Vaping: A Health Promotion Learning Journey Reflection

As a respiratory therapist, I am extremely intrigued and fascinated with the idea of vaping as a health promotion topic. Vaping has quickly integrated into society and has become a social norm amongst a vast majority of people. The Government of Canada (2024) found in 2022 that 6% of Canadians aged 15 and older had reported vaping in the past 30 days. Additionally, the Government of Canada (2024) reports that 17% of students in grades 7-12 reported using a vaping product within the last 30 days. Furthermore, it was found that 16% of students have used an e-cigarette with nicotine and 4% had used an e-cigarette without nicotine in the past 30 days (Government of Canada, 2024). Similarly, studies from the United States estimate that 20% of American high school students are regular vape users, in contrast to the 5% of adults who use vape products (Jonas, 2022). Teen and young adult uptake in vaping has been driven in part by a perception of vaping as a safer alternative to cigarettes, as well as marketing strategies that target adolescents (Jonas, 2022). 

Personally, I know many friends, acquaintances, colleagues, family members that vape. Unfortunately, my own younger brother vapes as well. Working as a respiratory therapist, I have firsthand seen what the effects of smoking and vaping can have on an individual's health. I have seen drastic declines in lung health ranging from the development of chronic obstructive pulmonary disease (COPD), lung cancer, immunocompromise requiring intubation and overall decline in health through the development of co-morbidities. As a result, this topic makes me extremely nervous as it effects individuals with whom I have close relationships with. Like many of us, witnessing individuals we care about becoming ill and suffering is extremely difficult. As a result, this motivates me to encourage loved ones and people I care about the importance of having a healthy lifestyle.  

I am excited to immerse myself in this topic and learn as much as I can. I want to be as up to date as possible surrounding the current literature around vaping. I have many personal learning goals surrounding this topic. Firstly, I would like to know why people vape, especially younger individuals. The Government of Canada (2024) found that the main reason for vaping in among 15-24 years was to reduce stress while the main reason for vaping in individuals 25 and older was to reduce, quit or avoid returning to smoking. However, when I ask my brother this question, I receive an unclear and vague response of I just like too. Secondly, I would like to learn more about the current literature on the extent of lung damage due to vaping. Personally, many individuals I know are under the false belief that vaping is not like smoking cigarettes and as a result you are not damaging your lungs. The EVALI study found an increase in vaping related lung injury however, no statistically significant link was found between lung injury and vaping as the pool of data was to small (Jonas, 2022). Furthermore, I would personally like to learn about different techniques, frameworks, and strategies that could be implemented and utilized to create change in vaping habits. This personally excites me as I have a lot of friends and family members that participate in vaping. I hope to use the knowledge I gain to create change in the vaping habits of individuals I interact with. Currently, literature and research on vaping is still very limited. There has been great head way into the topic but much about vaping remains unknown, more research is still required. As a result, and looking ahead in the future, this may present as an obstacle and challenge that I may have to navigate as I pursue this health promotion topic.

References:

Government of Canada. (2024). Vaping in Canada: What we know. Retrieved from https://www.canada.ca/en/health-canada/services/smoking-tobacco/surveys-statistics-research/vaping-what-we-know.html

Jonas, A. (2022). Impact of vaping on respiratory health. bmj, 378.

The Ottawa Charter’s role in Canada, Globally and Me

The Ottawa Charter has been an important basis for health promotion in Canada and worldwide since its inception in 1986. It has shaped the way we think about health globally. The Ottawa Charter’s values resonate with many countries and as a result there has been widespread global acceptance (Kirk et al, 2014). The charter has been seen as the formal birthplace of health promotion as it prompted action into a number of countries (Kirk et al, 2014). The Ottawa Charter defines health promotion as the process of enabling people with increased control over, and ability to improve their health (Fry and Zask, 2017). The Ottawa Charter highlights the core values of equity, participation and empowerment and the five areas of action (Fry and Zask, 2017).  The Ottawa Charter has also played an impact on my own practice as a Respiratory Therapist (RT) as well.

