PREVENTION AND CESSATION OF TOBACCO USE A MANUAL FOR CLINIC AND COMMUNITY BASED INTERVENTIONS
Prepared by
DIYANATH SAMARSINGHE with assistance from
VARUNI DE SILVA
PREVENTION AND CESSATION OF TOBACCO USE A MANUAL FOR CLINIC AND COMMUNITY BASED INTERVENTIONS
Prepared by
DIYANATH SAMARSINGHE with assistance from
VARUNI DE SILVA
Contents About the manual 1. 2. 3. 4. 5. 6. 7. 8. 9. Why bother about tobacco? How is tobacco use apread? Determining what works and what does not Reasons for success and failure so far General principles for health sector initiatives Implementing community preventive responses Implementing community cessation responses Measuring progress Reaching new heights Appendix (guidelines for quitting) Further reading
ABOUT THIS MANUAL
This manual is intended for people interested in reducing problems caused by tobacco. The damage caused by tobacco is so serious that everybody should really be interested in doing something about it. But this manual is for those who want to do a little bit more than the 'average citizen'. Although tobacco is a deadly serious issue, the flavour of activities that are needed to prevent its spread does not have to be heavy and serious. Tobacco use is spread by making it look appealing, attractive, casual and fun. The preventive effort cannot allow itself to appear serious, heavy, boring and uninspiring. But for efforts to be sustained some amount of underlying seriousness is necessary. We try to avoid the usual formats that make any activity look initially heavy or daunting. The approach used is therefore to give priority to the kinds of things that we need to say to people rather than to the means of organizing action groups, monitoring their activities, record keeping, evaluating impact and so on. But we have integrated these ideas too, into the day to day actions that are proposed. The manual is intended primarily for people who work in a health facility serving a 'local' population. A doctor or nurse or someone else in the health facility can use the guidelines to create changes in the communities served by them. But people outside the medical or health professions too can use these guidelines effectively. The interventions (except a few sections in chapter 8 on 'cessation') can be
In This Chapter Achieving the correct flavour How to use the manual Broad layout Scope of the manual Resources 6
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implemented by any concerned individual, and do not require special medical expertise. The manual can be used for self-instruction or for training. The activities suggested are for implementation at the level of local communities, not at national level. So the emphasis is on action relevant to a community or a clinic. Chapters 1-5 cover general theoretical issues, chapter 6 preventive measures, and Chapter 8 cessation of tobacco use. Theoretical issues dealt with in chapters 1 to 5 are restricted to basic information and background underlying the recommendations for action (made in the 'guidelines for action' in chapter 6 and 7). This overview of theory is not intended to be a comprehensive review of the existing studies. There is a great deal of progress in the world, in understanding how the spread of the tobacco habit can be curtailed. Some of the opinions that are currently held (based on existing evidence) are presented in chapters 1 to 5. It is helpful to keep in touch with new developments in the world even if we work in a very remote location, or with just one small community. The content in these five chapters will be mostly redundant to those who are familiar with the basic issues in smoking prevention and cessation. But the guidelines are meant to be used even by those who are not familiar with the subject, as a tool for training and monitoring activities. Someone who is already convinced of the need for action and familiar with the basic issues can skip the rest of the introductory section, and move directly to the sections on prevention or cessation. Just reading through the manual should provide ideas for a person interested in taking practical measures to curtail the harm caused by tobacco use. But for maximum usefulness they should be used as a guide for action in stages, where an intervention suggested is carried out and then the next step taken up. The strategy employed has been to put across the flavour of a given intervention by providing several examples, mostly in the form of questions that we should all try to answer and analyze. Some questions or issues that are relevant to prevention as well as to cessation efforts are mentioned in both. This repetition is intentional, as some readers may want to concentrate on either prevention or cessation alone. All sections in all parts do not need to be read completely, for success in implementation. The user can select the areas of interest to read in detail or to skim over or even omit. For interventions to succeed they need to be sustained. This is usually seen to require funds or resources. Interventions described in this manual require no extra funds for implementation. All the activities suggested can be carried out if there is enough interest and concern even in one person. Just two or three people working in a clinic or school can achieve significant results. The extent of change that is achieved can, of course, be increased that much more if there are more people interested. 2
Many activities can be spread more widely and effectively if we have money. But we should try to do only those things that we know we can sustain. Once activities are in motion and there is a good momentum built up, additional resources may be used to increase the scope and coverage of our work. It is generally unwise to start work on the basis of a small amount of funds that have become available. If any money becomes available at the outset it can be set aside for later use after some momentum is achieved. Momentum is best built up on goodwill and public interest.
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WHY BOTHER ABOUT TOBACCO? CHAPTER 1 The World Health Organization considers tobacco the single most important cause of preventable death worldwide. But there is widespread apathy about doing something to curtail its spread. Any effort to reduce its spread is often dismissed as being a needless preoccupation with a trivial problem. There seems to be a reluctance to take action that is appropriate to the harm that tobacco is known to cause. We know now that this is due in part to the activities of the tobacco industry itself. They would naturally prefer that too much attention is not focussed on the harmfulness of their product. But there are other reasons too, for the apathy.
In This Chapter Apathy and its causes Confusion deliberately created Blaming the victim Ignorance of effective interventions 5
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Failure to appreciate the scale of harm One reason is the failure to appreciate the magnitude of the harm that tobacco causes. Because it is such a powerful and widespread agent of disease, the number of deaths it causes is huge. When such large numbers are cited, they appear to be exaggerations. And because tobacco deaths happen more than 20 years after the initiation of smoking, the connection between the immediate cause of death (for example, a myocardial infarction) and previous smoking is not readily noticed.
Confusion deliberately created Even when people recognize that tobacco causes numerous diseases and premature deaths, they don't quite appreciate 4
the scale. Many people have been influenced by the propaganda that there is needless fuss about tobacco. One argument against taking action to prevent tobacco related harm is that, 'Many things are bad for your health and people have to learn to look after themselves'. Eating fatty foods, getting infected with HIV or inhaling exhaust fumes from motor vehicles, for example, are cleverly (and falsely) cited as risks equivalent to tobacco use. Trying to control the spread of tobacco is equated; through this kind of seductive argument, to an attempt to ban fatty foods, sex or motor vehicles! We need to understand how such reasonable sounding arguments are based on subtle distortion of facts to make them appear logical. We must learn to recognize the faulty reasoning that is smuggled in through these innocent sounding arguments and the resultant undermining of all efforts to reduce a needless, and easily controlled, cause of human suffering and death. We also need to examine the origin of these kinds of ideas, and how these are put about in nearly all countries of the world. Any effort to control tobacco related harm is quietly equated to a ban or prohibition on tobacco use, through various forms of sophistry. Health efforts to reduce tobaccorelated harm do try to bring about some controls on the promotion of tobacco. But prohibition of advertising and promotion is not the same as prohibiting the product. Even though health efforts are not in any way directed at banning the sale or consumption of tobacco it is made to look as if they are. Some controls on tobacco are indeed advocated. Opponents of any controls on tobacco promotion have succeeded in making the public forget that there are indeed a great many formal and informal controls on such things as motor car emissions too! And restrictions on tobacco are intended for a product that is unique in that it kills the consumer when used as intended by the manufacturer. Restrictions and controls need to be appropriate to the scale of harm. The impact of tobacco, compared to other health hazards, is enormous. For example few people, even among those working in the health sector, are aware that deaths due to tobacco exceed those due to motor vehicle accidents, suicides, homicide, AIDS, tuberculosis and maternal mortality combined. Even well informed health personnel find this hard to believe. (The reference can be found in the World Health Organization's release, Leave the Pack Behind, 1999, WHO, Geneva)
Blaming the victim A further reason for inactivity is the feeling that the victims have brought about their own suffering, and so they are to blame. This again is a result of the failure to appreciate the subtlety of the strategies that are used to make people take up smoking. The spread of tobacco is seen to be something that results from people picking up the habit quite by accident, presumably from existing smokers. Most people are unaware of the numerous tactics employed in the marketing of cigarettes. So they see initiation of smoking as a 'natural' event. 5
Smokers are seen as the agents responsible for bringing upon themselves any suffering that results from smoking. And they too eventually pick up this cleverly planted belief that they 'chooses to smoke'. All the subtle marketing and promotional ploys that makes them 'choose' to smoke and 'choose' to continue smoking are not recognized by most smokers.
