subjects.
A "strong" risk is one with an "odds ratio" of 5 to 20 - reflecting an incidence of the problem five to twenty times higher in a group that was exposed to something than in a control group that wasn't. 5 in a population of 100,000, say, compared to 1. (Or 500 vs 100, or 5 in a million vs 1; since it is a ratio, it indicates nothing about the size of the risk itself. Only the relative risk.) A ratio of 1 indicates no risk at all. Odds ratios under 3 are usually considered so low as to be the possible result of random variation or margin of error. The odds ratio of contracting cancer from chlorinated tap water, for example, has been calculated by the EPA to be 1.5 - not enough to worry about, in other words. Yet the EPA used an odds ratio of 1.19 - considerably smaller than that of chlorinated tap water - to classify ETS as a human carcinogen.
One of the largest and most recent studies of ETS is the Brownson study, partially funded by the National Cancer Institute. This study found odds ratios varying from .7 in non-smoking spouses of smokers exposed for fewer than 40 years, to 1.3 in those exposed for over 40 years. .7 is a negative correlation, meaning that those exposed to ETS for less than 40 years experienced fewer cancers than the control group. Since the implication that ETS actually protected those subjects from cancer is biologically implausible, the only other conclusion that can be drawn is that the study's margin of error, caused by random variation, is .3 or higher. This means that the 1.3 figure is equally suspect. The total risk for all groups averages out to exactly 1, or no risk at all.
The Brownson study was available to the EPA, but was not used in its report. Had it been included, the conclusions would have had to have been revised downwards to show no risk.
Though the EPA claims a "19% increase in risk", the actual order of magnitude is less than intimidating. Even if the odds ratio of 1.19 is eventually found to be accurate and not the result of random variation, what this would mean is that instead of the 6 lung cancers per year normally expected in a population of 100,000, we might find 7. Put another way, the average lifetime risk of dying from exposure to ETS (as opposed to eventually dying of something else) would be about 1 in 700. Furthermore, the risk (if real) is concentrated among the non-smoking spouses of smokers exposed to ETS (a heavier exposure than that found elsewhere) for upwards of 40 years, and cannot be extrapolated to include the general population. By way of comparison, the December, 1989 study by the Department of Transportation estimated the probability of contracting cancer from the cosmic radiation at cruising altitude as being some 2,000 times greater than the risk posed by ETS while on the aircraft. The question is, is this sufficient grounds to justify the subjugation of 50 million people? Before you answer, consider this: driving across town to your favorite restaurant entails a risk many times higher - 17 to be exact - than inhaling any secondhand smoke once you get there. If you include the risks associated with the food and drink you are likely to consume there, that multiple rises to over 450. And if you choose one of the many non-smoking restaurants provided by a free market, you get no exposure at all.
A look at the people who worked on this study explains this twisted methodology. Leading anti-smokers pervade both the EPA and the Science Advisory Board responsible for reviewing its analysis, and some of the work was contracted to the founder of a prominent anti-smoking group. It should come as no surprise that the EPA's Workplace Policy Guide was written well before the ETS risk study was completed.
The underlying philosophy at work here is that the end justifies the means; that since a smoke-free society is deemed to be a worthy goal, manipulation of data and even lies are permissible in achieving it. The EPA official responsible for the report admitted in "Science" magazine (7/31/92) that "she and her colleagues had engaged in some fancy statistical footwork" in order to arrive at the indictment of ETS. The opinions of dissenting EPA scientists were ignored, and references to works not in accordance with the EPA position were omitted from the bibliography of the report. Finally, those gainsayers who actually manage to make themselves heard are refuted not with data and reason but with character assassination.
