Smoking, A product of Environment?

Updated: Nov 10, 2020

(Image: https://www.imperial.ac.uk/news/186928/researchers-search-answers-incurable-lung-condition/)

Introduction

There are many influential factors that play a role in someone's health. The Social Ecological multilevel model of health breaks these factors down into five levels: individual, interpersonal, community, organization, and policy/enabling environment.

Smoking and Chronic Obstructive Pulmonary Disease (COPD) are directly related, there is no denying this fact. Smoking is the number one cause of COPD, however, in rare cases COPD can develop due to the genetic condition Alpha-1 Antitrypsin deficiency. The World Health Organization (WHO) estimates "COPD to be the third leading cause of death in 2012" (Government of Canada, 2019).

Applying the Social Ecological multilevel model of health to the population of COPD caused by smoking we will discover that there are many factors influencing if an individual becomes and smoker, quits or continues to smoke, and develops COPD. The figure below breaks the social ecological model down into five sections, in this blog post we will discuss how smoking and COPD are influenced at each level.

(Image: https://elink.io/p/9f89321)

Individual Level

Knowledge, Attitudes, and Behaviours.

Knowledge: The older generation make up the majority of the COPD population, in my current practice as a Respiratory Therapists. This portion of the population often have been smoking since they were teenagers and are now well into their senior years. Many decades ago in their teenage years many patients inform me that knowledge about the harmful effects of smoking were not readily available, many did not know that smoking was harmful to ones health. The lack of information in this era led to many people unable to make informed decisions regarding their health and weather to smoke or not. I have encountered patients who smoked tobacco as early as 6 years old with their family. This lack of knowledge led to addiction to cigarettes and nicotine, therefore, when knowledge was made available of the harmful effects of smoking they either were too addicted to quit or did not believe they would be affected. "Knowledge is not enough to change attitudes most of the time but, it helps a great deal by influencing key attitudes and decisions individuals make" (ER Services, n.d.).

There are differences between the number of COPD diagnosed cases in men versus females, which increases exponentially as age increases.

[Image: Government of Canada (2019).]

Attitudes: Many patients with COPD whom I care in the end-stages of their disease hold the attitude ‘it won’t happen to me.’ Often people in the twenty-first century are aware of the harmful effects of cigarettes, however, they believe they are invincible. It should also be noted that a portion of my COPD patient population have attempted to quit many, many times and failed. Attitudes affect the ability to quit smoking. With the right attitude and tools quitting becomes easier, yet often still challenging.

Behaviours: Cigarettes are a behaviour that smokers do, often many times a day. Smoking cigarettes is a very addictive habit, one that becomes a behaviour in a smoker’s daily life. When a smoker wakes up in the morning they may be in the habit of having a cigarette with their coffee, for example.

Interpersonal Level

Family, Friends, and Social Networks

Often times smoking for some starts as a social habit. A portion of the population only smoke when they are drinking alcohol or when socializing with other smokers. People who grew up in a smoking environment may also be more likely to pick up the habit of smoking, therefore, increasing chances of developing COPD as their life progresses. For some of the population work environment may influence smoking habits. If someone works in an environment surrounded by smokers or works outside where smoke breaks are easier to take they may be more likely to start or continue to smoke.

Social-economic status plays a role in the smoking population. "In Australia, rates of smoking in groups of lowest socio-economic position (SEP) are 26% compared to 13% for those in the highest SEP category" (Paul, C. et al, 2010). It is also important to note that despite there being higher numbers of smokers in lower SEP, the population of lower SEP smokers "attempt to quit at rates similar to those of all smokers, however, they are less likely to be successful in their quit attempts" (Paul, C. et al, 2010). There are many reasons why lower SEP smokers are less likely to succeed in quitting smoking for example, "higher rates of nicotine dependence, fewer prompts to quit, using smoking as a particular means of coping with daily stress and anxiety, and social or environmental factors" ((Paul, C. et al, 2010).

Community Level

Relationships between Organizations

The community someone lives in can play a role in if they become a smoker and continue to smoke. If the community someone lives in allows smoking in parks, public transit, and businesses it may increase the chance of someone becoming a smoker and continuing to smoke. Years ago smoking was permitted inside businesses, Tim Hortons for example, making smoking more socially acceptable and therefore likely increasing the number of smokers in the population. In some cultures and environments smoking is more popular and not looked down upon as a bad habit, versus other cultures and environments.

If the community a smoker lives in has easy access to smoking cessation and education then they may be more likely to quit smoking. If health events were available in the community it could increase knowledge of the population in the community and help decrease the smoking population.

Organizational Level

Organizations and Social Institutions

At the organization level, schools for example, may take it upon themselves to offer guidance for smoking cessation, supply information, or even make smoking cessation kits available for students who are trying to quit smoking. In current day vaping and e-cigarettes are widely used among the school age population, along with regular cigarettes, however, we are seeing a transition into increasing numbers of e-cigarette/vaping use. If schools have the resources to supply smoking cessation tools to their students this could help decrease the smoking population and in turn decrease cases of COPD over the years.

Organizations can provide counselling, and smoking cessation treatment such as hypnotism, for example. If these services were covered by insurance plans this would increase the likelihood of the population perusing smoking cessation help.

"Knowledge is not enough to change attitudes most of the time but, it helps a great deal by influencing key attitudes and decisions individuals make" (ER Services, n.d.).

Policy/Enabling Environment Level

Federal, Provincial, or Local Laws

According to Paul, C. et al (2010) age played a factor in the smoking population abiding by policies and laws surrounding smoking.

The impact of legislation to restrict smoking was generally accepted by younger

groups as an expected part of their lives. Older groups were less accepting, with

some expressing outrage at the removal of their 'rights' and a tendency to respond

angrily to public comments about their smoking. (Paul, C. et al, 2010)

Alberta Provincial Laws:

According to the Province of Alberta (2018) Smoking is prohibited - No person shall smoke:

(a) In a public place

(b) In a workplace

(d) In a public vehicle

(e) Within a prescribed distance from a doorway, window or air intake of a public place or workplace.

Canadian Federal Laws:

There are currently two federal acts in Canada that control tobacco and its use

According to the Government of Canada (2015),

First, there is the Tobacco Act administered by Health Canada. This act governs the manufacture, sale, labelling and promotion of tobacco products and provides the authority to the Governor in Council to make regulations on these issues.

Second, is the Non-smokers' Health Act which restricts smoking in federally regulated workplaces and public places under federal jurisdiction and provides the governor in council with the authority to make regulations on these issues. This Act is administered by the Department of Human Resources and Skills Development.

Conclusion

It can be concluded that there are many factors that affect if someone becomes a smoker, or not. Cultural, societal, economics, and environment factors, for example, all impact an individuals life and their decisions. Ultimately smoking often leads to COPD and other comorbidities. Despite COPD and smoking education a portion of the population will continue to smoke.