Ignorance of effective interventions Another important cause of apathy is the belief that things cannot be changed for the better. Prevention efforts are then seen as a useless fuss that achieves no benefit. When we think that there is nothing effective that can be done about a problem, we tend to 'switch off' from it. The result of this is that we then deliberately downplay the importance of tobacco related harm, even if it is pointed out to us. It is difficult to take serious notice of a problem and then do nothing about it. If we can think of nothing that we can do about it, it is easier to conclude that the problem is not really so serious. It is difficult to accept that something is a major problem, when we choose to do nothing about it.
Conclusion Many factors thus operate to prevent even a fraction of the deserved attention being focussed on tobacco control. We need to recognize the different influences that make people in our families, workplaces and communities feel unconcerned about the spread of tobacco use. Addressing the reasons for lack of concern is as important as informing people about why they should act. Even if people are given the statistics on the deaths, diseases and the financial burden resulting from tobacco smoking they do not respond because they have been cleverly 'immunized' against this information.
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HOW IS TOBACCO USE SPREAD? CHAPTER 2 We need first to understand correctly the factors that lead to the spread of tobacco use. We can then take appropriate action, based on right understanding. The reasons for the spread of tobacco are generally worked out on the basis of 'common sense'. Common sense can be misguided at times, just as much as it can be perfectly accurate. But it is important that guesswork based on 'common sense' is recognized to be pure guesswork. People tend to argue with great conviction about what should be done, even though their opinion is based purely on guesswork. One way of working out the causes of the spread of tobacco is by looking at the evidence from our own settings, and from elsewhere, as to what has already been found to work in its prevention. This could provide clues to the causes. And in a kind of roundabout way we can say that one of the causes of the spread of tobacco is the failure to implement the known effective control measures. Lack of effective policies Evidence is available in support of certain national policy measures. These include raising taxes on tobacco products so as to make them less and less affordable, preventing all advertising, sponsorship and other promotions of tobacco, and prohibiting smoking in public places. On the basis of these findings we may postulate that causes of the spread of tobacco use include the following. 7
In This Chapter Failure to implement good policies Tobacco promotions Positive image of smoking Behaviour of users Logical analysis 9
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Easy availability and affordability of tobacco. Promotion and advertising of tobacco. Integration and ready social acceptance of smoking behaviour.
For people working in a relatively small local health facility national policy measures may appear to be beyond their capability to influence. As a result they often give up trying to do anything to prevent the spread of tobacco. There is fortunately evidence, from experiences in the SEARO region itself, that local action has been found to be effective too.
Activities of tobacco promoters When we look at the basis of these locally successful interventions we find that one ingredient of successful interventions is the exposure of the tactics used to promote or push tobacco. Another ingredient in these successful efforts has been the active participation of people who already smoke and those most likely to be drawn into smoking. A third ingredient has been the active counteracting of those factors that make tobacco smoking appear glamorous, attractive or positive in any way. We can again postulate 'causes' of the spread of tobacco use, based on these successful community interventions. These include the following. ! ! ! Actions of the tobacco trade and its paid and unpaid allies. The perception of smoking as glamorous, attractive or positive. The attitudes and behaviour of current and potential users.
We can then proceed to analyze each of these factors separately and get a deeper understanding of how each factor operates. These subjects are examined in great detail in the sections dealing with action for prevention and cessation.
Logical analysis In addition to looking at the evidence from successful interventions, we can also try to understand the causes of the spread of tobacco by logical analysis . How this can be done effectively will be discussed under the interventions that follow later in the document. The analysis needs to be undertaken by the people who are doing the interventions, but the process has to be guided by good understanding of how causes should be worked out. 'Causes' that are worked out logically should not be accepted uncritically. We must work out interventions based on these 'causes' and test them out, first. Conclusions based on logical analysis can be accepted only after evidence from subsequent interventions become available. 8
Experimental interventions Successful new approaches can be developed by trying out new interventions. This can take the form of 'testing hypotheses', at field level. We often argue with great conviction about the 'real' causes of tobacco spreading or about what will definitely work, even when there is no evidence to support our position. We may be right in our opinion about what is likely to work. But the first step is to apply these ideas, at a scale appropriate to our resources, and see what happens.
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DETERMINING WHAT WORKS AND WHAT DOES NOT CHAPTER 3 What works? Scientists have many difficulties to overcome, to answer this question accurately. We must have a fair awareness of the issues involved to make sense of the numerous opinions that are constantly expressed. Among the opinions are those of people interested in deliberately creating confusion and casting doubts on the things that really are effective. We should always remember that people in the tobacco trade too can plant 'agents' to create doubts or distraction. Let us examine experiences from the SEA region of WHO a n d e l s e w h e r e , a n d t h e n a n a l y z e t h e d i ff i c u l t i e s encountered in trying to demonstrate effectiveness of interventions.
In This Chapter Difficulties in demonstrating effectiveness of interventions 16
16 Problems in measuring changes Problems in 16 selecting indicators Feasibility problems Difficulties in ensuring validity and reliability Difficulties of demonstrating causes Confusion created by the tobacco trade Examining sensitive indicators 17 17
Experiences throughout the world Good evidence is available from various parts of the world, for the usefulness of certain policy measures designed to reduce smoking. First among these is to increase the price of cigarettes. A great deal of controversy about this measure is created by the tobacco trade, to prevent it being effectively applied by governments. Restricting smoking in public places and stopping all forms of advertising and promotion helps to reduce tobacco use. Those who want to spread the tobacco habit resort to less obvious forms of promotion when the obvious ones are stopped. Including scenes in ordinary cinema and televised productions that make smoking look attractive and glamorous is an example.
