Smoking is an extremely crucial public health issue which is considered to be an immediate and serious threat to many developing countries across the globe (WHO 2005). Being one of the most significant determinants of increased rate of mortality and ill-health throughout the world, smoking is still a preventable epidemic (OTC 2005). Active cigarette smoking has long been known to predispose common people to several types of mouth diseases, lung cancer, atherosclerotic vascular diseases, impotence etc. and enhanced exposure to environmental tobacco smoke has deleterious effects to public health (Ong and Glantz 2004). Cigarette is utilised as an apparatus for self-administering nicotine which significantly causes drug dependency. It has been observed that nicotine inhalation via cigarette smoking is far more swift technique of drug intake as compared to heroin injections because nicotine takes not more than 7 seconds to travel from lungs into brain whereas, it takes 14 seconds for the heroin to reach the brain (DiFranza, Savageau and Fletcher et al 2007). Smoking prevalence as a global epidemic necessitates serious attention as about 1.3 billion people across the globe have been reported to smoke cigarettes and thereby experience numerous smoking-related health issues (Webb, Bain and Pirozzo 2005). In accordance with a study it has been estimated that by 2025-2030 approximately 10 million people are anticipated to die because of widespread smoking habitude (Edwards 2004). There are numerous ramifications of smoking in almost every area of knowledge including politics, economics, psychiatry, psychology, sociology, anthropology, pharmacology and pathology. This all-inclusive nature of the subject encompassing the bio-psychosocial segments of life makes it an appealing exploratory premise for the study.
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1.1 Overview of the Report
The report is designed to highlight the key epidemiological evidences pertaining to cigarette smoking, based on the global mortality rates and several stages of the worldwide tobacco epidemics. Moreover, the epidemiology of smoking habitude amongst general population of UK has been represented on the basis of age, gender and socio-economic factors. The central part of the report discusses a number of smoking related risk factors to public health and also evaluates the responsiveness of public towards the identified risks. Later segment of the report proposes the practical interventions to address the global epidemic of smoking which subsequently leads to conclude the overall study.
1.3 Rationale of the Study
The main objective of this report is to accentuate smoking as a major public health issue and highlight the related health risks to general society based on the epidemiological evidences. By expounding on the public behaviour towards smoking and its damaging effects to the general populace, the study attempts to appraise the subject area. The report also aims to evaluate the effectiveness of current public health services pertaining to smoking cessation by probing in the interventions designed to reduce the underlying risks and improve public health.
CIGARETTE SMOKING: EPIDEMIOLOGICAL EVIDENCE
The epidemiological evidences suggest that the consistently augmenting patterns of smoking lead to enhance worldwide mortality rates and the recent studies suggest that the developing countries have slightly higher smoking induced mortality rate especially in men, as compared to the developed countries (Table: 01).
Table: 01 Estimates of Smoking Induced Global Mortality Rates
Millions of Death from Smoking
2.43 (2.13 – 2.78)
2.41 (1.80 – 3.15)
4.83 (3.94 – 5.93)
Source: Ezzati and Lopez 2000
In western countries smoking prevalence has been estimated to be 30% which is considerably less as compared to Asian countries where smoking prevalence is evidently incremental as for example 53% in Japan, 63% in China and 73% in Vietnam (European Commission 2007). There has been significant variation in EU pertaining to smoking trends as for instance 18% in Sweden to 42% in Greece however; the average smoking prevalence in EU was about 32% (European Commission 2007). The segmentation of worldwide tobacco epidemic in four different stages has been exhibited below in Figure: 01,
Figure: 01 STAGES OF THE WORLDWIDE TOBACCO EPIDEMIC
Smoking trends in Great Britain indicate that the overall gender-specific adult smoking rates have been declined by approximately 0.4% per annum since the year 2000 (Robinson and Bugler 2008) however, the most recent statistics reveal that smoking prevalence during 2007-2008 in UK has remained more or less the same. Gender-specific cigarette smoking trends in UK during 2004-2008 are exhibited below in Table: 02,
TABLE: 02 CIGARETTE SMOKING BY SEX (2004-2008), UK
Source: General Lifestyle Survey 2008
