National Public Smoking Ban

Health Advocacy Campaign Development

Tiffany E. Snowden

Walden University

NURS 5050/6050 Section 06, Policy and Advocacy for Improving Population Health

February 8, 2015

Health Advocacy Campaign Development
Living a long, thriving and healthy life is a vision many Americans strive to make a reality. Unfortunately, many are deprived of that dream because of smoking and tobacco use. It is estimated that approximately 16 million Americans suffer from a disease as a result of smoking in addition to the one in five deaths that occur annually from smoking (Smoking & Tobacco Use, 2014). The purpose of this paper is to describe the population affected by smoking, summarize the attributes of two successful health advocacy programs and develop a successful health advocacy campaign for smoking.
Smoking and the Affected Population Tobacco use is the leading cause of preventable deaths in the nation (Smoking & Tobacco Use, 2014). There are many reasons that an individual chooses to partake in tobacco use including stress and peer pressure. In 2012, with an estimated 42.1 million Americans aged 18 years or older, approximately 18% of the adult population was cigarette smokers (Smoking & Tobacco Use, 2014). Aside from adult users, it is estimated that more than 3,200 adolescents smoke their first cigarette on a daily basis (Smoking & Tobacco Use, 2014). According to the 2012 Surgeon General’s Report, approximately 9 out of 10 smokers initiate smoking by the age of 18, and 99% will begin smoking by the age of 26 (Cigarette Smoking, 2014). Many people, regardless of age, race or socioeconomic status, interact daily with a tobacco user. Tobacco users tend to fail to realize that their choices affect not only them but those around them as well. Secondhand smoke exposure contributes to an estimated 41,000 deaths yearly in the United States (Smoking & Tobacco Use, 2014). Exposure to secondhand smoke is estimated to affect almost half of the non-smoking adult population and 60% of children in the United States (Cigarette Smoking, 2014).
Drug Abuse Resistance Education Program The Drug Abuse Resistance Education Program (D.A.R.E.) is a national drug, tobacco and alcohol prevention program that links law enforcement personnel to educational institutions to implement successful preventative strategies (Dilascio, Killeya-Jones, Merrill, Pinsky & Sloboda, 2006). The D.A.R.E. mission is: “Teaching students good decision-making skills to help them lead safe and healthy lives” (Mission | Vision - D.A.R.E. America. (n.d.). Currently, in the United States, D.A.R.E. is operated by more than 15,000 law enforcement personnel in approximately 8,300 schools within 1,800 school districts (Dilascio et al., 2006). Worldwide, D.A.R.E. has developed programs in more than 50 countries (Dilascio et al., 2006). Ensuring a program’s success begins with the initiative displayed. Organization is a critical component that directly influences the success or shortcomings of a program. With D.A.R.E., each state has the authority to shape their individual organizational model to ensure the individual needs of the community are being met (Dilascio et al., 2006). The diversity of structural organization enables enhancement of the organizational relationships throughout the communities. Offering programs for multiple age groups influences the success of a program. Currently, D.A.R.E. offers programs for four age groups: elementary, middle school, high school and parents (Dilascio et al., 2006). Formally training the police officers that direct such programs allows the officers to ensure the delivery of their message includes variety and appeals to the intended audience. Each program has its own extensive training. Training for these programs requires a minimum of 80 hours. Training for the programs beyond elementary include the 80-hour course as well as a minimum of one year experience educating at the elementary level (Dilascio et al., 2006). With extensive training programs in place, officers receive adequate direction in ensuring a successful program is executed. Mentors, or experienced D.A.R.E. officers, are provided as a resource to ensure the delivery of the program remains successful by observing programs, counseling junior D.A.R.E. officers and determining the necessity of additional training (Dilascio et al., 2006).
California’s Tobacco Control Program Established in 1989, the California Tobacco Control Program (CTCP) quickly became well-known. Improving health by reducing illnesses and premature deaths related to tobacco is the mission for the CTCP (California Tobacco Control Program, 2015). Initiated with funds from the Tobacco Tax and Health Protection Act, the annual budget for the program was $100 million (Miller, Max, Sung, Rice & Zaretsky, 2010). In 1990, the program introduced a statewide anti-tobacco media campaign as well as community-based and school-based prevention programs (Miller et al., 2010).
Implementing effective leadership, practice and exploration enables CTCP to encourage a tobacco-free lifestyle competently. The use of media campaigns in addition to state and community interventions were the primary objectives of the program’s organization (Roeseler & Burns, 2009). Educating the public through the use of media ensured the dangers of smoking and the resources available were being communicated to communities on a regular basis. The media campaigns implemented by CTCP included general market-specific as well as priority population-specific (Roeseler & Burns, 2009). Striving to accomplish ambitious goals mandated the program to educate aggressively about the importance of tobacco prevention and cessation.