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Most of these measures are in the hands of governments more than in the hands of ordinary people. We should look for things that have been found to work in local communities, independent of action by governments. This is not to say that government action is not important. But local community action too is important. For example, when communities start recognizing and counteracting the tactics used by tobacco promoters to make people start smoking, there is a beneficial impact. Action to expose the activities of the tobacco trade and to counteract their influence is therefore useful. Some responses in this regard are within the power of communities to initiate even at their own, local, level. Communities can also try to influence their governments to implement effective policies. Public pressure contributed significantly towards getting good policies enacted in countries such as Australia, Canada and Norway.
Experiences within the SEA Region There are many initiatives that are taking place in countries of the SEA Region, from which we can all learn. Different kinds of successes and failures are reported and all of these are instructive. One set of successes is in the policy field, where enlightened policies are operative in some countries of the region. These are of undoubted benefit. Legislation to restrict all promotions of tobacco, and its consumption in places where the non-smoking public is exposed to harm, should be pursued where such legislation is not yet operative. SEARO offers examples of countries with highly progressive and effective legislative responses (for example Thailand), those with hardly any effective responses and others where there are some measures in force (for example Bangladesh, Maldives and Nepal) or where legislation is in the process of being enacted (for example India and Sri Lanka). An indicator of strong national commitment is the designation of a special levy from each cigarette sold, to be used in reducing the harm caused by tobacco. This is done in only very few countries of the world. These few include countries in the South East Asia Region of WHO, such as Nepal and Thailand. Another kind of success from within the region is the effort to make current smokers quit. Again there is a whole range of interventions with varying degrees of success. These include activities conducted by centres connected to the health services (for example in the Maldives and Thailand) and interventions conducted by community based and other agencies outside the formal health sector. Equally interesting are the experiences from some settings within WHO's SEA region, where there have been highly successful interventions at community level to reduce the uptake of smoking, especially by young people as for example seen in Sri Lanka. These examples show that local communities too can make a significant 11
impact, even where the government is slow to initiate the necessary policy measures.
Difficulties in demonstrating effectiveness of interventions Changes in tobacco use are not easy to track. For our work we need to know what changes are taking place. But these are rather complicated to measure. There is the idea that we need to learn a lot about research methods to begin making assessments of the situation in a reliable and valid way. We should not be frightened by such ideas.
Problems in measuring changes Collecting information is important, if we want to do a scientific job in reducing tobacco problems. But many people in the field feel a little uncertain about 'research'. So they tend to avoid this aspect. Or they try to get outside help to deal with the research matters. This too often causes difficulties, even if an outside scientist can be found.
Problems in selecting indicators What is the information that is really useful to guide our work? Not all information, however 'scientific', is useful for our work. Having decided on the information that is really useful, we have to work out the best way of gathering this information, within our limitations. But we must realize that tracking changes in tobacco consumption is not easy to do with absolute accuracy, when our resources are limited. Most changes in consumption that are reported are of population smoking rates usually according to age and sex groups. Another kind of measure is the number of cigarettes smoked per person - above a given age. These kinds of findings, if they are done with reasonable accuracy, are helpful in comparing the situation in different places as well as in looking at changes over time in a given place. Feasibility problems Because some of these indicators are rather complicated to measure, people tend to avoid measurement altogether. The correct response is to make assessments to meet our needs in the most feasible way possible. Large-scale research can be left to those who are interested in assessing changes of that magnitude. We shall have to learn to do as best possible the measurements relevant to our level.
Difficulties in ensuring validity and reliability Because several factors can affect the answers we get when we try to assess smoking rates, for instance, it is difficult to draw firm conclusions about the changes in tobacco consumption with time. The biggest difficulty is in ensuring that the results that are 12
obtained are an accurate estimate of the real level of use. Accuracy can be affected because of many reasons. A simple example is that in a 'survey' kind of study people may give the wrong answer to questions about their smoking. Another difficulty is that we can get the wrong figures because the group that we questioned is very different from the general population that we are trying to measure. Despite these difficulties, many countries have estimates of the smoking rates of different groups of their population. These may be useful to compare the status at different times, if the information is collected in more or less the same way. Ensuring that such reliability is maintained is also difficult, and requires careful attention to details that may bias the results. We have to gather the most useful information for purposes of comparison or monitoring progress. In trying to learn from other people's efforts in reducing tobacco consumption, we need to look carefully at whether they have assessed the changes in consumption with an adequate level of accuracy. Fortunately there are studies which have been done with fair accuracy, where we can trust the findings relating to changes in rates of consumption.
Difficulties of demonstrating causes Where studies have demonstrated changes in consumption following efforts to reduce tobacco use, there is still the problem of demonstrating that such a change is due to the specific intervention. So a reduction in tobacco use following an intervention to reduce tobacco use, does not necessarily mean that the reduction was due to the intervention. We too shall face this problem, in our work. To prove that a reduction of tobacco use is the result of our intervention and not due to some unconnected coincidental occurrence is not easy. For complete proof well designed controlled studies are needed. This kind of study often requires a large amount of funds and a lot of technical expertise. If we are really interested in producing an impact we need somehow to learn the basics of more simply evaluating our work. Appropriate evaluation methods are included as a component of the interventions that are described in later sections on practical measures for prevention and cessation. Where there is a good result of interventions, the tobacco trade too will be interested in preventing this from being recognized.
Confusion created by the tobacco trade The tobacco industry, especially in the form of its 'multinational' companies, took a line that has been a hindrance to preventing the harm caused by their product. In some cases it has taken active steps to obstruct any measure that is likely to result in reductions in smoking. Those in the tobacco trade did not need to take this diabolical 13
course. But having embarked on it, they cannot now easily change the historical momentum, or their own established patterns of thinking. As a result of the activities of the tobacco trade, there has been confusion created in the minds of the public and policymakers, as to what helps in reducing tobacco consumption. In poor countries especially, the ideas that the tobacco industry chooses to propagate are more readily accepted than are those of people trying to stop the spread of smoking. This is because the tobacco trade usually has huge resources to spread its ideas compared to the minimal resources available to those trying to reduce tobacco use. And so it has greater access to people wielding 'power'.
Examining sensitive indicators A major reason for failure to demonstrate what works and what does not, is the failure to use the right kind of indicators to assess impact. To check whether young people have significantly reduced their smoking because of a single talk given by some medical expert is not very judicious. The result we can reasonably expect from such a small intervention is also small. So the measures we use to assess the beneficial impact of our work have to be appropriate to the kind of input we have made. To look for remarkable changes from a minor intervention is not prudent.