The age-specific smoking prevalence trends observed in UK indicate that the age group of women between 20-24 years i.e. approximately 31% of young women in UK are indulged in smoking behaviour and similarly, men aged between 25-34 i.e. approximately 30% of men are also found to be regular smokers (Friis and Sellers 2009). Age-specific cigarette smoking trends in UK during 1978-2008 are exhibited below in Table: 03,
TABLE: 03 CIGARETTE SMOKING BY AGE (1978-2008), UK
Source: General Lifestyle Survey 2008
Representing the link between cigarette smoking and socio-economic sector of the UK society, it has been observed in a survey that smoking is much more prevalent amongst people associated with routine and manual occupations which includes approximately 30% of men and 27% of women whereas, people associated with managerial and professional occupations exhibit a slightly reduced smoking trend which includes 14% of men and 14% of women following smoking behaviour (Robinson and Bugler 2008). Socio-economic classification of cigarette smoking trends in UK during 2008 are exhibited below in Table: 04,
TABLE: 04 SMOKING IN UK: SOCIO-ECONOMIC CLASSIFICATION
PERSONS AGED 16 AND OVER, GREAT BRITAIN: 2008 (%)
Large employers and higher managerial
Lower managerial and professional
Small employers / own account
Lower supervisory and technical
Source: General Lifestyle Survey 2008
SMOKING INDUCED RISK FACTORS TO PUBLIC HEALTH
Smoking patterns are greatly influenced by the individual’s bio-psychosocial status and considerably vary depending upon diverse factors including fiscal condition, population size, age, gender, and the existence of regulatory models. It has been studied that social pressures play an integral role in an individual’s conformation towards a specific set of beliefs or behaviour and smoking too, like other forms of substance dependencies is shaped up in accordance with the surrounding environment of a smoker (Killoran et al 2006). Gender-specific smoking induced risk factors considerably fluctuate depending upon the societal, cultural and religious beliefs as for example 40% of young women in Spain have been reported to indulge in active smoking behaviour on the other hand, China remains less affected when it comes to smoking habitude in women which has been reported to be less than 5% only (European Commission 2007). Similar is the case with other Asian countries including India, Pakistan, Bangladesh etc. where smoking induced risks to women are significantly less as compared to men because of conservative culture and traditions in the region. Moreover, the statistics also exhibit that the smoking induced risk factors are less common in older age groups, in both men and women as the lowest ratio of smoking has been observed amongst people aged 60 and over (Merrill 2010) because younger generation is much more enthusiastic to experiment and usually exhibits callous attitude towards health risks. There has been a sustained and analogous pattern of smoking induced risks observed between both the manual and non-manual populace of the socio-economic sector in UK, which signifies the growing awareness of public towards the underlying public health issue. Apart from bio-psychosocial risk factors there are a number of other smoking related risks to public health which are summarised as follows:
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3.1 Passive Smoking
Second hand smoking, environmental smoking or passive smoking are all detrimental and risk the life of a non-smoker that is consciously or unconsciously exposed to hazardous effects of smoking induced chemical compounds and probable human carcinogens. Passive smoking has been identified as the most critical cause of smoking related ill-health and incremental mortalities in general population, due to lung cancers and coronary heart diseases.
3.2 Tobacco Carcinogenesis
Excessive tobacco consumption in the form of cigarette, cigar, pipe smoking enhances the risk to mouth, larynx, and oesophagus cancers and if complimented by heavy alcohol intake, can subsequently trigger the tumours in tobacco carcinogenesis (DoH 2007).
3.3 Occupational Hazards
Persistent interaction between smoking and a variety of industrial agents can develop a number of cancers as suggested by numerous experimental and epidemiologic data. It has been studied that the smokers working within the environment containing asbestos or uranium ores significantly provides the means to stimulate tobacco carcinogens and an increased risk of lung cancer (DoH 2007).
3.4 Coronary Heart Diseases
Several studies suggest that cigarette smoking significantly contributes in premature sudden death from coronary diseases especially in populations where arteriosclerosis is prevalent thus, exerting a pronounced secondary effect to hyperlipidemia and hypercholesteremia subsequently increasing the risk of hypertension and heart attack (Ong and Glantz 2004).