Corrupt scientists have always been eager to ride the bandwagon of popular opinion. Early in this century, Russian scientists drew diagrams purporting to show that the skulls of Jews were smaller than average, reflecting a smaller brain and therefore a lowered intelligence and moral sense. This "justified" the pogroms. In our own country, studies claiming a lower IQ among African Americans (referred to in the studies as "Negroes") "justified" segregation. The damage done by these studies took decades to undo, while millions suffered. Both conclusions share an insidious and horrifying circularity: if the subject of the slur has the temerity to question the evidence, the response is "You can't believe him, he's stupid. Look: my charts prove it!" And that is exactly what is being repeated today. Using corrupt science, the EPA has manufactured a conclusion which states, in effect, that smokers and the tobacco companies are killing 3,000 Americans each year and are by implication morally corrupt. When anyone disagrees, the anti-smokers have the perfect counter argument: "You can't believe them, they're morally corrupt. Look: the EPA report proves it!"
"Political science" has taken on a whole new meaning.
Heart DiseaseWith the appellation of "Doctor" and his little black bag of anti-smoking calculations, Dr. Stanton Glantz is generally assumed to be a medical doctor. Nor is he eager to dispel that notion among his listeners. Actually, he has a PhD in Mechanical Engineering, and no medical training at all. His field of expertise notwithstanding, he gets paid handsomely for doing what he loves most: slandering smokers.
In the not too distant past, researchers (using smokers' tax dollars, naturally) claimed that non-smokers exposed to secondhand smoke over a long period of time exhibited a tiny but measurable increase in fatty deposits on their arterial walls. Given the bias of such researchers, their tendency to make leaps of faith when interpreting inconclusive data and the difficulty of eliminating confounding factors, one cannot accept with any degree of certainty that what they claim is true. However, let us assume for the sake of argument that the phenomenon is real, and proceed.
The arterial deposits in question are caused by diets rich in fats and cholesterol, and by lack of exercise. When coronary arteries become so clogged up that sufficient blood can no longer pass, a fatal heart attack can result. Clearly, this does not happen until a critical degree of obstruction, or "threshold", has been reached. A microscopic buildup in an otherwise healthy person is simply a curiosity, nothing more.
Enter Stanton Glantz, PhD. Each year some 1,000,000 Americans die from heart disease. Ignoring the concept of a threshold, Glantz "reasoned" that if the fatty buildup claimed by the researchers to be attributable to ETS was only one-twentieth as thick as that required to produce a heart attack, then surely it must be producing a twentieth of the heart attacks, or 50,000 of them. He then wrote a thick paper saying so. This is like saying that if a million people cross a body of water ten feet deep and 100,000 drown, then 1,000 would drown if the water were an inch deep. This claim is not just absurd. It is pure fantasy.
Stanton Glantz knows this.
No matter. His paper was his ticket to the lucrative anti-smoker lecture circuit, where his adoring audiences hear what they most want to hear, namely that smokers are killing people. He also found a receptive audience in the American Heart Association, which acts as a sort of wholesale distributor for his misinformation. AHA representatives are to be seen and heard at every City Council hearing on proposed anti-smoking ordinances, where they parrot this pernicious poppycock ad nauseum.
Doubtless the more educated members of the AHA realize what is going down. Perhaps they justify this to themselves by rationalizing that the claim is not really theirs, but rather the "work of a credible expert". Warranties, in other words, are the responsibility of the manufacturer, not the distributor. And since smoking itself is associated with heart disease, and since the goal of the AHA is to get smokers to quit, by outlawing tobacco if necessary, the end justifies the means. Doesn't it?
Respiratory IllnessesThe phrase "respiratory illnesses", when used in connection with ETS, is usually found appended to a list of other claims, as in "cancer, heart disease and ...". It seems to round off the list nicely and is purposely left vague. If pressed, anti-smokers will, as if by rote, recite "... such as asthma, colds, influenza and pneumonia". But none of these ailments is caused by smoking, much less by ETS. Pressed further, the antis will backpedal to the claim that ETS "aggravates" these conditions. The degree of this "aggravation" I shall examine in a moment. First, however, some interesting numbers bear looking at.
Since 1979, the number of smokers has declined significantly, from about 33% of adults, or higher, to a proportion varyingly reported as being from 20% to 25%. During the same period, a host of anti-smoking laws have dramatically curtailed smoking in public places. Today, exposure to ETS is not one tenth of what it was in 1979. Yet, according to an article in the San Jose Mercury News (October 12, 1993), fatal asthma attacks have nearly doubled in that time. More than 5,100 Americans suffered fatal asthma attacks in 1991, up from about 2,600 in 1979. Clearly, some scapegoat other than ETS will have to be found.