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REASONS FOR SUCCESS AND FAILURE SO FAR CHAPTER 4 Because the focus of this document is on activities for local health personnel, we shall not go into detail of the reasons for success and failure of national efforts. The reasons for the success or failure of initiatives of the local health personnel within their own areas is of more relevance to us. Some health workers, for instance, have succeeded dramatically in reducing the rate at which young people in their areas start to smoke. Others have failed to have any impact on this occurrence. Similarly, some have had significant success in inducing people to give up smoking. Others have failed completely. One obvious reason for such differences in the rates of success is the level of interest shown by each agency or individual worker. There are other factors too. And it is important to examine these factors because there is much to learn from these, about the theoretical basis of successful prevention work. Successful interventions have all engaged the relevant groups in taking the forefront of activities. This means that prevention efforts are better led by young people who are the group most at risk of starting to smoke. Among young people too, the sub group that is most at risk of becoming smokers should be actively involved and preferably take the lead. Similarly, in cessation activities the lead is best taken by smokers who have quit or those who are making progress in quitting. Non-smokers active in community based cessation efforts should include those
In This Chapter Level of interest Engaging high risk groups Addressing real issues Counteracting tobacco promoters The image of smoking Changing the image of smoking Changing current users Looking for results 20 21 21 21
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who are close in their thinking to the smokers that they are trying to influence. Successful efforts have reached people through existing active agencies and groups. Thus sports clubs, women's development agencies, agricultural extension workers are examples of agencies and people who have taken on the task of reducing tobacco use, as part of their ongoing work. Another feature of successful interventions is that they address issues that are relevant and real for the people concerned . Disease and death due to tobacco use is not perceived by many young folks as a real threat for themselves. How they are duped by the tobacco industry is a more real issue. So also the fact that, in poor families, tobacco takes away scarce resources from basic needs. For smokers too, recognizing the fact that they have been taken in, by an industry cynical about the harm that its products cause, is a very real issue. This recognition is facilitated by discovering that the same industry that seduces young people in poorer nations to start smoking simultaneously pays out large amounts of money in countries such as the USA to compensate for the harm they have done. A most important ingredient of success has been the recognition of the different, and often cynical, ways in which the industry promotes smoking. This recognition has to be matched by efforts to counteract them. A community served by a health worker may not have sufficient power or authority to impede tobacco's promotional tactics . But it usually has the strength to protect the people in their community. A step beyond counteracting the tobacco trade is engagement of people working within it. Most people who work for the tobacco trade are now aware that they are selling a lethal product and justify their actions by accepting the false claims that the tobacco trade puts out from time to time. These are intended to make the employees feel that they are doing a decent and respectable job no different from promoting any other legal substance. But most of those who work for tobacco are aware that their trade is in fact very different from any other legally permissible business. When the conscience of people within the tobacco industry is addressed, at least a few respond in an honest way. Such people are invaluable allies in helping to formulate counter strategies to the various hidden promotions that the industry indulges in. Even those who do not progress this far may develop somewhat. For instance, they may become less vicious and vigorous in promoting tobacco. A feature of successful community interventions that needs to be highlighted is their focus on changing the image of smoking from one that is glamorous or attractive to one that is crude and inelegant.
Current tobacco users misguidedly try to promote smoking. They are unaware of how they are used by the tobacco trade for this purpose. Engaging current users to recognize how they have conducted themselves thus far and how they can stop promoting smoking is a useful measure. 16
Agencies that have shown successful results have taken the trouble to look at the impact of their efforts from the start itself. They have not just done something for 'prevention' and been satisfied, nor have they done some small activity and looked for major results a long time afterwards. They have looked for relevant changes in the immediate or short term. If they have tried to make smoking to be perceived as rather unattractive and brainless, they examine whether there is at least some movement in the right direction as an immediate result of their efforts. This habit of looking for relevant results in the short term too is important in any effort that hopes to succeed. As was said earlier, an effort to make smoking appear unattractive must be accompanied by some form of assessment to see if the activities undertaken do in fact make it look unattractive. The groups conducting these interventions then work out what sort of indicators will show them that the community now sees smoking as rather ugly or as a sign of being easy to trick or gullible. Early indicators of change may simply be a chance occurrence that did not happen before. A child may remark, on seeing a young man trying to smoke in a showy way, 'Mother doesn't that man look foolish?' Or someone else may say, 'Look, he's trying to imitate so and so whom we saw in the film last night poor chap'. These chance observations or anecdotes are an early indicator that something new is happening. But more systematic attempts are also made to check whether the change we want is happening. Those carrying out the intervention therefore spend some energy first, trying to see how they will assess whether the community's perception of smoking changes. This discipline is necessary to make sure that the energy spent in trying to improve things is not wasted.
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GENERAL PRINCIPLES FOR HEALTH SECTOR INITIATIVES CHAPTER 5 A few general principles are listed here about how people in the health sector should set about doing tobacco cessation or prevention work.
In This Chapter Going beyond just ‘giving advice’ Changing public perceptions Recognizing the need for action Having a model for understanding the issues Mobilizing the team Engaging relevant people Checking impacts 24 25 25 26
Going beyond just 'giving advice' Those in the health sector are biased towards giving advice to people about their health and related behaviour, in the expectation that the advice will be followed. When people are ill they tend to obey instructions given by their doctors or other medical staff. But when they are not ill they don't obey instructions all that readily. Doctors' advice alone is helpful in promoting quitting by some people who consult them. But those smokers who are not yet ill too need to be helped to quit, before their health is significantly impaired. And for them, it may not be enough just to give advice. We suggest alternatives later, but it is worth pausing a few minutes at this point to see what other ideas may come to your mind. Another aspect of community based work is to prevent people from starting to smoke. Starting to smoke happens mostly in the younger age groups. For these groups especially, advice about health damage should be supplemented by other approaches.
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Changing public perceptions Those working in the health sector need to learn about strategies that work more effectively with people who are not ill. A major requirement in this regard is to change the way that a behaviour or a social custom in perceived by the public in general. If a behaviour or an object is seen as 18
fashionable or attractive people tend to acquire it, even if there is a price to pay. To be highly effective in tobacco prevention work, health sector staff too need to learn how to change fashions. A few other points are worth noting here, as general principles, to follow in cessation and prevention work.
Recognizing the need for action There is a widespread perception that tobacco is not worth taking the trouble to control. Even among health sector staff there are many who have succumbed to the propaganda that there is an exaggerated fuss about tobacco. Staff needs to understand the size of the impact that tobacco has, compared to other health hazards. And they must act to prevent the harm from tobacco being trivialized by clever propaganda. The propaganda has been clever enough to engage even some people within the health sector to spread it free of charge.
Having a model for understanding the issues When there is an interest and willingness to act, staff needs to work out the ways they want to proceed and the measures they will use to assess success. To do this effectively, they need to have a model of how tobacco use is to be reduced. Without such a model for shared understanding, there is no way of ensuring progress.
Mobilizing the team To do an effective job the health team or staff has to be well mobilized. The use of tobacco by members of the health team needs to be addressed as well. Too often, the people who smoke are alienated from efforts to reduce tobacco consumption. All members of the health team, whether they use tobacco or not, should be active members of the effort to reduce consumption.
Engaging relevant people A key measure of success of community initiatives is the level to which those whom we most want to reach are engaged in the activity. It is only after this step succeeds that we can expect reductions in tobacco use.
Checking impacts Results to look for are many. Not all of these require high-powered research methods. But certain indicators should be formally or informally monitored to see if the changes we want are beginning to occur. Indicators that are relevant include: visible changes in way tobacco is perceived; changes in the way that the tobacco trade is perceived; changes among persons engaged in promoting tobacco (namely, their becoming more 19
sensitive to the harmfulness of their product and trying to counteract the spread in their own private way); and, later on, reductions in consumption and sales of tobacco and eventually a drop in diseases and deaths caused by tobacco use.
