Eliminating Influential Factors in Smoking with the use of SEM

How use of the Socio-Ecological Model of health can diminish smoking prevalence.

Socio-Ecological Model (SEM) of health is the multilevel model of health that has been built upon and expanded upon Urie Brofenbrenner’s 1977 multilevel framework of social ecology (Earp and Golden, 2012). This model recognizes the broader interplay of influencing factors and how they interact with one another (Early, 2017). It breaks down these influencing factors into the individual, interpersonal (relationships), organizational, community, and societal/policy factors (Early, 2017). The SEM of health clearly demonstrates how an individual’s health is not determined by just disease and genetics but is also determined by societal factors. Recently many have even included the internet as a new influencing factor after societal/policy factors. The internet and digital content are classified as the virtual system (Greiner, 2021). The influence of the internet in today’s age is significant as many people obtain information through the internet. Additionally, the reach of the internet is global and ideas from around the globe can potentially influence individuals and systems (Greiner, 2021).

The SEM of health recognizes individuals are entrenched within larger social systems and the interactions of an individual’s characteristics and environment result in health outcomes (Earp and Golden, 2012). As a result, when examining the SEM of health, we must consider the Social Determinants of Health (SDoH). The World Health Organization (WHO) identifies SDoH as the non-medical factors that influence health outcomes (WHO, n.d.). While the government of Canada elaborates and expands the WHO's definition by defining SDoH as specific group of social and economic factors within the broader determinants of health. These determinants of health are broken down into 12 main determinants by the government of Canada (Government of Canada, n.d.). These factors include income, education, employment, childhood experiences, physical environment, social supports/coping skills, access to health services, genetics, gender, culture, and race. All these factors make up an individual’s health status and creates health inequalities among individuals (Government of Canada, n.d.). Due to all these social and other influencing factors in an individual’s life, a multilevel approach is needed to tackle change and change at all levels is required. At the individual and interpersonal level, interventions that are aimed at knowledge, beliefs and skills are required. Additionally, at the interpersonal-level and organizational-level, interventions need to be designed to create change in social relationships and organizational environments. For changes in the community level, partnerships with agencies, churches, neighborhoods are needed with the aim of community-focused interventions. Finally, implementing public policies with regards to health need the backing of politicians and public outcry for these interventions to work (Earp and Golden, 2012).

As a Respiratory Therapist, the SEM of health can be applied to patients suffering from chronic obstructive pulmonary disease (COPD). Majority of the individuals suffering from COPD can contribute their disease to years of smoking. Over 80% of current lung cancer and respiratory diseases such as COPD are caused by excessive tobacco smoking or exposure (Pierce and Kealey, 2021). On average, 20% of the population smokes, thus making 20% of patients admitted to hospital potentially smokers (Government of Ontario, n.d.). From a glance, this statistic seems like a relatively small number. However, when applied to the total population of Canada, this still accounts for millions of individuals. As of 2017 it still accounted for 4.6 million Canadian who smoke (University of Waterloo, n.d.). This clearly demonstrates that a large proportion of Canadians still smoke.

Using the SEM of health, Pierce and Kealey (2021) came up with a lot of potential interventions to help with smoking cessation. At the individual level they recommend additional tobacco education and tobacco free schools. Pierce and Kealey (2021) state that targeting the age group which smoking initially occurs will have the best results. Most smokers first start between the ages of 12 to 25 years old (Pierce and Kealey, 2021). They also state that education alone will not work and that creating an environment that promotes anti-tobacco beliefs and behaviors will have the best success (Pierce and Kealey, 2021). British Columbia (BC) has taken steps to increase education at the individual level. BC has developed lots of smoking cessation and educational resources that can be find on their website and have links to smoking cessation websites like “QuitNow.ca”. Furthermore, majority of the resources are translated into various languages for individuals (British Columbia govt, n.d.). To tackle interpersonal and organizational influences they recommend interventions like smoke-free workplaces and the use of the internet to promote smoke-free homes (Pierce and Kealey, 2021). In BC, smoking is completely prohibited in workplaces (British Columbia govt, n.d.). For the community level, the recommendation for stricter enforcement of “No sales to minors” laws were proposed (Pierce and Kealey, 2021). This would require buy in from shop owners in the community. There are fines in place for selling to minors but are not enforced enough to deter shop owners. Finally, Pierce and Kealey (2021) on a societal/policy level recommend implementing an increase in tobacco taxes. They believe that increasing the cost of a cigarette will deter people from smoking. However, a study by Huisman et al (2011) found that money was not as big as a deterrence as education was for smoking cessation. Additionally, on a societal and policy level, Pierce and Kealey (2021) recommend increasing insurance coverage for medical treatments such as pharmaceutical treatments and behavioral coaching to increase smoking cessation. This method has already been implemented in BC. The BC government offers residents of the province 100 percent coverage for the cost of nicotine replacement therapy (NRT) and cover some of the cost for specific smoking cessation prescription drugs (British Columbia govt, n.d.).