So where are the mystery deaths caused by "respiratory illnesses" that can be blamed on ETS? There aren't any. The diabolical innuendo of the phrase "... cancer, heart disease and respiratory illnesses" causes many to believe people die this way and to repeat the rumor. But it is akin to saying "nuclear bombs, biological warfare and firecrackers."
So far, in this country anti-smokers have enjoyed free rein to make wild claims about ETS without having to back them up with rigorous evidence in an objective, impartial setting such as a court of law. With the pending challenge to the EPA's report, that is about to change. For a preview of the truth likely to emerge, we have only to look at a recent Australian court case in which the Australian Department of Occupational Health, Safety and Welfare was pressing a complaint against a casino in an attempt to enforce a no-smoking law.
The question of "respiratory illnesses" quickly became a question of whether the effect of ETS should more properly be characterized as an "irritation" [the defense] or an "inflammation" [the prosecution]. After considering the evidence and witnesses from both sides, the judge likened it to "the experience of ordinary people who sneeze, or whose eyes water when peeling onions." The infamous "respiratory illnesses", in other words, were boiled down in the crucible of truth to simple runny noses.
In addition, the prosecution introduced as part of their evidence the January '93 EPA report on lung cancer and ETS. About this report the judge had these words: "I would have thought that these reports would be those which supported the prosecution case most strongly, but they appear not to. One of these reports is the American EPA report... Chapter 7.9 of the report covers passive smoking and respiratory symptoms and lung function in adults. Table 7.11 tabulates 6 studies and their results, which really show the contrary to what the prosecution witnesses say." The decision, handed down in Perth on September 17, 1993, concluded: "Whilst ETS is annoying and of discomfort to non smokers it has not been proved at the required standard, or at all, that it is a risk to the health of the employees at the Casino."
Smoking & Smoking Cessation in the Workplace
Table of Contents
Introduction p. 3
Purpose ... p. 3
The Effects of Smoke and Second-Hand Smoke ... p. 4
Do Non-smoking Policies Succeed? .. p. 5
Why do People Continue to Smoke? . p. 6
Promoting Smoking Cessation ... p. 9
Conclusion .. p. 15
Recommendations ... p. 15
References ... p. 17
Smoking & Smoking Cessation in the Workplace
The single most preventable factor that contributes to the major health problems facing Canadians today is the use of tobacco. The very mention of the word smoking can evoke an argument from the calmest of people, whether they are smokers or non-smokers. The former feel threatened, while the latter feel they may have the chance to bring an end to an activity they have long disliked and disapproved of. Workplaces across the country are adopting smoke-free policies in order to provide clean air and to protect employees and the public alike from the harmful, if not life-threatening effects of smoking. According to the American Lung Association (1997), 94 per cent of smokers and non-smokers now believe companies should either ban smoking totally in the workplace or restrict it to separately ventilated areas.
In response to an increased awareness of the dangers of smoking, there has been a growing interest in the introduction of smoking policies for the workplace. The purpose of this paper will be to outline some of the effects of smoking and the effectiveness of implementing smoking cessation programs. This paper also contains specific goals and strategic direction with which to achieve these goals and provides the groundwork for the formation of a committee to review the research and aid in implementing the recommendations. Well-designed and implemented programs and policies can aid in preventing the use and effects of tobacco and second-hand smoke.