Learning from others The lessons to be learnt from various successful interventions are incorporated in the two chapters that follow (Chapters 7 and 8). These are focussed primarily on prevention and cessation of tobacco use. We must be alert to further lessons to be learnt from outside this manual too.
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IMPLEMENTING COMMUNITY PREVENTIVE RESPONSES CHAPTER 6 Let us examine each issue in the 'Model for Action' in a little more detail. Each item in the model will be analyzed in this chapter. There is no restriction on who could implement the activities in the community. In implementing preventive action, you will need to decide whom you will work with, to reach the people that you wish eventually to reach. Any interested person or group can try to generate the necessary response from within each community. And we need to work out in our locality the best way of reaching every community. Members of the health staff who go out and reach communities are an appropriate channel for reaching the people that we wish to reach. Such staff are not always available in a hospital or clinic. Even in a hospital or clinic we can develop contacts who can reach out to the wider public. We do not personally have to spend a great deal of time outside of the hospital to bring about the changes that we wish to. All we need is to keep looking for ways to reach out repeatedly and regularly to the public at large. It will be easier to work out how this can be achieved, once we have understood the changes that we want to create within each community. This is best discussed in relation to the items listed in our 'model' which follows.
In This Chapter Factors that promote tobacco Learn to engage these forces 32 49
How are vulnerable 57 recruited Counteract harmful influences Why should we act? Is atmosphere changing? Be vigilant 69 83 93 99
Deal with problems 105 Measure progress Celebrate success 111 115
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This is our community
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A Model For Preventive Action
Learn about the forces that promote tobacco
Influence the environment to change towards being good for our community
Community understands how vulnerable members are influenced
Community understands why they should counteract these influences
Community understands how to counteract these influences
Community takes action
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Is the atmosphere in the community beginning to change in the right direction
Join the community in celebrating successes
Strengthen the Community to deal with problems
Create vigilance amongst all, about how efforts may be undermined
Work out new ways to get more exciting results even faster
Ensure sustained progress
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6.1 Learn all about the forces from inside and outside our small community that promote or prevent the spread of tobacco. How can we help people to find out how new recruits are induced to start and then to continue smoking? There are many ways of doing this. Let us assume that we have means of reaching people in the community through a 'community worker'. It does not matter whether we have a person who has this designation. All we need is someone who is a member of the community concerned or someone who has enough interest to visit the community from time to time. Such a person can be a regular field health worker paid by the health service, a member of a clinic's staff who likes to take on this activity, or a volunteer. For convenience we shall name this person the 'community worker'. The community worker can be male or female. She or he will need to start a dialogue with different groups in the community. Progress will be through repeated and continued contact with such a group or groups. As a first step, we want to increase the awareness in the community about a particular set of issues. We want then to indicate to the community why these issues are a matter of concern to them, and what action is possible. With increasing awareness and concern, communities begin to take action. The process does not begin by pressing people to do things. But it doesn’t stop with just creating awareness either.
RECOGNIZING INFLUENCES FROM OUTSIDE OUR COMMUNITY Our community worker could begin by asking individuals and groups of people that she meets within the community, questions such as the following. ! How do you think Suresh (a young person in the community) was induced to start smoking? Do you think it is only because of his friends that he started to smoke? Does this group of youth think that smoking looks fashionable or attractive? If so, how has that opinion been formed? Have you seen the way in which smoking is shown on television? Is it shown in a way that makes young people feel like smoking or makes them feel like not smoking? What ways of depicting smoking make it look attractive, especially to young people? 25
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What ways of depicting it will make smoking look unattractive, especially to young people? Let's look at the ways in which smoking is shown on television in the next week - and see whether it is made to look attractive or unattractive.
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These questions are intended to engage people in the community in examining something that they may not previously have noticed. Our interventions must always take people’s understanding at least a little bit forward. The example of how smoking is shown in films or television programmes is just one possible way of starting the process of discovery. Whatever is most relevant to our particular community may be used instead. For example there may have recently been a concert or ‘musical show’ in our area in which tobacco was promoted. Helping people discover the ways in which they are quietly made to see things in the way that tobacco promoters want them to see things, is better than just telling them this directly. For example, we know that large amounts of money have been spent by the tobacco industries to get smoking scenes inserted into popular films. But people may not believe our statements even if we back it up with evidence. Helping people to look at these scenes critically is much more powerful. People will begin to discover how smoking is shown or depicted in most programmes, after their attention is drawn to it. In most of our countries, it is rarely or never shown as wretched or dim-witted. It is sometimes shown as bad or harmful to health, but the image of being fashionable or attractive is reinforced at the same time. Is this true of the programmes watched by people in our community too? If this is the case, we should start thinking about the reasons for tobacco being portrayed so positively.
How is smoking shown on television?
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PROGRESS REVIEW Has there been some progress thus far? If people in the community say that they have seen that most programmes show smoking in ways that make it look very attractive and positive to the youth in that community, that is an indication that something has changed. People are now more aware. Results of our interventions can be checked at the next visit itself. If there has been no progress we need to remind them of our last conversation. We can even give examples from the television programmes that we too saw since our last conversation. We can keep slowly reminding people at each visit, providing examples, and encouraging more attention the next time they see any reference to smoking or any scene showing smoking.
Visit 1 Intervention
Visit 2 Check progress
Aware of media portrayals of smoking
Next intervention
No progress
Repeat first intervention with added examples
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Our community worker can start raising additional questions, on subsequent visits. The idea of raising an issue is to follow it up on a subsequent visit. These visits do not have to be specially undertaken to work on the tobacco issue. Just a question or two can be raised in the course of visits for any other purpose. Once awareness is created about the image that the media project or create about smoking, we can take the process of understanding and discovery one step further. Again raising new questions, such as the following, will be relevant. ! How can we make sure that these outside influences do not induce more young people to see smoking positively (through programmes in the media such as television)? Since young people should take the lead in counteracting these influences, how can we get young people to see how their opinions are influenced by these depictions on TV, for instance? How can we make sure that young people in our community are not induced to see smoking as something special, tough or attractive because of these media depictions? Can we address the media people who show smoking in these attractive ways? Can we get them to try depicting smoking differently - for example, as a sign of insecurity or of being gullible (or easy to trick)?
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If our community is very isolated and without access to electricity or newspapers we shall have to keep our questions relevant to the realities in our community. But such communities are now rare. The intention of raising these new questions is to make the earlier understanding more secure. It also helps to generate a desire to do something to protect the people in our community from these previously unnoticed tobacco promotions.
PROGRESS REVIEW Are people in our community more strongly aware of hidden ways in which tobacco is promoted? Have they also begun to feel unhappy about this? Are they likely to be more resistant to these kinds of promotions? Do they now recognize examples of how our opinions on issues other than tobacco can be manipulated in the same way? Is there no real increase in the concern that the community feels about hidden promotions of tobacco? Is this because they don't understand how these media depictions can create a climate that encourages people, especially young people, to smoke? 28
Shall we go over the reasons why the spread of tobacco should be a cause for concern? Let us see what steps can be taken to awaken a feeling of concern, and try them out until we see a response.