Canada

The impact of the Ottawa Charter in Canada has been immense. Health promotion has become a vital part of the national health framework. The Ottawa Charter’s principles have helped shift the focus onto the social determinants of health within Canada.  By focusing on the social determinants of health, Canada’s healthcare system recognizes that social factors such as education, income, childhood experiences, gender, culture and living conditions can significantly impact health (Government of Canada, n.d.). As a result, Canada has focused on implementing policies that reflect equity, access and reduce health inequalities such as the Pan-Canadian Healthy Living Strategy (Government of Canada, n.d.). Prior to this national initiative, provincial governments were prioritizing healthcare policies and initiatives that reflected the principles found in the Ottawa Charter.  British Columbia had previously implemented the Core Functions Framework. The Core Functions Framework strategies were used for the implementation of programs that addressed the population and inequity (Fry and Zask, 2017). As illustrated, the Ottawa Charter has had a strong influence in Canadian healthcare.

Worldwide

Globally, the implementation of the Ottawa Charter has been mixed. A study by Wilberg et al (2019) found that 50% of respondents felt that health promotion was well established in Europe. Additionally, only 43.7% of respondents felt that the field of health promotion is well established in their country (Wilberg et al, 2019). This demonstrates that the overall impact of well-known health promotion innovations in Europe such as the Investment for Health Approach, Healthy Cities, Health-Promoting Hospitals, and Health-Promoting Schools have been relatively limited (Wilberg et al, 2019). However, promisingly, 80.0% of survey participants felt that the topic of health promotion has progressed over the past 30 years in Europe (Wilberg et al, 2019). In England, in a response to an over emphasis on an individualistic approach to healthcare the government implemented an increase in initiatives directed towards the underlying determinants of health and health promotion (Thompson et al, 2018). However, in recent years there has been a shift back to an individualistic approach with changing ideologies in England (Thompson et al, 2018). Similarly, the implementation of health promotion in India has been very limited. In India, health promotion is built into the concept of all the national health programs. These health programs incorporate principles such as equitable distribution, community participation, intersectoral coordination and appropriate technology (Kumar and Preetha, 2012). However, a stronger priority is placed on clinical care compared to health promotion. The Indian government has placed strong priority on addressing the issue of lack of knowledge within the population of India as it is a major barrier in the accessibility of health care services (Kumar and Preetha, 2012). In Korea, there has been an increase in health promotion. There has been some progress made in equity, public and community participation, empowerment, and socio-ecological approaches (Lee, 2015). However, more work still needs to be done. Areas like intersectoral collaboration and partnership have not been considered in public efforts relating to health promotion in Korea (Lee, 2015). In China, healthcare reforms have placed a greater emphasis on health promotion and disease prevention (Lee et al, 2007). Although, there still needs to be further reform in policies and infrastructure to incorporate multisectoral cooperation (Lee et al, 2007). As illustrated, the implementation of the Ottawa Charter has greatly varied globally. Globally, the ideology of the Ottawa Charter is widely accepted however the implementation of the charter has been relatively limited.

Health Promotion and Me

The Ottawa Charter has played a significant impact in my role as an RT. As an RT, we are often required to provide respiratory education to our patients. I am often providing education that promotes healthy living. An example of this would be in the capacity of smoking cessation. I often educate patients of the negative effects smoking can have on one’s health and provide resources to help quit. Additionally, I often provide education around the proper use and technique of bronchodilators in the hopes to help prevent patient acute exacerbations. Furthermore, in my role I am often align my patients with the appropriate resources and support tools need. This often required me to refer my patients to the appropriate support programs such as Lung Health, community respiratory services, home oxygen program, the Provincial Respiratory Outreach Program (PROP) and CPAP companies. My role as an RT has helped develop my knowledge and understanding of the impact socio-economic factors can have on health outcomes for individuals. This knowledge and understanding allows me to tailor my care to help support health promotion for my patients. In the future, I hope to have the opportunity to develop and disseminate health promotion initiatives to further expand my reach.