The Effects of Smoking and Second Hand Smoke
The effects of the use of tobacco are well researched and well documented. Tobacco use poses a risk to both those who participate in the behavior, and to those who passively take in second-hand smoke. Stillman (1995) found that smoking is the leading cause of preventable death, and smoking related diseases are involved in more than one third of all hospital admissions. Fried (1994) reported that women who smoke are more often subject to infertility, miscarriage, spontaneous abortion, stillbirths, and underweight babies. Fried also found that crib death (sudden infant death syndrome, or SIDS) occurs 2.5 times more often in babies whose mothers smoke. Albrecht, Cassidy, Reynolds, Ketchem, and Abriola (1999) reported that more than 400,000 annual deaths are associated with tobacco use and the cost to health care and lost productivity is almost $100 billion per year. Moreover, maternal smoking in pregnancy has been linked to learning disabilities, hyperactivity, impulsivity, and soft neurological signs in school aged children. Albrecht et al (1999) also reported that maternal smoking and second hand smoke are associated with increased incidence of acute respiratory infections and more frequent hospitalization for severe bronchitis, pneumonia, asthma, and otitis media during the first year of infancy. Similarly, current estimates of the number of deaths attributed to smoking in Canada range as high as 38,000 per year (Albrecht et al, 1999). A large amount of deaths is also associated with involuntary exposure to the tobacco smoke.
According to Single, MacLennan and MacNeil (1994) in 1991, 46.8 billion cigarettes were sold legally in Canada. Thus, an estimated 35,717 deaths were attributed to smoking in Canada in 1990, a rate of 135.6 per 100,000. Single et al (1994) revealed that although Canadian men were once much more likely than women to smoke, men and women are now almost equally likely to be current smokers (31% vs. 28%). Also, men are more likely than women to be former smokers (39% vs. 31%). Meanwhile, smoking is highest among those aged 25 to 44 (35%) and lowest among those over 65 (15%).
The effects of smoking and second-hand smoke are many in number. Tobacco smoke represents the single most significant source of indoor air pollution. The smoke and second-hand smoke from tobacco contains over 4000 chemicals, both gas and particulate. The American Nurses' Association (ANA, 1998) researched and found that the gas phase of second-hand smoke contained such poisons and irritants as carbon monoxide, acrolein, ammonia, nitrogen oxides, benzene, pyridine, and hydrogen cyanide and the particulate phase contains nicotine and many known or probable carcinogens, which have no safe level for human exposure.
The seriously damaging health effects of tobacco smoke continue to be documented. ANA (1998) found that children and adults exposed to tobacco smoke experienced increased rates of respiratory illness, including lung cancer (approximately 3000 deaths per year in adults exposed to tobacco smoke), higher rates of respiratory tract infections (bronchitis and pneumonia), and exacerbation of asthma symptoms. The ANA (1998) also found that high exposure to tobacco smoke nearly doubles a woman's risk of heart attack, and also causes eye, nose, and throat irritation, leading to excess coughing, chest discomfort, and difficulty breathing.
Do Non-smoking Policies Succeed?
Joseph, Knapp, Nichol, and Pirie (1995) found that smoke-free hospital policies are designed to minimize patient, employee, and visitor exposure to secondhand smoke, encourage patients to quit smoking, and set an example for the community of institutional policies that reflect scientific knowledge about the health risks of smoking. David (1992) implemented a survey at a 38-bed hospice, where 119 staff is employed, as a preliminary way to introduce a no-smoking policy. The survey proved to be valuable in introducing staff to the concept of a policy, making them feel involved, and supplying the policy-makers with background information. Literature suggests that positive behavioral changes occur among employees after the introduction of a no-smoking policy. Shirres (1996) found in a study that the introduction of non-smoking policy and education programs induced positive behavioral and attitudinal changes in smoking. Martin (1998) states that providing a tobacco free environment that establishes nonuse of tobacco as a norm offers opportunities for positive role modeling. Joseph et al (1995) also found that having a person at the hospital dedicated to enforcing the no-smoking policy greatly improved the chances of success.
If a smoke-free work environment is to be achieved, greater efforts to assist smokers to quit will be necessary. Interventions to reduce smoking must become a priority for health care providers, as physicians and nurses come into contact and interact with a large number of smokers every year. Health promotion advocates must also communicate the cost savings and health benefits garnered from workplace smoking cessation programs.
Why do people continue to smoke?
