Inhale. Exhale. Simple, but not easy for everyone.
- Tara Thomas Tarcza
- Mar 6, 2021
- 7 min read
Updated: Mar 8, 2021
Health is multifaceted and we must consider that there are many factors that influence it. For a clinical dietitian, smoking cessation may not seem relevant. I encounter several patients in my practice who suffer from Chronic Obstructive Pulmonary Disease (COPD) because of smoking while working on an inpatient Respiratory Unit. My role typically involves finding ways to meet the metabolic needs of the patient to help prevent unintentional weight loss that can lead to malnutrition and further deterioration in health status. Recently I was reminded about the social determinants of health (SDOH), which has piqued my interest in learning more about social causes behind development of COPD (Braveman & Gottlieb, 2014). People with COPD typically have a high incidence of malnutrition and require nutrition intervention as part of their hospital stay (Mete et al. 2018).
Acknowledging the situations that individuals are in can be a useful tool in promoting healthy behaviour (Golden et al, 2015). I pride myself as a clinician who focuses on being patient-centred, however I recognize that there is a gap in my understanding of some of the social factors associated with the development of COPD. Learning more about other aspects that have led to the patient being hospitalized with an exacerbation of their lung disease is important as it can play an important role in the intervention I would recommend and follow up care available.
COPD leads to non-reversible lung damage that is typically underdiagnosed and leads to significant costs to the individual and the health care system (Osman et al, 2017). People living with COPD experience frequent admissions to hospital due to exacerbations of their disease and require extensive follow up care in the community (Mittmann, 2008). Noting that COPD is the number 2 reason for hospitalization in May 2020 should highlight the importance of addressing ways to reduce disease development (CIHI, 2020) (Figure 1). I recognize the impact that COPD has on a person’s nutrition status due to the nature of the disease, however I wonder if there are other factors at play that could be worked on to help the patient avoid hospitalization (Golden et al. 2015).
Figure 1.
The Social Ecological Model (SEM)
SEM offers insight into five levels of influence that can impact health behaviour and recognize individuals and their environment work together in the development of health outcomes: the individual, interpersonal, organizational, community and policy (Golden & Earp, 2012). Health is multifaceted and certainly we must consider that there are many factors that influence it. The model in figure 2 shows the layered spheres of influence in the model.
Figure 2. Social Ecological Model
Applying a multilevel model of health to this topic can help us better understand how to influence change in smoking habits through the Smoke-Free Ontario Act (SFOA), 2006. As part of this legislation Ontario took a downstream approach through policy with increased taxes and prices for tobacco, restrictions on smoking in public spaces and even programs to eliminate farm operations to grow tobacco at the policy level (SMDH Exec summary). Likewise, through community engagement by utilizing social marketing campaigns, school-based programs for children and adolescents to never smoke, and workplace education and elimination of smoking on any workplace property (Executive Steering Committee, 2017). This plan seeks to utilize the important influence of social support by incorporating smoke free homes and cars and significant program development for multiple forms of smoking cessation programs – a smokers helpline, free nicotine replacement therapy and some community-based programs (Executive Steering Committee, 2017). All well intended ideas to reduce tobacco but missing the key component at the centre of the SEM, the individual. The model as depicted in Figure 3 highlights the key efforts at three levels of the SEM – Policy, a combination of Community and Organizational and Interpersonal as referred to by Cessation Services.
Figure 3: Smoke-Free Ontario’s Comprehensive Approach to Tobacco Control. (2006)
In 2018, the Ontario government recognized a need for change and an update to the previous SFOA was made. This included identifying new risks for use of electronic cigarettes and change in federal law surrounding cannabis and created the Smoke-Free Ontario strategy (SFO). Three priorities were established to support efforts in cessation, prevention, and protection for tobacco control (Ontario, 2018). Certainly, there have been some wins with this approach as there were observed trends in reduced smoking rates by 8.5% in six years when the act was first established (Ontario, 2018). Figure 4 depicts the shift from the original Smoke-Free Ontario’s Comprehensive Approach to Tobacco Control (2006).
Figure 4. Smoke-Free Ontario Strategy (SFO), 2018
The new model of SFO puts the individual in the centre like the SEM but combines the other levels into the same sphere to create a more streamlined approach that we have seen in Ontario that is inline with the current government’s goal of health care in Ontario (Ontario Health, 2020). SFO identifies that the smoking cessation programing is an integral part of supporting the individual (Ontario, 2018). Smoking cessation programs have the capacity to support many smokers to quit (Roberts et al, 2013). Helping the individual to gain new knowledge about the long-term effects of smoking and giving skills to make change is essential for success with cessation programs. Successful motivation tools like nicotine replacement therapy and ongoing support to stop smoking will help to increase eagerness to quit and give the smoker purpose (Roberts et al, 2013). Golechha (2016) purports that using a 3-tiered approach to smoking cessation is most effective as individual behaviour change is difficult to achieve on its own. Starting with community level of influence may be more beneficial in supporting individuals (Golechha, 2016).