Are people aware of hidden ways of tobacco promotion? There are other ways too, in addition to how smoking is shown on television programmes or films, which can influence its image among people in our community. We are concentrating here on influences that come from outside our community. Other examples are as follows: seeing popular figures such as singers and film stars being shown flaunting a cigarette, photographs in popular magazines, periodicals and newspapers, and statements or quotations about tobacco. Another set of influences is the direct and indirect advertising and promotion that the tobacco trade does, to make its products look sophisticated, glamorous or positively linked with sexuality and with adventure, novelty, excitement or physical prowess. So there are many other themes too, to which we should gradually sensitize members of the community. They should become increasingly aware of the forces from outside that set the mood, to induce people in our community to start smoking. Just as we did about depictions of tobacco in the mass media, we can create increasing understanding among people about these other factors too. Our community worker may ask whether people have seen pictures in newspapers and other publications where popular persons are shown with cigarettes in their hands. Similarly, he can ask about the advertisements and sponsorships of sports events that they notice. Is the community aware of the fact that linking smoking to sports gives it a positive image? Do people in our community know that the tobacco trade does a lot of things to build up such positive associations? We can raise issues relevant to such direct promotions of tobacco by the tobacco trade. ! ! What does the tobacco trade do to make people feel like smoking? What are the themes that the industry tries to promote, in its advertising? 29
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When there are pictures in tobacco advertisements, whom to they mostly show? Where open advertising of tobacco is not permitted, what does the tobacco trade do to create a positive image of smoking? What is the likely result when the tobacco trade itself starts a campaign, for instance, that smoking is ‘only for those over 18’? What does the tobacco trade do to make the harm from tobacco appear trivial? What do they do to make people who want to reduce the spread of tobacco appear moralistic and against fun?
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As our community worker progresses, the level of understanding of the community, including that of the youth, will increase. They will become increasingly sensitive to the less obvious factors that come from outside, which induce all of us to see tobacco use or cigarette smoking positively (or at least, less negatively).
PROGRESS REVIEW Have people become more sensitive to the wide range of influences that contribute to a positive image of smoking? Will they recognize a new form of promotion that is launched in the future, even if we do not point it out to them? Or, are people still mostly ignorant of the range of influences that are responsible for creating a positive image of smoking? A positive image of smoking is the one that induces young people to take up the habit. If people still do not recognize these influences shall we show them practical examples? We can ask about examples that were noticed in the last few weeks.
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Visit 2 Check progress
Sensitive to influences that contribute to a positive image of smoking
Next intervention
Get through different influences Ignorant of influences Discuss practical examples
Encourage them to look for further examples
There are also influences from outside which create, or attempt to create, a negative image of tobacco. Most of these, in our countries, are aimed at 'creating awareness about the harm' of smoking. Our worker can raise these issues too. ! What is the influence on young people of messages explaining the harm from tobacco? Are there other things, to which some young people give more priority, than the potential hazards of their actions? How may wrongly conveyed messages about the dangers of smoking serve even to enhance its attractiveness to some young people? What kind of young person is likely to be discouraged from smoking through knowledge about its dangers? What kind of young person is likely to be unconcerned about harm, or even to see the risk of harm as an added incentive to smoke? How can we make sure that messages about the harm from tobacco do not have an unexpected positive or attractive effect on some young people? 31
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What are the things that we can convey, so as to make even the more foolhardy or careless young people feel less interested in smoking?
The intention here is to make people in our community understand that even messages about harm from tobacco can make it attractive to some young people. This does not mean that we must not explain the dangers. But we must take care not to do it in a way that even a few young people don't see the danger as a challenge. Ideas about harm should be put across whilst also creating a mood of devaluing tobacco use rather than making it look some grand and `risky' thing to do. Pause briefly to see whether people in our community have realized this potential risk, especially when they try to create fear. To create genuine concern or fear about risks that occur many years later is not easy. To create such a fear among the less intelligent or foolhardy youth is even more difficult if not impossible.
INFLUENCES FROM WITHIN OUR COMMUNITY Let us now look more at the influences from within our own community that serve to make tobacco use look either more attractive or less attractive. These are easier to spot than the forces from outside, because we can see the people amongst us who are responsible for creating these perceptions. One factor which is responsible for making more young people take up smoking is whether they see it as attractive, fashionable and a challenge. There is another local factor, which does not depend on increasing the attractiveness of smoking, to make people take it up. This is the use of personal influence to make someone smoke even if he does not particularly want to. In most groups there are people who like to push others to behave in a way that they want. Some of these people already smoke. And because it is their habit to force others too to do the things that they do, they put pressure on non-smokers to smoke at least once with them. In this process people are made to start smoking irrespective of whether they like it or not. And these people smoke just to avoid the trouble of refusing a loud or pushy person. Sometimes it is just to avoid a negative comment from such people that someone smokes. This tendency for a few loud and dominant persons to push others into using a substance is seen even more strongly with alcohol. We can raise these issues too with our community.
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The community includes:
Smokers
and
Non Smokers
Those who are vulnerable
and
Those who are not
Those who care
and
Those who don’t
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Are there people in our village or community who can influence others to smoke? How do they influence others to start smoking? Why do these people have more influence than someone who would want to stop people smoking? What do we do when we too are confronted by such people? What are the arguments that they use to make tobacco use appear ‘the done thing’? What are the kinds of comments these people use to make non-smokers appear weaklings?
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So far we have given examples of things that are worth raising with our community. We shall expand on this further in section 6.3
PROGRESS REVIEW The expected result of these questions is that people will become more vigilant about how certain influences within our community operate. We can check this out briefly, but the issue is dealt with in more detail in section 6.3 The entire content of this chapter is directed to making people more sensitive to a set of issues that they had not carefully thought about previously. When people learn to recognize how they are being influenced they may feel like taking action to protect themselves from these. And this feeling should extend to include all members of the community - especially those that the tobacco trade now finds easy to fool, trick or seduce. To judge whether we have been successful we need to see if people in our community have begun to realize the ways in which they are targeted through different routes. The targeting is to create among them a mood that favours the spread of tobacco. Smoking is only one form of tobacco use, but it is the form in which it is most popularized. Other forms of tobacco use are harmful too, and we should not forget these. But in preventive work, the most highly popularized form needs to be countered with the greatest vigour. We must examine whether there is a change in perception within our community while we are in the process of changing it, not later. The ‘progress review’ sections in the text are intended to draw attention to this. Checking on whether there has been some impact is part of the activity itself. Let us pause for a moment here to see what this entire section (6.1) had to say. And then we can look at the communities to see how much of this has reached them. 34
ASSESSING IMPACT Let’s see how successful we have been. If we are successful there should be an increased understanding within our community of some major influences that create a mood that promotes initiation of smoking. There should also be a feeling or wish to see how these influences can be prevented or counteracted. Ideally, a process should have started in the community to keep track of present and new developments in tobacco promotions, and then to respond appropriately. One simple way of checking whether the people in our community are becoming more perceptive is to ask a selected number of people a few questions at the start. This can be about their awareness of the various obvious and less obvious ways in which people are made to feel like using tobacco. If they are asked the same questions a few months later, and they show much greater understanding about the way these influences are at work in our community, then we know that the community has become more sensitive to this issue. We can also see if they are now unhappy about these influences and want to protect their community, especially the young people, from these forces. If things have progressed even better, there will be signs that people want to take active steps to counteract or prevent these influences. Measuring the response of the community is another way of assessing the outcome of our efforts. If people show more concern, that is a sign that the community has gone beyond just becoming sensitive to the problem. They do not necessarily have to form ‘organizations’ and formal ‘action committees’. Existing or ‘natural’ groups are far more likely to persist with an activity. Even an enlightened family can be an ‘organization’ that takes up the task of protecting the community from tobacco promotions.