Tobacco use, which occurs primarily through smoking, is a behavior influenced by pharmacological, psychological, social, and environmental factors (Fisher, Haire-Joshu, Morgan, Rehberg, & Rost, 1990). The U.S. Department of Health and Human Services (1988) state that nicotine, the major addictive agent in tobacco, provides both euphoric and sedating effects and serves as powerful pharmacological reinforcement for maintenance of the behavior. Christen and Christen (1994) suggested that recognizing tobacco use as an addiction is both critical for treating the tobacco user and for understanding why people continue to use tobacco despite the known health risks. Shiffman (1979) adds that in addition to its pharmacological effects, smoking involves a strong psychological dependence in that smokers report engaging in the behavior to soothe negative affective symptoms, such as tension, anxiety, boredom, and irritability. When these affective symptoms are reduced, it leads to an increased activity in the behavior.
Christen and Christen (1994) state that smoking is seldom a take-it-or-leave-it activity. Most smokers cannot choose to use tobacco one day and leave it alone the next. Most smokers admit that they would like to quit, but are unable to do so. Christen and Christen (1994) further argue that some individuals use nicotine as a tranquilizer: they believe that smoking keeps them on an even emotional keel and reduces their feelings of anger, fear, and frustration. In addition, Christen and Christen (1994) stated that smokers commonly reported smoking helps them to regulate their dysphoric moods or negative affect, and those who experience excessive stressors tend to increase their consumption. As mentioned, social and environmental conditions also influence tobacco use. McIntyre-Kingsolver, Lichenstein, & Mermelstein (1983) and Ockene, Benfari, Nuttall, Hurwitz, & Ockene (1983) state that a majority of smokers are surrounded by family members and friends who engage in the behavior, providing strong cues to continue smoking.
Albrecht et al (1999) found that adolescents are faced with lifestyle choices that are influenced by developmental level, cognitive understanding, decision-making skills, and social influences such as family values and peer pressure. Fried (1994) reported epidemiological data and study of psychological, biological, sociocultural, and physiological variables reveal a gender-related proclivity for females to initiate and maintain the tobacco habit. Young women appear to be more vulnerable to starting smoking and less amendable to stopping it. Fried (1994) reported a woman's fear of weight gain is a deterrent to cessation and an impetus to continue the tobacco habit. Women tend to report less confidence in their abilities to quit, perceive more barriers to abstinence, and anticipate negative consequences of quitting.
Fried (1994) suggested low income, poor housing, lack of education, single/divorced or separated marital status, unemployment, city dwelling, lack of independence, housewife, or single working parents are characteristics of a smoker. As mentioned, social and environmental conditions also influence tobacco use. These factors alone make it hard to resist and quit smoking, but when adolescents face smoking cessation, it can be even more difficult.
Christen and Christen (1994) state that smoking has both similarities to and differences from other addictions. Cigarette smoking, a special form of addiction with its own unique features, is incredibly resistant to long-term modification. Nicotine is addicting and smoking represents an addictive disorder, such as alcohol, cocaine, and heroin dependence. It is further argued that cigarette smoking is psychologically as well as physically addicting. Christen and Christen (1994) suggested that nicotine is now understood to be a strongly addictive mood-altering drug, with properties that clearly reinforce the continued use of tobacco products. They further argue that nicotine, as an ingestive disorder, compulsive nicotine intake causes physiological tolerance, tissue dependence, psychic dependence, and relatively well defined physical withdrawal symptoms.
Promotion Smoking Cessation
According to Blair (1995) one objective of wellness program activities is to foster employee health. However, workers whose health stands to gain the most from wellness programs are the least aware of their unhealthy lifestyles and the least motivated to change. According to Nagel, Mayton, and Walner (1995) since values are a central concept in understanding and predicting human behavior, health education aimed specifically at cigarette smoking or other habits treated singly rather than in relation to each other. Effective health promotion programs, that attempt to change negative behaviors while reinforcing existing positive behaviors must understand the attitudes and behavior of target audiences, are necessary. Mintz (1989) argued that for health promotion to be of any use in a practical sense, it must be put into the hands of those who can use it. Mintz (1989) suggested that the value of health information to society could only be fully realized if information is absorbed and acted upon to a significant degree by the audience that the information is intended to reach. According to Novelli (1997), successful utilization of health promotion is dependent upon understanding or identifying the target consumers' needs, expectations, satisfactions and dissatisfactions. Lefebvre and Rochlin (1997) and Wilson and Olds (1991) suggested that promotion of health products should consider the objectives of the promotion, the target audience, the desired effect, and the optimal reach and frequency.