Diversity, stemming from state and community interventions, played a critical role in CTCP’s success. On a state-level, training and direct services, including cessation quit-lines, are provided (Roeseler & Burns, 2009). Community interventions provide comprehensive and single-issue driven programs which ensure that all members of the community are provided with adequate services (Roeseler & Burns, 2009). To ensure CTCP’s effectiveness is maximized, a variety of evaluation efforts are implemented. An evaluation of media campaigns, community programs, school-based programs and tobacco industry marketing strategies empowers CTCP to make the necessary changes needed to maintain the program’s sustainability (Roeseler & Burns, 2009).
Advocacy Campaign Proposal
Pertinent health risks related to smoking and tobacco use continuously receive attention via media, prevention programs and even legislature. With the tobacco industry consistently developing new marketing strategies, health advocacy campaigns must continuously evolve and progress to ensure communities have adequate support readily available. A life is taken approximately every six seconds due to tobacco use (Tobacco Statistics & Facts, n.d.). Secondhand smoke takes more than 600,000 lives yearly with one-third of that statistic being children (Tobacco Statistics & Facts, n.d.). Tobacco use harms everyone exposed; there is no safe level. In 2014, the United States spent approximately $170 billion in tobacco related health care costs (The Toll of Tobacco in the United States, 2015). To overcome the obstacles communities face as a result of tobacco use, developing effective health advocacy campaigns are imperative. Enacting a nationwide smoke-free policy for public establishments will aid in decreasing the negative impacts from public tobacco use. Implementation of this policy helps smokers begin their path towards cessation and non-smokers avoid the negative impacts of secondhand smoke. Preventing exposure to secondhand smoke is a driving force behind the smoke-free policy. Specific objectives to implement for this proposed policy include: protect communities from secondhand smoke, support smoking cessation of current smokers and reduce the occurrence of new smokers. Educating policymakers on the dangers and risks associated with tobacco use, as well as the financial liability, is the first step in developing a successful platform for the campaign. To effectively convey necessary information to policymakers, a task force focused specifically on the campaign is required. Not only does this provide a means for establishing a rapport, it also provides a means for connecting with other professional organizations and resources. Developing strong ties to the communities affected by this issue and those professional organizations allows for increased exposure to the topic at hand as well as increased support for the passage of the campaign. Adequate support and resources are essential in making a significant impact on policymakers.
Applying Attributes of Effective Advocacy Programs Applying attributes from effective advocacy programs already in place can contribute to the success of a proposed campaign. Characteristics from the D.A.R.E. program, such as diverse organization structures, can be implemented to guarantee that each state is implementing the policy to maximize the benefits for their communities. All communities are different and therefore need to be approached differently. Providing formal training about tobacco use and the necessity for smoke-free environments for community leaders, such as mayors and governors, will enable the leaders to provide direction for their communities on the importance of the act. Implementing characteristics of the CTCP will ensure that all communities have multiple resources available at all times to promote smoke-free environments. Using media outlets as a means of education for communities can help stimulate an effective enactment of the new policy. Providing quit-lines for tobacco users creates a resource that helps stimulate tobacco cessation. Through the development of comprehensive and single-issue driven programs, each member of the community will have access to a program that is best suited for them.
Proposed Policy Enactment Enacting this proposed policy could be achieved by modifying existing laws. As of 2011, a total of 25 states have laws implemented regulating tobacco use in public indoor facilities; However, seven states have no sort of smoke-free policy in place (25 States and DC are Smoke-Free, 2011). There are many supplemental active resources that can be used to help facilitate the enactment of this policy. For example, the Framework Convention on Tobacco Control is an established treaty that encourages nationwide action on reducing the growing use of tobacco (Roemer, Taylor & Lariviere, 2004). Statements, including those from the American Cancer Society, Tobacco Free Kids, the American Lung Association and many other prominent organizations, regarding the importance of this policy have been documented. While there are multiple