Conclusion

The Ottawa Charter has been played a significant role in health promotion in Canada and globally. In Canada, healthcare is guided by the principles set forth in the Ottawa Charter and this is clearly evident in the Pan-Canadian Healthy Living Strategy. Additionally, the Ottawa Charter has played a significant role globally, however the implementation and adoption of health promotion has been mixed. Many countries across the world have taken great strides to incorporate health promotion and the principles set forth in the Ottawa Charter, but much work still needs to be done. The impact of the Ottawa Charter is still present globally and has had a significant impact in my role as a RT. The principles of the Ottawa Charter and health promotion help guide the care I provide as an RT to my patients.

References:

Fry, D., & Zask, A. (2017). Applying the Ottawa Charter to inform health promotion programme design. Health Promotion International, 32(5), 901-912.

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

Kirk, M., Tomm-Bonde, L., & Schreiber, R. (2014). Public health reform and health promotion in Canada. Global health promotion, 21(2), 15-22.

Kumar, S., & Preetha, G. S. (2012). Health promotion: an effective tool for global health. Indian Journal of Community Medicine, 37(1), 5-12.

Lee, A., Fu, H., & Chenyi, J. (2007). Health promotion activities in China from the Ottawa Charter to the Bangkok Charter: revolution to evolution. Promotion & education, 14(4), 219-223.

Lee, M. S. (2015). The principles and values of health promotion: building upon the Ottawa charter and related WHO documents. Korean Journal of Health Education and Promotion, 32(4), 1-11.

Pdhpe (2008). The Ottawa Charter as an effective health promotion framework. YouTube. Retrieved from https://www.youtube.com/watch?v=90bGyRWCAd8&t=5s

Thompson, S. R., Watson, M. C., & Tilford, S. (2018). The Ottawa Charter 30 years on: still an important standard for health promotion. International Journal of Health Promotion and Education, 56(2), 73-84.

Wilberg, Angelika, Luis Saboga-Nunes, and Christiane Stock. "Are we there yet? Use of the Ottawa Charter action areas in the perspective of European health promotion professionals." Journal of Public Health 29 (2021): 1-7.

Summarizing MHST 601 in the context of COPD

A introspective look at COPD using concepts and elements learned in MHST 601

As I look back and reflect on my journey through MHST601, my learning was guided by my personal and professional experiences. As a Respiratory Therapist (RT), my learning was linked to diseases specifically related to my profession. I related course units such as social determinants of health, vulnerable populations, multilevel models of health, vulnerable populations and future directions of health to Chronic Obstructive Pulmonary Disease (COPD). COPD patients are a big component of a Respiratory Therapists career. Using my experiences as a RT working in Surrey Memorial Hospital, I was able to visualize and conceptualize how these concepts and frameworks related to patient care in Canada’s health care system. Through the weekly readings and content curations, I was able to construct critical foundations in health disciplines that will forever shape my current practice.

Chronic Disease: COPD

In 2000, Canada chronic diseases accounted for $31.6 billion in direct patient costs (BC Ministry of Healthy Living and Sport, 2010). Since than the cost of chronic diseases has drastically risen. It is estimated that chronic diseases account for $68 billion in direct patient costs (Chronic Disease Prevention Alliance of Canada, 2018). And as our population continues to age, these costs are only expected to continue to rise. Currently in Canada, 44% of adults 20+ have at least one common chronic condition (Health Canada, n.d.). 10% of these individuals are affected by COPD (Health Canada, n.d.).

COPD is a chronic disease that is characterized by persistent and progressive airflow limitations that is caused by an enhanced chronic inflammatory response in the airways and the lungs to noxious particles or gases (Qureshi et al, 2014). It has been widely documented that smoking is the number one leading cause of COPD (Canadian Lung Association, n.d.). COPD is estimated to roughly affect 16 million adults in the United States (Bollmeier & Hartmann, 2020). In 2011-2012, COPD roughly affected about 2 million Canadians aged 35 years and older (Government of Canada, 2018). The number of Canadians affected by COPD today is expected to be much larger. In BC alone, approximately 138,500 individuals aged ≥ 45 years in BC have been diagnosed with COPD (Government of BC, n.d.). This makes up roughly 6% of British Columbians aged ≥ 45 years (Government of BC, n.d.). This number however may not represent the true number of people living with COPD as many individuals go undiagnosed.