In Ontario, the Ottawa Model Smoking Cessation Network implemented a smoking cessation program that currently has a 50% success rate for patients at six months (Government of Ontario, n.d.). Within 6 months 50% of individuals are smoke-free. This program targets smokers by establishing a provincial wide protocol that requires health care providers to ask every individual admitted into hospital their smoking status regardless of the reason for their visit. Once smoking status is identified and documented, the appropriate treatment is provided (Government of Ontario, n.d.). If the individual is a smoker, the protocol requires that a nurse visit the patient and offer smoking cessation assistance, including cessation medications (Government of Ontario, n.d.). Patient follow-up is managed by nurses who monitor the Interactive Voice Recognition System (IVR). The IVR consists of yes or no questions, and questions that use a numerical scale for its answers. The answers are automatically recorded in an excel spreadsheet and highlights any patients that are struggling (Government of Ontario, n.d.). Patients that are struggling are contacted by nurses and offered one-on-one support and access to additional resources in the community (Government of Ontario, n.d.). The success of the program has prompted the launch of ten similar pilot programs in BC and New Brunswick (Government of Ontario, n.d.). Looking at this from the SEM of health perspective, this program does a great job of tackling the influencing factors. From an individual factor, the province wide protocol identifies individuals who smoke and give them the appropriate education. Additionally, the province wide protocol tackles organizational influences as all the hospitals in Ontario are required to ask smoking status. The program provides additional smoking cessation in the community for patients. This helps combat negative community influencing factors that may be present in the patient’s community. The introduction of this program in different provinces and the backing from the Canadian government to establish this program nation wide will help alter societal opinions on smoking. Additionally, the successful implementation of this program nation wide will usher in new political views and policies. With all this information and other various smoking cessation education available on the internet the program can reach more people.

As a Respiratory Therapist and like most health care professionals, I believe smoking is very detrimental to one’s health. As a bedside therapist, I always try to promote smoking cessation in patients who are currently smoking and provide educational resources if they are open to reading them. Smoking is an extremely difficult habit to break and it takes multiple failed attempts before an individual will kick the habit (Pierce and Kealey, 2021). I believe using a SEM of health approach to tackle smoking is extremely important. I believe that the interventions recommended by Pierce and Kealey (2021) need to be implemented everywhere and programs like the IVR system in Ontario need to be established nation wide. Additionally, all the recommended interventions need to implemented together to target all the different influencing factors in an individual’s life. Earp and Golden (2012) found that implementations of interventions that only target one or two levels have no significant impact in causing change. Without targeting all levels, we will never accomplish any real change.

References:

British Columbia Government. (n,d). BC Smoking Cessation Program. British Columbia. Retrieved February 22, 2022 from https://www2.gov.bc.ca/gov/content/health/health-drug-coverage/pharmacare-for-bc-residents/what-we-cover/bc-smoking-cessation-program

British Columbia Government. (n,d). Tobacco and Vapour Free Places. British Columbia. Retrieved February 22, 2022 from https://www2.gov.bc.ca/gov/content/health/keeping-bc-healthy-safe/tobacco-vapour/requirements-under-tobacco-vapour-product-control-act-regulation/tobacco-vapour-free-places#:~:text=The%20Tobacco%20and%20Vapour%20Products%20Control%20Regulation%20sets%20a%20six,can%20stand%20and%20use%20tobacco

Communities for Healthy Living. (2017). Ecological Model. Communities for Healthy living. Retrieved February 21, 2022 from https://www.youtube.com/watch?v=e9UyplfevyQ&feature=emb_imp_woyt

Early, J. (2016). Health is More than Healthcare: It’s Time for a Social Ecological Approach. Journal of Nursing and Health Studies, 1, 1-2. https://www.imedpub.com/articles/health-is-more-than-healthcare-its-time-for-a-social-ecological-approach.php?aid=17440

Greiner, K. P. (2021, April 19). Concept 3: Spheres of influence (SEM 2.0). The Social Change Cookbook. Retrieved February 22, 2022 from https://medium.com/the-social-change-cookbook/concept-3-spheres-of-influence-44bd5bd940ac

Golden, S. D., & Earp, J. L. (2012). Social ecological approaches to individuals and their contexts. Health Education & Behavior, 39(3), 364–372. https://doi.org/10.1177/1090198111418634

Government of Canada. (n.d.) Social determinants of health and health inequalities. Government of Canada. Retrieved February 28, 2022 from https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html

Government of Ontario. (n.d.). The Ottawa Model for Smoking Cessation, The Network’s Success: Simply Smoke Free. Government of Ontario. Retrieved February 28, 2022 from https://www.health.gov.on.ca/en/pro/programs/cdpm/pdf/ottawa.pdf

Huisman, M., Van Lenthe. F.J., Giskes, K., Carlijn, K., Kamphuis, B.M., Brug, J. & Mackenbach, J.P. (2012). Explaining socio-economic inequalities in daily smoking: a social–ecological approach. European Journal of Public Health, 22(2), 238–243. https://doi.org/10.1093/eurpub/ckr039

Pierce, J. P., & Kealey, S. (2021). Socio-ecological model and health promotion in the healthy people initiative.

Public Health Agency of Canada. (2019). Health Inequalities in Canada. Public Health Agency o Canada. Retrieved March 31, 2022 https://www.youtube.com/watch?v=RMkBUXJLW9g

University of Waterloo. (n.d). Current smoking prevalence. Tobacco Use in Canada. Retrieved February 28, 2022 from https://uwaterloo.ca/tobacco-use-canada/adult-tobacco-use/smoking-canada/current-smoking-prevalence#:~:text=In%202017%2C%20the%20overall%20prevalence,the%202015%20estimate%20of%2013.0%25.&text=Approximately%2010.8%25%20of%20Canadians%20(3.3,daily%20smokers%20(Figure%201.2)

World Health Organization. (n.d.) Social determinants of health. World Health Organization. Retrieved February 28, 2022, from https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1