states that have smoke-free policies in place, there are many states that are lacking such a policy. Implementing this policy on a national level will ensure that all populations are being protected from the harmful effects of tobacco use. With the current smoke-free policies in place, approximately 47.8% of the U.S. population benefit from smoke-free environments (25 States and DC are Smoke-Free, 2011). From the beginning of the implementation of CTCP until now, approximately 20 years, California’s health care costs have been reduced by $134 billion (Hernandez, 2013). According to James Lightwood, PhD, “These health care cost savings began to appear almost immediately after the program started and have grown over time, reaching more than $25 billion a year in 2008” (Hernandez, 2013). Providing statistics about the states with smoke-free policies in place supports the implementation of a nationwide policy.
Influencing Legislative Support Support from both local and national levels of legislature are necessary for the successful implementation of a policy. According to Milstead (2013, p. 53), effective lobbying is much like a three-legged stool; each leg is essential for success. The first leg is the development of relationships with lobbyists from professional nursing and health organizations, such as the American Nurses Association(ANA) and CTCP. By focusing on building these successful relationships, I will increase my chances of making a great impact on policymakers. Relationships with professional lobbyists are vital in this process because legislators often rely on the expertise of lobbyists to help understand the issue that is being voted for or against (Milstead, 2013, p. 53). Grassroots lobbying, sometimes thought of as the most effective effort of lobbying, form the second leg (Milstead, 2013, p. 54). Establishing effective communication with legislators is the essence of lobbying. In-person visits, written letters, fax messages, phone calls and e-mails are measures that should be implemented to ensure communication is maximized throughout the policymaking process. Focusing on in-person visits, the most effective route, will enable me to build a stronger rapport. Establishing a relationship with staff of lawmakers is valuable because these connections often lead to valuable tips that will allow me to redefine my strategies for enacting this policy. Timing is essential to success, and having knowledge about the developments during the policymaking process could be the difference between success and failure. The final leg is financial means. Unfortunately, passing a policy can require millions of dollars. By utilizing the relationships formed with professional organizations, endorsements would be elicited and grants would be sought to ensure the proper funding for this process was available. Establishing a website that contains finance reports related to the policymaking is another avenue to implement when trying to increase the funds available for the process. Without the proper financial support, enactment of the policy is likely to result in failure.
Obstacles in the Legislative Process There are a multitude of obstacles that may be faced during the legislative process of implementing this policy. The success of an effective policy relies heavily on the implementation of the policy and the enforcement. Without a proper strategy for enforcement, policymakers may be reluctant to enact the policy. To begin with, information regarding smoke-free environments will be published and offered to the public as a means to educate on the benefits in abstaining from tobacco use. In addition to education, information will also be provided on the consequences for policy violations. Ensuring communities are educated on the policy and the consequences of violations are components that will contribute to the enforcement of the policy. While many individuals agree with smoke-free environments, there are also individuals that do not. A common theme for implementing smoke free policies is that it’s said to be bad for business. Educating policymakers on information available that contradict this statement will help successfully overcome economic-related obstacles. According to the California Board of Equalization, California has greatly benefitted financially from becoming smoke-free (Economic Impact of Smokefree Laws: Case Studies, 2005). After the smoke-free policy took effect in California, establishments offering beer and wine saw an increase of $2.44 billion in sales tax from 1997 to 2002; establishments offering all types of alcohol saw an increase of $2.66 billion for the same time period (Economic Impact of Smokefree Laws: Case Studies, 2005). In addition, bars and restaurants in California employed approximately 200,500 more employees in 2003 than in 1995 (Economic Impact of Smokefree Laws: Case Studies, 2005).
Without displaying our knowledge and competence, policymakers may not be as receptive to our efforts. Providing proposed strategies and statistics from previously implemented policies enables the task force presenting this policy to gain the confidence and respect of the policymakers deciding on the issue. Collectively presenting information and strategies regarding this policy will enable the task force to have a greater impact on policymakers. It is imperative that policymakers understand the interactive factors affecting this policy as well as the potential outcomes.