Multi-faceted strategies are needed when developing chronic disease prevention and maintenance strategies. Strategies that focus on prevention and maintenance will help reduce the amount of re-hospitalization. For preventative and maintenance measures in COPD, Qureshi et al (2014) recommend smoking cessation, pulmonary rehab, disease management programs and an appropriate pharmacological regiment for patients. In BC, the provincial government and the various health authorities place a huge focus on educating patients. This is accomplished through the use of community RTs and RTs who work in clinics. These RTs provide education on smoking cessation, education regarding technique and optimal use of medications and help educate patients to recognize COPD flare-ups and how to initiate self-management for COPD flare-ups (Fraser Health, 2021). Patients are also educated and advised on when they should seek medical attention (Fraser Health, 2021).

COPD outpatient clinics also aim to optimize care in COPD patients according to best clinical practice (Providence Health, n.d.). This is achieved through a multidisciplinary team and the team is composed of a respirologist, a respiratory therapist, a dietitian, and physiotherapist (Providence Health, n.d.). These COPD clinics use interprofessional collaboration to provide quality care and better meet the needs of COPD patients. Interprofessional collaboration occurs when 2 or more professions work together to achieve common goals and solve variety complex issues (Green & Johnson, 2015). In health care it is generally believed that collaborative efforts yield better health outcomes (Green & Johnson, 2015). These COPD clinics provide education and tips on how to better manage COPD condition at home. Programs that involve a multidisciplinary approach that include exercise therapy and patient education, have been shown to improve quality of life in patients with COPD (Bollmeier & Hartmann, 2020). These programs give patients the tools they need to keep charge of their lives and not succumb to being prisoners to COPD.

Vulnerable Population:

The smoking population is the most vulnerable to COPD development. It is well documented that the Incidence of COPD is highest in patients who smoke or have a history of tobacco use (Bollmeier & Hartmann, 2020). 80% of the individuals who have COPD in Canada have smoked at some point in their life (Osman et al, 2017). Additionally, Osman et al (2017), found that current smokers are five times more likely to have COPD compared to individuals who have never smoked. Over the years the prevalence Canadian smokers has and continues to decrease. However, roughly 20% of the population still smokes (Government of Ontario, n.d.). As of 2021, five million Canadians still smoke according to Health Canada (CBC Radio, 2021). This clearly shows a large proportion of Canadians still smoke. Many of these individuals can contribute their smoking addiction to social and environmental factors that have influenced their lives.

Social Determinants of Health:

The World Health Organization (WHO) identifies social determinants of health (SDoH) as the non-medical factors that influence health outcomes (WHO, n.d).The government of Canada elaborates further 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 (Government of Canada, n.d.). It is noted that SDoH can influence an individual’s health equity in a positive or negative way depending on the conditions where they are born, grow, work, live, age and the political systems in place (WHO, n.d). All these factors make up an individual’s health status.

When applying SDoH to the smoking population, Brady (2020) found a strong correlation within smokers associated to low education and income. In a study conducted by Osman et al (2017), it was found individuals reporting an annual income of <$20,000 and individuals with less than a secondary school graduation had the highest rates of COPD. Clearly demonstrating that a low socioeconomic status directly impacts an individual’s smoking prevalence. A study conducted by Pakhale et al (2021) supports this notion as they found the prevalence of COPD is significantly higher in Ottawa’s urban poor population compared to general Canadian population. Furthermore, Brady (2020) states gender, race/ethnicity, cultural characteristics, social marginalization, stress, lack of community empowerment and unequal distribution of resources and services as additional SDoH that are present in and affect smokers. All these social factors influence whether an individual will smoke or not.

Smokers and SEM:

Socio-Ecological Model (SEM) of health is the multilevel model of health that recognizes the broader interplay of influencing factors and how they interact with one another (Early, 2016). It breaks down these influencing factors into the individual, interpersonal (relationships), organizational, community, and societal/policy factors (Early, 2016). The SEM of health recognize individuals are entrenched within larger social systems and the interactions of an individual’s characteristics and environment result in health outcomes (Earp & Golden, 2012). As a result, when examining the SEM of health, we must consider SDoH. The SEM of health clearly demonstrates how an individual’s health is not determined by just disease and genetics but is also determined by social factors.