Many serious public health and social problems of the day have their root in behaviors that begin in late childhood and adolescence. Nagel et al (1995) advised that drug education programs designed to keep adolescent from becoming daily users of tobacco (prevention) should be encouraged to focus on changing the value placed on health. According to Andreasen (1995), an extremely important task during the formative stages of the strategic planning process is to gain an understanding of the extent to which interpersonal influences are likely to be important for one or more target groups. When helping a smoker to quit, the smoking cessation facilitator needs to consider the smoking behaviors and attitudes of family members and significant others. Social support is an extremely important factor in any effort to change personal behaviors. Albrecht et al (1999) said aspects of development must be considered when developing health educational programs for adolescent females. They further advise that health providers must be aware of this educational barrier when counseling teens regarding health related behavior. Albrecht et al (1999) stated that adolescent development has a significant impact on strategies for health promotion. Behavioral experimentation is a common pattern in this age group and is related to the task of separation from family and identity development. They further indicated that rebelliousness and identification with peer groups influence adolescent behavior.
One of the most persistent findings is that children and adolescents are much more likely to participate in a particular high-risk behavior or activity if their friends also engage in that behavior or activity. Greenlund, Johnson, Webber, and Berenson (1997) found that from third grade through to sixth grade, there was five times the risk of an individual to smoke if a best friend also smoked. Grunberg, Winders & Wewers (1991) found that boys have decreased, but girls have increased, their likelihood to try cigarettes. Tobacco use in adolescent females is also associated with personal factors including self-image and self-esteem. Christen & Christen (1994) studied that tobacco use is learned and typically initiated during adolescence, when the need to achieve acceptance through peer conformity is particularly strong. They suggest that the desire to feel more grown-up and the drive to become self-defined and individuated can cause adolescents to rebel against the strict parental control or to challenge cultural and /or religious expectations. If social marketers are to develop effective health promotion programs to prevent the onset of high-risk behaviors in adolescents, such as smoking, it is crucial that they understand the exact role that social influence plays in this process.
According to Fried (1994), several variables in addition to gender are associated with the prevalence of cigarette smoking. These include socioeconomic status (SES), level of education, race, and occupational status. Fried further suggested that the difference in how young girls and young boys relate to their social contexts appear to create gender-distinct smoking behaviors and perceptions. Christen & Christen (1994) stated that the two major predictors of early cigarette use are experiencing peer pressure to smoke and having one or both parents whom smoke. Fried (1994) stated that a host of environmental factors predispose the adolescent female to tobacco use. The prime influencing factor is the tobacco industry's seductive advertising that depicts women smokers as powerful, glamorous, happy, successful, and attractive. Fried (1994) also suggested that the adolescent female, struggling with her negative body image and searching for beauty, views cigarette smoking as a means to achieve thinness and shape a feminine gender role. Fried (1994) found less educated adolescents females from lower socioeconomic strata are most likely to become one of the new smokers who start each day. In addition, 20 to 30 per cent of these adolescent smokers will become regular users by age 18.
Christen and Christen (1994) suggested, early in the cessation process, nonjudgmental and empathetic friends and family members can be enlisted to actively support recovering smokers. Likewise, healthy competition among recovering friends may also become a potent smoking cessation motivator. Tripp & Davenport (1989) suggested several strategies could be implemented in order to be successful in utilizing social marketing to promote smokers to reduce or cease smoking behaviors. These include:
1. Smokers don't want to be threatened. They don't want be bullied or made to feel ashamed of smoking.
2. A message that smoking causes death is not successful. All smokers know smoking causes health risks and that is it associated with a variety of health problems. Smokers know many people, who are healthy, yet have smoked regularly for many years. Smokers also know many people, who are sick, yet have never smoked a cigarette. Smokers also know many doctors, who surely know the facts, but are smokers.
