Social Determinants Affecting the Cigarette Smoking Epidemic

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Tobacco has been used for centuries, even before Christopher Columbus brought it back to Europe. The widespread use of tobacco for smoking cigarettes grew in popularity throughout the early 20th century partially propagated by the widespread distribution of cigarettes during world wars (Cancer Council NSW, 2015).  The Centers for Disease Control (CDC) defines a smoker as someone who has ever smoked 100 cigarettes in his lifetime and who currently smokes cigarettes every day or some days (CDC, 2017; Belbeisi et al, 2009).” The physical and mental addiction to cigarettes and cigarette smoking precludes dire consequences for both the individual and the nation.

The Surgeon General through the U.S. Department of Health and Human Services has been tracking cigarette smoking and health consequences for more than fifty years. The CDC also gathers statistics regarding cigarette smoking from National Health Interview Surveys and Youth Risk Behavior Surveillance (CDC, 2018a; CDC, 2018e). Table one is a comprehensive snapshot of current cigarette smoking statistics among U.S. adults. Multiple person characteristics are accounted for in this table. One trend of note is that the higher the education level, and the higher the income level the fewer adults report to be cigarette smokers. This shows a strong socioeconomic connection to cigarette smoking (CDC, 2018b). On a global scale the World Health Organization (WHO) monitors the tobacco epidemic and prevention policies (WHO, 2017). Table 2 condenses data for smoking prevalence by world regions and compares male and female prevalence. In all regions the smoking prevalence is higher for males than females (Gowing et al., 2015). In 2015 the WHO also published a detailed report on the trends in prevalence of tobacco smoking over time which displays very detailed data for many countries. The next global report will be published in 2020 with another following in 2025 (WHO, 2015). Figure 1 displays information for the Global number of smokers compared with population. Data is also compared between males and females in low, middle, and high-income countries. Males and females in middle income countries have the highest proportion of the population who smoke cigarettes. Figure 2 is a unique set of data within the 2014 Surgeon General Report displaying the number of smokers with respect to social events. Since the 9th Surgeon General published the first Report regarding the negative effects of smoking on health in 1964 and the U.S. strategic plans to reduce the number of cigarette smokers there has been a steady decline in cigarette smoking. The WHO also implemented a school survey to examine tobacco use. This is called the Global Youth Tobacco Survey (GYTS) (Tobacco, 2002).

The epidemic of smoking is one of the greatest threats to public health also posing a significant financial burden to the nation. Millions of people suffer a premature death or prolonged illnesses due to smoking or exposure to secondhand smoke. To put it in perspective; “more than 10 times as many U.S. citizens have died prematurely from cigarette smoking than have died in all the wards fought by the United States during its history (U.S. Department of Health, 2014, p.1).” More than 45 million Americans smoke and 8 million are living with a serious illness caused by smoking (CDC, 2006). Smoking increases the risk for a variety of adverse effects including, but not limited to, coronary heart disease, respiratory diseases, cancer, and reproductive and birth outcomes. Table 3 displays the severe influence that cigarette smoking has on mortality.  Age, education, socioeconomic status, and ethnicity are all factors influencing cigarette smoking behavior. The highest prevalence of cigarette smoking can be found in the following groups; those with less than a high school education, those with no health insurance, those living below the federal poverty level, and those aged 18-24 years (CDC, 2018c). Prevalence of cigarette smoking among U.S. adults is similar between those living in rural areas (28.5%) and those living in urban areas (25.1%). Although the percentages are similar, the CDC mentions that those living in rural areas are more likely to smoke 15 or more cigarettes per day than those living in urban areas (U.S. Department, 2014). Shan, Jump, and Lancet, 2012 found socioeconomic factors are a greater predictor for cigarette use than geographic location. They confirm that education and income level were greater determinants. However, they also found that smoking among pregnant women in rural areas was disproportionality high compared to urban areas. The U.S. Cen The damage to the physical health of the public is compounded by the financial burdens to a nation. Medical care costs to the United States are estimated to be in excess of $130 billion. Additionally, the loss of productivity due to premature death are exorbitant and estimated to be about $150 billion per year. Even deaths related to second hand smoking cost the nation about $5.6 billion per year (U.S. Department, 2014). The consequences of cigarette smoking are deadly and extremely expensive. This commands that the U.S. and global organizations continue to implement initiatives to reduce the use of cigarettes.

Descriptive Epidemiology

The Surgeon General Report of 1994 states that virtually all cigarette smoking begins before adulthood (U.S. Department, 1994). This report states that the earlier adolescents begin smoking the heavier they will smoke into adulthood. This report also makes note that this early nicotine exposure may have lasting consequences for brain development. Every day 3,200 youth smokes their first cigarette and 2,100 youth and young adults becomes cigarette. Because 9 out of 10 cigarette smokers begin smoking by age 18 the disparities reported for adult smokers reflects that of adolescents as well smokers (U.S. Department, 2014). There are biological and genetic factors which influence adolescent smoking behavior. Youth may become dependent upon nicotine sooner than adults. The children of a mother who smoked during pregnancy may be more apt to become a regular smoker (U.S. Department, 2014).