For change the SEM recommends implementing interventions that tackle every level simultaneously. Interventions at the individual and interpersonal level need to be aimed at education, beliefs and skills. Additionally, at the interpersonal-level and organizational-level, interventions need to be designed to create change in social relationships and organizational environments. For changes at the community level, interventions need to be community-focused. Finally, implementing public policies with regards to health need the backing of politicians and public outcry for these interventions to work (Earp & Golden, 2012).

Using and applying the SEM to smokers clearly demonstrates their vulnerability as a population. These individuals are negatively affected at each level and these influential factors tend to promote smoking habits.

Individual Level:

Low socioeconomic status plays a huge role in the individual level of SEM. Many individuals who smoke have low levels of education and low income. At the individual level, Pierce and Kealey (2021) recommend tobacco education and tobacco free schools.

Interpersonal Relationships Level:

It is noted that individuals with parental and peer smokers in their lives exponentially increases the odds of smoking (Australian Government, n.d.). Additionally, nicotine exposure during childhood plays a major role in enabling smoking behavior (Australian Government, n.d.). Promoting smoke-free homes could help prevent individuals from smoking (Pierce and Kealey, 2021).

Organizational Level:

Many individuals are more likely to smoke depending on the organizations they belong to. An example of this is an individual’s job. It is noted that physically demanding jobs were linked with heavy smoking. Work that involves high physical exertion is associated with heavy smokers, roughly 2.5 times more than people whose jobs involve low physical exertion (IWH, 2019). Creating smoke-free workplaces may help create an environment that promotes smoking cessation.

Community level:

Adults that live in rural areas smoke at a higher rate compared to adults that live in urban areas. This relates back to a lack of education and low incomes (Australian Government, n.d.). In these communities, smoking is more common and socially acceptable. Creating communities that promote smoking cessation will help deter individuals from smoking.

Societal/Policy level:

The introduction of policies that deter smoking can increase smoking cessation rates. A common recommended policy is increasing taxes on tobacco products (Pierce & Kealey, 2021). Additionally, Pierce & Kealey (2021) recommend increasing insurance coverage for medical treatments such as pharmaceutical treatments and behavioral coaching. Changes in policies that promote smoking cessation can lead to creating a society that is tobacco free.

Future Directions:

Prior to the pandemic, in 2018–2019, clinicians conducted only 8% of their clinical visits virtually but during the pandemic this percentage increased to approximately 60% in Canada (Mohammed et al, 2021). The use of digital health services has significantly increased. Digital health encompasses telehealth, centralized electronic health records, wearable sensors, cloud technology, machine learning, and artificial intelligence (Hamoni et al, 2021). The pandemic made advancements in technologies related to health more widely accepted in society.

The use of telehealth specifically has drastically increased. Telehealth is an alternative to in-person consultations with healthcare professionals. Telehealth services are conducted through electronic communications such as audio or video calls, text messages and emails (Hamoni et al, 2021). Telehealth has been noted to have higher patient satisfaction, better access to care, decrease in costs and increased access to specialist care (Mohammed et al, 2021). However, some challenges are digital competency among both healthcare providers and patients, affordability and accessibility of technology required and internet access (Mohammed et al, 2021).

Ambrosino, N., Vagheggini, G., Mazzoleni, S., & Vitacca, M. (2016). Telemedicine in chronic obstructive pulmonary disease. Breathe (Sheffield, England), 12(4), 350–356. https://doi.org/10.1183/20734735.014616

In terms of COPD and smoking cessation, I believe telehealth can potentially play a significant role in patients. Education on smoking cessation, medication use and technique, and COPD self management can be delivered through telehealth. This would provide patients with all the resources and tools they would need in the comfort of their homes. Additionally, telehealth eliminates the distant travel required for some patients (Hamoni et al, 2021). It has been noted that telehealth saw a reduction in out-patient visits, early detection and proactive intervention in the patients before the occurrence an acute COPD exacerbation (Ambrosino et al, 2016). A telehealth program currently in Ontario has shown great promise in smoking cessation. The program uses Interactive Voice Recognition System (IVR) to provide smoking cessation in smokers. 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.). Participants were noted to have a high satisfaction with this program and currently has a 50% success rate in smoking cessation for patients at six months (Government of Ontario, n.d.).