Ethical Dilemmas Considering potential ethical dilemmas that may arise is a must when developing a strategic plan for an advocacy campaign. Three major concerns for ethical conflict include: 1) conflict between researchers, administrators and advocates; 2) conflict between the right to know and the right to privacy; and 3) conflict between the demands of the evaluator, political officials and/or stakeholders (Milstead, 2013, p. 146). However, as a nurse, my primary obligation is to effectively advocate for my patients, whether they be individual, families, groups or communities (American Nurses Association, 2001). Provisions 7-9 of the ANA Nursing Code of Ethics focus on: 1) nurses participating in advancing the nursing profession by contributing the development of practice, education, administration and knowledge; 2) nurses collaborating with other health professionals and the public in an effort to promote local, national and international efforts to meet health needs; and 3) use of the nursing profession to maintain the integrity of the profession and shaping social policy (Code of Ethics, 2011). Implementing a smoke-free policy could potentially create ethical dilemmas. One potential ethical dilemma could arise from the health advocacy campaign would be an administrator acting as an evaluator as well. In order to avoid this possible role conflict, ensuring that there is a designated individual assigned to coordinate the program and another designated individual to evaluate the program is a must. Along with role conflict, evaluators may be challenged with supporters that have a personal attachment to the campaign. Because of their personal attachment, they may try to protect the program, as well as the participants, from scrutiny during the evaluation aspect of the campaign. Ensuring that confidentiality will not be breached and that all statistics will consist of numbers only is essential to avoiding this conflict. Inevitably, autonomy will be a major ethical dilemma that will present itself. Many smokers will feel that their right of choice is being infringed upon by implementing a smoke-free policy. Ensuring that non-smokers are protected from the harmful effects of tobacco is the top priority in this policy. It is our obligation to focus on our commitment to our patients and to use collective efforts to improve the welfare of our societies.
Ethics Laws Protecting communities from harm and ensuring no harm is brought on by the implementation of this policy is an ethical priority that must be addressed for each advocacy campaign (Milstead, 2013, p. 147). By implementing this smoke-free policy a lower amount of individuals will be affected by secondhand smoke. The most effective way to reduce exposure to secondhand smoke is through establishing policies that promote smoke-free environments. There are ethics laws and reporting requirements that apply to this advocacy campaign. When eliciting financial support, detailed program evaluations are a must. For nonprofit organizations, lobbyists must register with the Secretary of the Senate and the Clerk of the House of Representatives (Tenenbaum, 2002). In addition to registering, semi-annual reports must be filed. Information regarding changes made in the lobbying registration, issues that were lobbied during the reporting period and estimated lobbying expenditures must be included in the reports (Tenenbaum, 2002). Public access to these records are required and must be available for six years (Tenenbaum, 2002).
Ethical Challenges In an attempt to educate communities on the harmful effects of tobacco use, ethical challenges will develop. A core ethical challenge that will be presented while implementing this policy will be depriving individuals of their right to smoke in public. However, using tobacco is merely a personal choice, not a constitutional right. Although where an individual is allowed to smoke is limited, they still have the choice to partake in tobacco products if they choose. Lifestyle changes may be initiated with the endorsing of a smoke-free policy but they are not required.
Smokers are considered to be the minority group when compared to non-smokers in the United States. Some may feel that the enactment of this policy is discriminating against a minority group and therefore will not support it. However, smokers are not considered to be protected under the Equal Protection Clause of the 14th amendment. Reiterating that the rights of smokers are not being violated is crucial. As discussed above, there is no fundamental right to smoke. Enacting this policy simply protects non-smokers from the exposure to secondhand smoke.
Conclusion
Patient advocacy is a fundamental component of nursing practice. According to provision three of the ANA Nursing Code of Ethics, nurses promote, advocate for, and strive to protect the health, safety and rights of the patient (Code of Ethics, 2011). Social policies and their effects on the health of individuals, families and communities are part of nursing care and nursing research according to the ANA Social Policy Statement (Milstead, 2013, p. 141). As patient advocates, advance practice nurses must be proficient in fulfilling that role by influencing social policies that enhance the health of our patients.

References:
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