Studies suggest that excessive air pollution complimented by cigarette smoking, leads to death from acute pulmonary disease and lung cancer. The carcinogens contained in pollutant air is inhaled in relatively small doses and on the other hand, cigarette smoke is highly concentrated and inhaled directly into the lungs therefore, the damaged caused to the respiratory tract by the air pollution alone, is comparatively less than the damage caused by the intense tobacco smoke. However, for non-smokers the passive smoking in combination with the pollutant air can be a serious risk to health as heavily polluted air contains approximately 100,000 particles per cubic centimetre whereas inhaled cigarette smoke contains more than 5 billion particles per cubic centimetre (Webb, Bain and Pirozzo 2005).
ANALYSING PUBLIC RESPONSIVENESS TO THE IDENTIFIED RISKS
Despite of consistent efforts by the local governments and numerous international health organisations, it has been observed that the public awareness programs regarding smoking cessation are considered to be effective to varying degrees; as it is extremely difficult to determine the consumer’s perception towards the smoking related health consequences and addictive nature (Bauld et al 2003). The consumer base in the developing countries remain exceedingly unacquainted with the country-specific smoking related information and health policies as the preventive interventions like awareness campaigns, registration system to assess disease patterns and the identification of smoking related trends are not vigilantly established. Moreover, the consumer base in the developing countries expect low-cost and reliable preventive measures however, the fiscal limitations makes it difficult for the local governments to entrench inexpensive and equally effective smoking awareness schemes and interventions; as a result of which the public responsiveness towards addressing the smoking epidemic is significantly pitiful especially where it looms largest. In addition to this, smoking cessation becomes a complex issue due to its addictive attribute and several studies have rated it as amongst the most evil drug dependency as compared to heroin and cocaine (Donaldson and Donaldson 2003). The addictive trait of cigarette smoking is characterised by a cluster of behavioural, cognitive and physiological phenomena which consequently develops due to enhanced substance use resulting in increased desire for smoking which becomes a persistent exercise and as the time passes, the chances of withdrawal becomes unattainable. It has also been studied that the superfluous social acceptance of smoking has significantly contributed to its sweeping popularity and prevalence amongst the general population (Marmott and Wilkinson 2006) and this ignorant public attitude combined with lack of awareness; results in natural inclination of the masses to consider it a harmless and a nontoxic habitude (Stevens, Raftery, Mant and Simpson 2004). From the economic perspective, the tobacco industry generates humungous revenues by influencing the developing countries as a profitable target for market expansion, which is mutually advantageous to the developing countries leading them to compromise on their public health issues against enhanced fiscal benefits. Tobacco industry considerably influences the political set-up of several countries to advertise and promote cigarette smoking and their intriguing commercial campaigning significantly draw the attention of younger generation that are already less-informed and easily fall prey to such marketing tactics. Pre-targeted and smartly designed commercials significantly mislead the naive public and successfully manoeuvre them by relentless denial of tobacco’s unfavourable health impacts.
PRACTICAL INTERVENTIONS FOR SMOKING EPIDEMIC
The smoking related health outcomes can be substantially controlled by integrating effective tobacco control policies and interventions that are capable to cease or significantly reduce its prevalence and consumption amongst the general population. It has been studied that tobacco smoking does not limit the effects of its pervasiveness to smoker itself rather the people present in the surrounding environment (Farmer and Lawrenson 2004) as for example, non-smoking adults including cohabiting partners and children of the smoker are also adversely affected. Hence, it becomes essential to edify the smokers to acknowledge their social responsibility towards the general public and strongly discourage them to exhibit their smoking habitude in public (Douglas et al 2007). The success rate of the practical interventions adopted in the developed countries has found to be much practicable as compared to the developing countries because the regulatory frameworks are stringent and the law enforcement agencies are also equally efficient. In order to enable the general population to effectively combat with smoking-related public health issues, it is imperative to establish prudently designed and effectually devised practical interventions; for discouraging cigarette smokers and providing maximum protection to children, pregnant women, elders and other non-smoking adults by entrenching a number of the below mentioned tobacco controlling key initiatives:
5.1 Establish a Highly Informative Setting
A highly informative environment can be established by effectively conveying the most updated and evidence-based tobacco related public health information to the general population and specifically highlighting all the associated risk factors. The local governments must exhibit maximum commitment towards smoking cessation campaigns by formulating effective regulatory framework and providing suitable means to the healthcare professionals to implement it (Scott and Mazhindu 2005). Highly developed countries and the international health organisations must also facilitate the poor countries by financing the research projects to evaluate causes, consequences and costs of tobacco use in the respective regions and thereby, devise a preventive strategy accordingly.