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ASSESSING IMPACT
How many people generally understand the influences that promote smoking
Number strongly aware
Number unhappy about promotion of smoking
Number resistant to these
“Groups” (formal and informal) that have become active
Effectiveness of attempts made to counteract these influences
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Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
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6.2 Do all we can to influence the external and internal environment towards being good for our community. If we find that insertions in the media and the way smoking is shown in dramas and films and on television is likely to induce people to see it as attractive, what can we do? There are many things that are possible. What is actually done depends upon the interest and level of enthusiasm in our community. The community worker can raise questions that could awaken an interest, as follows. ! If certain magazines regularly carry pictures depicting popular film stars smoking in a very attractive way, what can we do to prevent this influence? Can we as a small community influence the way smoking is shown in foreign and national films or TV shows? If we create a strong opinion in a few other communities too, will that lead to people in the media taking more notice of our comments? Or, are we completely helpless if the media aggressively promote smoking? Can we stop the promotions of tobacco that is carried out through members of our own communities? Does the local shop or boutique that sells cigarettes have to put up posters and pictures advertising cigarettes? How can we persuade people who sell tobacco in our communities to avoid promoting it to people, and only just sell to customers who ask? Can we show people who promote slogans to show tobacco smoking as an 'adults only' behaviour, that it can be an added attraction for some young people? Should we monitor those newspapers and magazines that are most active in promoting smoking, and write or speak to the publishers about the harm they are doing to our community? Is there anything we can do to persuade film and television directors, producers and actors and actresses to be careful about how they show tobacco smoking in their productions?
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As with the first task, we need to see if people in our community will be induced to take some action to reduce the harm that is coming to the community from these 38
outside sources. The progress in this task is more difficult than in the other aspects in this section on prevention, because we have to address powerful or well known people outside our community too, who are not likely to pay any attention to what we say. We will not find it easy to motivate ourselves to write to, or telephone, a well-known film director saying that his productions are a harmful influence on the youth in our village. We may feel it is a waste of time, or that we will become unpopular as a result. How much action the community takes will depend on the spirit of that particular community. But the experience in settings where communities have started addressing these powerful agents outside the community is that many of them are responsive, because they too have some feeling for their country or people. Not all those who are addressed will respond positively, but some do. Another difficulty in this regard is that we have no way of assessing the impact our action has created on a well-known TV personality, for instance. They may not reply us, but still be influenced to change things at least a little. If we are really interested we can monitor the productions of such a personality, to see if things become better. But it is not a very good way to assess improvement because there is a long lag period before a production being made today is finally released to the public. There is another important reason for addressing people outside our community who deliberately or unthinkingly promote tobacco to our youth. And that is that we all grow as a community, through such efforts. Famous and powerful people in the media are mostly controlled by those with money. They may take no notice of what people from a small community say to them. But we learn an important lesson. And that is that we should try to counteract even what very powerful and influential people to do harm us. By taking steps to address those who try to persuade our people to smoke, we may create a small change that benefits a much wider population. Should that fail, we still benefit as a community. When we all want to do something about a harmful influence, it makes us more vigilant to such influences. So there is the benefit that people in our community at least, will be `immunized' against such promotions of tobacco.
Immunize against tobacco promotion 39
Targeting children
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PROGRESS REVIEW Let us quickly check whether there is a `resistance' to these outside promotions of tobacco that are reaching our community mainly through the mass media. Let's ask, or try to verify is some other way, whether any member of our community has tried to address those who are responsible for showing highly promotive tobacco scenes on, say, television. If even one person, family or group from our community has done so, that is a sign of remarkable progress. We should see how we can get them to share this news with others. Will others see them as a good example? Or will they be seen in a negative way? There is further work to be done in this regard. If nobody has taken any steps to address these outside elements, what shall we do? We can keep the issue on our agenda, and raise it on future occasions too. Let's recognize the fact that we as a community are being targeted and that we don't feel that we have any control over this. Or, that we as a community have not yet felt that it deserves a response. Recognition of this may prompt a response on a later day. It is easier to detect changes in the influences that previously promoted smoking within our own community. ! Who are the people that we identify as strong promoters of smoking within our community? Can they be helped to see the harmful influence they have on the community? Should they not reconsider whether it is a good thing or not to make others take up this habit?
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If these people begin to see that they have so far been providing free promotions for the tobacco trade, they will be able to understand better the harmful influence they have had on the community thus far. ! Should they feel happy or unhappy if a youth in our community starts to smoke tomorrow? Can they too feel part of the community rather than be more loyal to an industry that has made them addicted to a destructive habit? How can they change the way they behaved previously, so as to be an asset to our community even if they are not yet ready to quit smoking? 41
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PROGRESS REVIEW Have people become more sensitive to the way that some members of our own community too promote a positive image or attitude towards tobacco? Are those who previously promoted such an image or attitude now more sensitive to hat they had been doing? We wanted here only to remind people in passing that there are influences within the community too that we should address in this regard. We will take up practical examples in much greater detail in the next section.
ASSESSING IMPACT The primary aim of this chapter was to see whether a response of any kind could be awakened in our community regarding tobacco promotions. This response may be visible most strongly in the form of people directly addressing those responsible for directing such promotions at us. But even a feeling of unhappiness about the continual promotion of tobacco is a positive response. How shall we check whether there is some form of response in this way? The best way to find out may be to look for `anecdotes' or instances that show that people are now opposed to these promotions. The reaction may only be a comment that someone makes. But that too is important. If we don't live in that community we shall not find it easy to check whether people are beginning to feel unhappy about the promotion of positive images of tobacco to their community. We could perhaps ask those we meet about their own reactions now when they recognize subtle promotions of tobacco that are reaching the community through the media. Do they say something immediately to whoever is with them? Do they feel unhappy about the possible influence of such an instance on a 10-year-old child in their community? Have they sensed that others too are reacting in this way? We could even write down these observations, and compare with the situation that emerges in a few months from now. We should protest to the local council about this billboard
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Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
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6.3 Ensure that people understand how vulnerable members of the community are persuaded to take up smoking. To make our preventive efforts effective, we must understand the range of factors that have to be successfully counteracted. Some of these were discussed in section 7.1. All influences that serve to create among us a mood that is favorable to the spread of tobacco use have to be recognized and countered. Some of the attitudes and perceptions that make smoking an accepted or even positively rated activity are fostered among us deliberately. In addition to these deliberate promotions there are other influences and situations too, which occur within our community, that push non-users into starting to smoke. These too need to be perceived and counteracted if we are to succeed. Some of these influences are created by people who are not really interested in promoting smoking. Sometimes those who want to prevent smoking too can unwittingly do things that are helpful in making tobacco use appealing. But most importantly, we should look at the people in our community who take a lot of trouble to push others to start smoking and see how we can persuade them to stop doing this. This issue too can be raised in the same way as the other issues dealt with previously. But it is important to include people who smoke and those who promote smoking too in this round of discussions. Let us see what kinds of questions will be relevant to raise. Even those who are keen to prevent smoking should be sensitized to the risk that wrong ‘education’ could worsen the situation. ! What are the things that make smoking appear, especially to the young, as something that should be done? Do our own prohibitions sometimes have the effect of making the act of smoking a cigarette look special, adult or a sign of independence or rebellion? What precautions should we take to avoid creating this image?