3. Smokers need encouragement to quit. Many smokers have tried or know somebody who attempted to quit but could not. Smokers want more than punitive measures to help them stop smoking. The findings of these studies revealed that, supportive tone of the ads make the female smokers feel understood, reassured them that they were not failures and supported them in their efforts to quit. (Tripp & Davenport, 1989)
4. Smokers want realistic guidance about quitting. Smokers responded positively and were receptive to messages that revealed people often fail to quit in the first few attempts, and that kind of failure is normal. These messages gave smokers a reason for trying again and again.
Christen & Christen (1994) said recognizing tobacco use as an addiction is critical both for treating the tobacco user and for understanding why people continue to use tobacco despite the known health risks. They also suggested tobacco is a potent drug that exerts strong control over its regular users and reinforces the need to use and re-use. Albrecht et al (1999) stated that developmentally, adolescents focus on the present, the immediate effects of tobacco use, such as bad breath, stained teeth, and high cost of cigarettes, and this should be the focus of the education effort.
Christen and Christen (1994) reported that about 70 to 80 per cent of smokers who do quit are likely to relapse within the first 3 months of cessation. In addition, 50 per cent or more of patients who are recovering from surgery for a smoking related disease continue to smoke while they are hospitalized or resume smoking shortly after they are discharged. In essence, smoking is an extremely multifaceted, addictive behavior that involves pharmacological, environmental, cognitive, and affective factors.
Albrecht et al (1999) recommended programs that involve role modeling, peer resistance, and booster sessions, focused on attitude and behavior change, to achieve cessation while recognizing issues of adolescent development can be highly successful. They also suggested when working with teens, parents of the adolescent must be included in health promotion activities. Tripp & Davenport (1989) examined advertising directed at smokers found that fear tactics were a most ineffective means of encouraging smokers away from their smoking behavior. They found advertisements that provided information about the dangers of smoking and offered some suggestions that are effective methods to quit were effective. This study concluded positive ads seemed to motivate people to a moderate degree. Tripp & Davenport (1989) opposed the use of fear tactics to help teenage female smokers decide against initiation or cessation of smoking. They found that fear tactics failed to address the real concerns of female adolescent smokers, which center on the difficulties and frustration involved in breaking an addiction.
Albrecht et al (1999) further recommended the following steps as effective guidelines for smoking cessation for high-risk populations:
1. Awareness: understanding of the unique needs of the high-risk population.
2. Ask: inquire about lifestyle to assess high-risk areas to target cessation activities.
3. Advise: education should center around specific short and long-term effects smoking has on the high risk population and reversible effects that occur with cessation.
4. Assist: self-help educational material must be supplemental with counseling sessions that specifically address quit preparation, smoking triggers, and alternative coping responses that enhances lifestyle changes.
5. Arrange: follow-up appointments can be scheduled closely around quit date for reinforcement and support of cessation efforts.
6. Again: repeating process reinforces cessation efforts and addresses relapse issues.
A healthy and safe environment is a public health priority. Clean air, free from tobacco smoke, is particularly vital since researchers have documented the link between tobacco smoke and increased morbidity and mortality in both smokers and non-smokers. Health professionals can play an essential role in both clinical and community settings to reduce tobacco use, one of the leading causes of health problems in this country. Work site environments must have policies established and enforced that restrict or prohibit smoking. Health professionals must make it their duty to enhance public awareness and education about the hazards of tobacco smoke within the work setting, and the benefits
no-smoking policies as mechanisms for enhancing the health of both smokers and non-smokers.
A committee needs to be created to steer this organization to form and adopt a policy that satisfies all involved. The committee must include all employees representative and other stakeholders. We also advise, open procedures that motivate active decision making participation of all participants. The overall goals for the policy ensure that its scope of action is extensive.
These three goals are:
+ to protect the health and rights of non-smokers (protection);
+ to help non-smokers stay smoke free (prevention);
+ to aid and encourage those who want to quit smoking to do so (cessation).
To achieve this, the following six strategic directions have been identified:
+ access to information;
+ access to services and programs;
+ message promotion;
+ support for action;
+ Intersectoral policy coordination;
+ research and knowledge development
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