African American youth have a lower prevalence of cigarette smoking than Hispanics and white and they also initiate smoking at a later age (CDC, 2015). The prevalence of cigarette smoking among Asian American/Pacific Islander adults is also lower than other racial groups (CDC, 2014). Regardless of age group and gender, adults with mental health disorders or substance Abuse smoke more cigarettes than the general population (Lipari & Van Horn, 2017). Table 4 from the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality details the prevalence of cigarette smoking among young people with data regarding gender, race/ethnicity, age groups, poverty status, and geographic region (U.S. Department, 2012a).

There is a higher prevalence of smoking among youth sexual minorities compared to heterosexuals. Black lesbians-gays, Asian American and Pacific Islander lesbians-gays and bisexuals, younger bisexuals and bisexual girls were at greatest risk for smoking cigarettes (Corliss et al., 2014).

Johnston, O’Malley, Miech, Bachman, and Schulenberg (2016) report that cigarette smoking among adolescents has continued a steady decline and is now at the lowest levels in the history of the survey beginning in 1975. Prevalence of cigarette smoking reached a peak in 1996 for grades 8-10 but has since fell, but the most significant decline was for 12th graders since 1997. They also observe that increases in perceived risk and disapproval positively correspond to the decline in cigarette smoking.

Lower prevalence of smoking has been found among youth who participate in religious activities, have strong racial identity/ ethnic pride, and those who have higher academic achievement and aspirations (U.S. Department, 2012b).

Prevention of Cigarette Smoking

Early prevention efforts began in the 1960’s and included; requiring health warnings on cigarette packages, banning cigarette advertising in broadcasting media, and implementing annual reports on health consequences. The National Clearinghouse for Smoking and Health was established and 29 reports on the consequences of smoking were published (CDC, 2009). Since the U.S. has implemented initiatives to spread awareness about the health consequences of smoking and reduce exposure of youth to cigarette advertisements there has been a decline in usage. Because most smoking behaviors originate in adolescence it is most practical to align prevention efforts with the unique behaviors and trends of adolescents.

Behavioral patterns of adolescents are unique to the subgroup and heavily influenced by peers. Behaviors are influenced by family economics, local crime, and racial-ethnic make-up (Battistich et al., 1995). While it has been found that youth may adopt a variety of delinquent behavior, they may be more apt to initiate cigarette smoking because it is seemingly minor compared to others. Adolescents spend a disproportionate amount of time with classmates and are therefore very sensitive to social pressures (Suh, Shi, & Brashears, 2017).

Baramidze and Mirzikashvili (2018) found that adolescents do not receive appropriate education in primary health care centers. They mention that providers do not provide full information about healthy lifestyle and health promotion issues. They suggest that face to face consultation is necessary. These primary prevention efforts are simple and vital to encouraging youth to avoid even one cigarette.

Various programs have been currently used to prevent youth tobacco use. It has been found that raising the cost of cigarettes, due to increasing taxation on cigarettes, helps to reduce the purchase of cigarettes by youth. Antismoking campaigns via TV, radio, posters, and other media help to counter tobacco advertisements. Community, school, and college interventions which outline tobacco-free environments and reduce tobacco advertising, promotion, or availability of cigarettes for purchase have also been shown to help reduce cigarette use (U.S. Department, 2012b). Demi et al. (2018) found a 33% reduction in smoking prevelance from 2009-2017 which may have been partially attributable to school-based intervention programs aimed at youth. Data was collected before and after the implementation of the program. In a Belgium study by Annendijck (2018) found that Facebook, Instagram, Snapchat, and YouTube were effective methods by which to reach local youth between ages 12 and 15 years of age. They report reaching 81% of all young people on Facebook with their anti-smoking campaign. Continued efforts to screen American youth are important to continue to identify risk factors and trends so that primary prevention efforts remain focused and relevant to today’s youth.

Conclusion

Cigarette smoking is detrimental to society. The health and financial repercussions are severe, yet preventable. Most smokers report smoking their first cigarette before age 18, making the adolescent population vital for targeted prevention programs. Adolescents are highly influenced by peers. Efforts to prevent adolescents from smoking will create a downstream effect of reducing the prevalence of adult smokers and thus decreased mortality.

This paper discusses multiple upstream social determinants affecting the cigarette smoking epidemic. Social disadvantage approaches include lower incomes and lower education, the link perhaps being that stress factors might influence the initiation of cigarette smoking. Health equity considerations include sexual orientation, mental illness, and substance abuse disparities. Upstream social determinants clearly play a role in the decision of adolescents to begin smoking.

The psychiatric mental health nurse practitioner (PMHNP) may be an effective interventionalist for the prevention of cigarette smoking. The assessment of a patient by a PMHNP is likely to include information related to critical social determinants. In this case the practitioner can readily identify youth at higher risk for cigarette smoking and address primary prevention efforts on an individual/personal level. In-office healthy lifestyle education may give adolescents the information needed to make informed decisions regarding risky behavior including cigarette smoking. An advanced practice NP might also be necessary in a consulting position when creating or modifying existing programs for the prevention of smoking. Community and school-based programs, statewide tobacco control programs, and mass media campaigns might all benefit from the input of a PMHNP who understands and interacts with the at-risk subpopulation. Advocation efforts at a political level would include influencing and restricting tobacco advertising and promotional activities including decreasing depictions of adults with cigarettes in popular and visible media.

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