My time in this course has really changed my perspective on health. I have learned the importance of SDoH, multilevel health approaches, chronic diseases, vulnerable populations and the future of health. Through the readings and engagement with fellow classmates, my professional identity has further developed and blossomed. I have developed various skills to promote and advocate for patients and health care. As a RT, I was able to apply COPD in context with our learning objectives for this course. In doing so I was able to develop critical thinking tools that will enable me to continue advocating and championing on their behave. As I continue on in other courses in this program, I will feel at ease as i have built a strong foundation thanks to this class.

References:

Ambrosino, N., Vagheggini, G., Mazzoleni, S., & Vitacca, M. (2016). Telemedicine in chronic obstructive pulmonary disease. Breathe (Sheffield, England), 12(4), 350–356. https://doi.org/10.1183/20734735.014616

Australian Government. (n.d.). Factors influencing smoking levels among high smoking prevalence groups. The Department of Health. Retrieved April 4, 2022 from https://www1.health.gov.au/internet/publications/publishing.nsf/Content/smoking-disadvantage-evidence-brief~factors-smoking-levels#:~:text=Research%20has%20identified%20a%20range,pressure%20and%20stress%3B%20(28)

BC Ministry of Healthy Living and Sport. (2010). Model Core Program Paper: Chronic Disease. BC Ministry of Healthy Living and Sport. Retrieved April 4, 2022 from https://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/public-health/healthy-living-and-healthy-communities/chronic_disease-model_core_program_paper.pdf

Bollmeier, S. G., & Hartmann, A.P. (2020). Management of chronic obstructive pulmonary disease: A review focusing on exacerbations, American Journal of Health-System Pharmacy, 77 (4), Issue 4, 259–268, https://doi.org/10.1093/ajhp/zxz306

Brady, K. (2020). Social Determinants of Health and Smoking Cessation: A Challenge. The American Journal of Psychiatry, 177(11), 1029-1030 https://ajp.psychiatryonline.org/doi/epub/10.1176/appi.ajp.2020.20091374

Canadian Lung Association. (n.d.). Chronic Obstructive Pulmonary Disease (COPD). Canadian Lung Association. Retrieved April 4, 2022 from https://www.lung.ca/copd

CBC radio. (2021).How the pandemic impacted vaping and smoking rates — and why it showed vaping is 'here to stay'. CBC Radio. Retrieved April 4, 2022 from https://www.cbc.ca/radio/whitecoat/how-the-pandemic-impacted-vaping-and-smoking-rates-and-why-it-showed-vaping-is-here-to-stay-1.6068729

Chronic Disease Prevention Alliance of Canada (2018). 2018 pre-budget submission to the House of Commons Standing Committee on Finance. Chronic Disease Prevention Alliance of Canada. Retrieved April 4, 2022 from https://www.ourcommons.ca/Content/Committee/421/FINA/Brief/BR9073636/br-external/ChronicDiseasePreventionAllianceOfCanada-e.pdf

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

Fraser Health Authority. (2021). Community Respiratory Services. Fraser Health. Retrieved April 4, 2022 from https://www.fraserhealth.ca/Service-Directory/Services/home-and-community-care/community-respiratory-services

Fraser Health Authority. (n.d.). COPD Self-Management Program. Fraser Health. Retrieved April 4, 2022 from https://www.fraserhealth.ca/Service-Directory/Services/chronic-disease-management/copd-self-management-program

Fraser Health. (n.d.). Chronic Obstructive Pulmonary Disease (COPD). Fraser Health. Retrieved April 4, 2022 from https://www.fraserhealth.ca/health-topics-a-to-z/copd#:~:text=COPD%20is%20a%20lung%20disease,last%20year%20in%20the%20province.