Future tobacco initiatives need to take a closer look at some of the SDOH related to COPD risk to help guide efforts. There are noted correlations between gender, income, education level (Osman et al. 2017). I think it is important to take this into consideration when creating programs to support smoking cessation. Females in Canada tend to smoke more than males and therefore have higher rates of developing COPD (Osman et al, 2017). There is minimal attention to the adverse effect of COPD on women’s health, yet more women die from COPD than breast cancer (Jenkins, et al 2017). There is also an association between smoking (including exposure to smoke) and income: lower income households are almost twice as likely to smoke in comparison to higher income households (1 in 5 low-income vs 1 in 10 higher income households) (Stats Canada, 2017). Women typically are paid less than men and, more likely to be employed in part time or casual jobs (Jenkins, et al, 2017). Likewise, lower income and not attaining high school diploma increase risk for impaired lung health (Osman et al, 2017).
Some research points to gender-specific risk related to SDOH in developing COPD but this information does not seem to inform health promotion strategies as noted in the SFO. This should be considered in program planning. Golden & Earp (2012) concur that most health promotion strategy focuses on lifestyle changes and disregards related forces that impact health. Noting that the SEM recognizes individuals within larger social systems, it should highlight the importance for tobacco reduction programs to consider that the determinants of health may differ for men and women (Golden & Earp, 2012).
Figure 5. The impact of female sex on COPD
Gaining insight into addressing the interconnected risk factors for COPD (gender, smoking trends, and socioeconomic status) can support an individual in making change in an upstream way and may help to achieve more longer-term benefit from smoking cessation programs (Osman et al, 2017) (Amos et al. 2012). This will further enhance some of the other spheres of influence and produce long term changes. With this new knowledge on COPD risk factors and understanding of how various factors can influence tobacco use, I feel better equipped to address patients needs in a more patient-centred way. I will be able to advocate for additional supports in the community for more comprehensive support. I recognize that there are many things to consider when supporting patient that may beyond the nutrition care plan.
References:
Amos, A., Greaves, L., Nichter, M., Bloch, M. (2011). Women and tobacco: a call for including gender in tobacco control research, policy and practice. Tobacco Control, 21(2), 236-243. https://tobaccocontrol.bmj.com/content/tobaccocontrol/21/2/236.full.pdf
Braveman, P., Gottlieb, L. (2014). The social determinants of health: it's time to consider the causes of the causes. Public Health Reports, 129(Suppl 2), 19-31. https://doi: 10.1177/00333549141291S206
Canadian Institute for Health Information. (2020). Hospital stays in Canada. https://www.cihi.ca/en/hospital-stays-in-canada
Executive Steering Committee. (2017, Aug 23). Smoke-free Ontario Modernization Report. https://www.simcoemuskokahealth.org/docs/defaultsource/hulibrary/reports/sfo_modernization_esc_report.pdf?sfvrsn=0
Golden, S., McLeroy, K, Green, L., Earp, J., Lieberman, L. (2015). Upending the social ecological model to guide health promotion efforts toward policy and environmental change. Health Education & Behavior. 42(1 Suppl):8S-14S. https://doi.10.1177/1090198115575098
Golden, S. D., & Earp, J. L. (2012). Social ecological approaches to individuals and their contexts: Twenty years of “Health Education & Behavior”. Health Promotion Interventions. Health Education & Behavior, 39(3), 364-372.
Golechha M. (2016). Health promotion methods for smoking prevention and cessation: A comprehensive review of effectiveness and the way forward. International Journal of Preventative Medicine, 11;7:7.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4755211/
Jenkins, C., Chapman, K., Donohue, J., Roche, N., Tsiligianni, I., Han, M. (2017). Improving the management of COPD in women. Chest, 151(3) 686-696 https://doi.org/10.1016/j.chest.2016.10.031.
Mete, B., Pehlivan, E., Gülbaş, G., & Günen, H. (2018). Prevalence of malnutrition in COPD and its relationship with the parameters related to disease severity. International journal of chronic obstructive pulmonary disease, 13, 3307–3312. https://doi.org/10.2147/COPD.S179609
Mittmann, N., Kuramoto, L., Seungal, J., Haddon, M., Bradley-Kennedy, C., Fitzgerald, M. (2008). The cost of moderate and severe COPD exacerbations to the Canadian healthcare system. Respiratory Medicine, 102(3), 413-421. https://doi.org/10.1016/j.rmed.2007.10.010
Ontario. (2018). Smoke-Free Ontario: the next chapter. http://health.gov.on.ca/en/common/ministry/publications/reports/SmokeFreeOntario/SFO_The_Next_Chapter.pdf
Ontario Health. (2020) What we do. https://www.ontariohealth.ca/our-story
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, 1-7. https://doi:10.4103/ijpvm.IJPVM_330_17
Roberts, N., Kerr, S., Smith, S. (2013). Behavioural interventions associated with smoking cessation in the treatment of tobacco use. Health Services Insights, 6, 79-85. https://doi.10.4137/HSI.S11092
Statistics Canada. (2016). Health Fact Sheets, Smoking. https://www150.statcan.gc.ca/n1/pub/82-625-x/2017001/article/54864-eng.htm
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