5.2 Media Campaigning
Media is the most constructive tool to speedily communicate with the masses therefore, it is imperative to utilise both print and electronic media for positive campaigning and specifically rope-in the e-media to target today’s internet savvy, younger generation. In the wide-ranging interest of public health, it is the social responsibility of media world to completely prohibit the enticing cigarette advertisements and instead make noble use of the media by broadcasting regular public service messages to discourage the prevailing smoking behaviours.
5.3 Stringent Policies to Reduce Tobacco Consumption
Substantial increase in tobacco prices can significantly reduce its consumption especially amongst younger generation or those that are unable to afford. Governments must also concentrate on formulating such policies that can completely forbid the promotional campaigns and considerably restrict the sales through vending machines (DoH 2007). Since smoking is one of the most prevailing global epidemics therefore; strict rules and regulations shall be imposed to discourage smoking in public places as for example bus stops, restaurants, educational institutions, offices, hospitals and cinemas etc. This would not only limit its consumption but will also signify the government’s seriousness towards addressing the underlying public health issues. Moreover, the tobacco industry shall be consistently introduced to consistent and rigorous tax networks so that the target of promoting controlled use of cigarette smoking can be achieved (DoH 2007). On the other hand, governments can attain dual benefits by expanding the tax network for the tobacco industry thus reducing its consumption amongst general populace and can generate more taxed revenue.
5.4 Discouraging Nicotine Dependency
Regular smokers become heavily reliant upon nicotine intake and therefore, seek for certain other alternatives as a substitute to cigarettes including chewable tobacco, tablets, patches and inhalers, if their accessibility to cigarette smoking has been disrupted. The governments while designing smoking related preventive strategies must acknowledge that nicotine is highly addictive and therefore, it is wise to introduce less-harmful and inexpensive alternatives to regular cigarettes and subsequently educate them to overcome their nicotine dependency by adopting practical interventions through professional medical assistance (Prabhat, Chaloupka, Corrao and Binu 2006). Moreover, the developed countries and international health organisations can also donates such inexpensive nicotine alternatives to poor and deprived countries in order to promote smoking cessation and healthy living across the globe.
5.5 Support Groups
Nicotine dependency significantly damages the internal health of people which restricts them to participate in healthy sports activities. Governments can help the local bodies to establish tobacco control support groups in their respective neighbourhoods and to organise healthy activities and events to promote constructive attitude amongst general population. A strategically designed tobacco control program also facilitates in mobilising the civil society to effectively contribute both their money and time to engage nicotine dependent people in healthy activities (Prabhat, Chaloupka, Corrao and Binu 2006) and thereby, motivating them to overcome their cigarette smoking habitude. Formation of such support groups provide easy and consistent access of tobacco-specific valuable information to the smokers and also enhance their awareness to the associated risk factors.
Smoking has been established as a consistently prevailing global epidemic and that is so, because the related effects of smoking are not restricted to the smoker himself, but also extend to others through a range of risk factors including passive smoking and air pollution etc. which makes it a substantial risk to public health. Provided the fact, it is not only essential to discourage smoking behaviour in smokers but also educate the non-smokers to protect themselves from the associated health risks. Apart from individual preventive measures, there is a growing need for integrating practical interventions to ensure reduced exposure to tobacco smoke especially in public places by providing separate smoking and non-smoking areas or installing ventilation or completely banning smoking through industry led voluntary agreements or by introducing stringent statutory requirements. To conclude, cigarette smoking is radically injurious to public health and honest efforts are required at both individual and communal level to enhance public awareness towards the associated risks and particularly support the smokers to quit their smoking habit.
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