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 British Columbia. (n.d.). Chronic Obstructive Pulmonary Disease (COPD): Diagnosis and Management. Government of BC. Retrieved from April 4, 2022 from https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/copd#:~:text=Approximately%20138%2C500%20individuals%20aged%20%E2%89%A5,Columbians%20aged%20%E2%89%A5%2045%20years).&text=Many%20individuals%20have%20unrecognized%20COPD%20and%20remain%20undiagnosed.

Government of Canada. (2018). Asthma and Chronic Obstructive Pulmonary Disease (COPD) in Canada, 2018. Government of Canada. Retrieved April 4, 2022 from https://www.canada.ca/en/public-health/services/publications/diseases-conditions/asthma-chronic-obstructive-pulmonary-disease-canada-2018.html

Government of Canada. (n.d.) Social determinants of health and health inequalities. Government of Canada. April 4, 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 April 4, 2022 from https://www.health.gov.on.ca/en/pro/programs/cdpm/pdf/ottawa.pdf

Green, B. N., & Johnson, C. D. (2015). Interprofessional collaboration in research, education, and clinical practice: working together for a better future. The Journal of chiropractic education, 29(1), 1–10. https://doi.org/10.7899/JCE-14-36

GSK. (2016). Living with COPD - A Patient's Perspective. Retrieved April 4, 2022 from https://www.youtube.com/watch?v=OzOXiM-0dtA

Hamoni, R., Matthews, M., and Watson, M. (2021). Digital Transformation: The Next Big Leap in Healthcare. Information and Communications Technology Council (ICTC). Retrieved April 4, 2022 from https://www.ictc-ctic.ca/wp-content/uploads/2021/08/ICTC_Report_DigitalTransformation_August-12.pdf

Health Canada. (n.d.). Prevalence of Chronic Diseases Among Canadian Adults. Health Canada. Retrieved April 4, 2022 from https://www.canada.ca/en/public-health/services/chronic-diseases/prevalence-canadian-adults-infographic-2019.html

Health Science Channel. (2015).Struggle to Breathe: COPD (Chronic Obstructive Pulmonary Disease. Retrieved April 4, 2002 from https://www.youtube.com/watch?v=ehh89UrZtZU

Institute for Work & Health. (2019). Examining the link between working conditions and tobacco-smoking habits. Institute for Work & Health. Retrieved April 4, 2022 from https://www.iwh.on.ca/summaries/research-highlights/examining-link-between-working-conditions-and-tobacco-smoking-habits

Mohammed, H. T., Hyseni, L., Bui, V., Gerritsen, B., Fuller, K., Sung, J., & Alarakhia, M. (2021). Exploring the use and challenges of implementing virtual visits during COVID-19 in primary care and lessons for sustained use. PloS one, 16(6), e0253665. https://doi.org/10.1371/journal.pone.0253665

Newsy. (2017). Most smokers have low socioeconomic status. Retrieved March 22, 2022 from https://www.youtube.com/watch?v=6dJ-5Zz6JF4

NYU Langone Health. (2014). Smoking Cessation: Taking Back Control By Quitting. Retrieved April 4, 2022 from https://www.youtube.com/watch?v=ouDPuj8VIe0

Osman, S., Ziegler, C., Gibson, R., Mahmood, R., & Moraros, J. (2017). The Association between Risk Factors and Chronic Obstructive Pulmonary Disease in Canada: A Cross-sectional Study Using the 2014 Canadian Community Health Survey. International journal of preventive medicine, 8, 86. https://doi.org/10.4103/ijpvm.IJPVM_330_17

Pakhale, S., Tariq, S., Huynh, N. et al. (2021). Prevalence and burden of obstructive lung disease in the urban poor population of Ottawa, Canada: a community-based mixed-method, observational study. BMC Public Health, 21, 183 https://doi.org/10.1186/s12889

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

Providence Health. (n.d.). COPD Clinic. Providence Health. Retrieved April 4, 2022 from https://www.providencehealthcare.org/copd-clinic

Qureshi, H., Sharafkhaneh, A., & Hanania, N. A. (2014). Chronic obstructive pulmonary disease exacerbations: latest evidence and clinical implications. Therapeutic advances in chronic disease, 5(5), 212–227, https://doi.org/10.1177/2040622314532862

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