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This is an issue that is dealt with easily with people who are already trying to prevent the spread of tobacco use. Because their objective too is genuinely to prevent tobacco use, they will be sensitive to the need to avoid the risk of inadvertently adding a symbolic value to smoking. We need to look for progress in understanding among the people who are supportive of tobacco prevention efforts. There are other people who are not particularly interested in preventing tobacco use, who too inadvertently add to the symbolic value of tobacco, but they are not so easy to reach or change. 44
PROGRESS REVIEW Have people recognized the possibility that too strong a line in prevention can make tobacco more attractive to some young persons? If not, we will need to keep occasionally referring to this risk through practical examples, until the idea has got through. We can, for example, point to a ‘rebellious’ boy in the village and ask how he’d feel about an attempt to prevent him buying cigarettes from the local trader. And the risk is worsened if so-called restriction of access to young people is only cosmetic or in name, with no real difficulty for them in physically obtaining tobacco. It is important to emphasize that we are not advocating easier and more abundant availability of tobacco. Recognition of the slight risk of making tobacco attractive, like ‘forbidden fruit’, is all that is needed. Attempts to restrict the easy availability of tobacco should always be done with care. Restriction of access should not unwittingly be made into a challenge for the daring or venturesome. We can proceed with the theme of addressing deliberate promotion of tobacco by people within our community. The following questions are relevant to direct to the ‘general population’ of our community, and especially to people who may still be smokers. ! Who are the people in our community, who directly persuade young people to try a cigarette? What are the methods they use to make a young person feel that trying a cigarette is something he should do? If a person trying a cigarette for the first time does not like the effect of it, does he usually try to hide the fact or not? Why would someone who does not like the effect of smoking his first cigarette feel that he should not let anybody know that he is uncomfortable smoking? What makes a young person take a second cigarette, even if he did not like the first one? Who are the people who most actively persuade a person in our community to try a cigarette and then to keep smoking even if he does not like the experience? If these people who make others smoke are not paid by the tobacco industry, why do they continue to persuade more young people to start smoking? 45
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From non smoker
to smoking the first cigarette
to smoking the second cigarette despite the first usually being an unpleasant experience
What are the influences that push someone through each of these stages?
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Can we explain to current smokers why they should actively prevent newcomers being recruited into their habit? How can we get the cooperation of current smokers to avoid persuading young people to start smoking? How can we identify the people in our community, who promote smoking among the young?
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This too, like our previous sets of questions, is a series of issues that can be raised over a period of time. If things are progressing there should be increasing awareness about people among us who spread the tobacco habit, without even being paid by the tobacco trade to do so.
PROGRESS REVIEW Are people beginning to recognize the ways in which newcomers usually young are being persuaded to take up smoking? Do they realize that this pressure has to be sustained so as to make the novice continue to smoke, even though he may find the initial experiences unpleasant? If there is inadequate progress we must, as before, keep repeating the theme until people begin to recognize the way in which newcomers are persuaded to start smoking by people in our own community. Having recognized the influences from within the community too, have people begun to react to them? If there is a general feeling of concern, that alone helps to reduce the local promotions. People who promote tobacco are doing so mostly out of ignorance of the harm they are doing. When they realize that there are at least a few people in the community who are unhappy about their actions, they tend to stop this habit. Concern about ‘local’ tobacco promotions should automatically result from the awareness of its occurrence. We can add to this process by raising a few relevant questions with people that we regularly meet. ! Who are the people who most strongly push others to experiment with tobacco? Are they doing so for a particular personal gain? Shall we gently explain to them that they should stop doing this from now on? Will they listen to us if we simply go up to them and ask them to stop? 47
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What are the better ways of persuading them to stop promoting tobacco to the local youth? What approach will best encourage them to listen to us? Through whom should we reach them? What is the best way to make them understand why they should not persuade others to take up tobacco use?
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PROGRESS REVIEW Are people who persuaded others to start smoking (usually a small group among those who still smoke) aware of the new feeling in the community? Do they realize that there are at least a few people in the community who will be unhappy if they learnt of attempts to recruit young people into the smoking habit? Is there awareness among those who were promoting tobacco that we want now to prevent new users being recruited from our community? If so how can we let these persons know about the community’s efforts? We can see whether simply addressing some current users directly will help. We can show them examples of changes in tobacco use in other settings. In any event we need to keep this group in mind, to address at all convenient opportunities.
People have changed
They don’t like it, when young people start smoking
Tobacco promoters aware of changing trends
People are discouraged from promoting smoking
Current users aware of changing trends
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We need next to see if the people who were responsible for inducing others to use tobacco are beginning to change. There are questions that are directly relevant to people who were in the habit of persuading others to start smoking. Our community health worker can ask these questions from them directly. If she is not close enough to these groups who now use tobacco, she can address them through others who are closer to them. Or she can work through just one or two current users with whom she can build up a link. Suggested questions follow. These are questions to be taken up by those who still smoke. ! ! ! Are some current tobacco users still persuading others to start smoking? How shall we help them to stop this practice? Are they continuing to promote smoking because they have some personal benefit from doing this? Shall we, as a group of people who still smoke, decide that we shall not induce anybody else in our community to start? How shall we get the cooperation of those among us who do not understand the need to do this?
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Once again, we need to pause at this stage to see if there is even a slight change.
PROGRESS REVIEW Is there indeed a change in our community, especially among those who still smoke, that we should not persuade young people to start smoking? Has it progressed to the point that anyone who does so will be seen as a harmful influence on our community? Is there little or no change? If so we need to go on with further efforts to reach people who are still smoking in our community. It will be useful if we can, for instance, show them how someone has recently tried to persuade a young person to experiment with a cigarette. We can then ask our group how such incidents can be prevented. There are people, other than current users, who promote tobacco due to ignorance. Others try to promote it because of their links with tobacco pushers from outside our community. They are sometimes offered payments or other rewards for doing so. At other times they do this simply out of habit, or just because of a personal friendship with someone engaged in promoting tobacco. Such persons within our community should be addressed. ! If people in our community are supporting the tobacco trade in promoting the 49
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uptake of smoking by young people, how can we influence them to stop doing so? Do they promote smoking because of some personal reward that the tobacco trade gives them? Or do they do so out or habit, or simply because they were asked by someone from the tobacco trade? How can we persuade them to take a stance in favour of protecting the young people in our community?
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PROGRESS REVIEW Are people who formerly promoted tobacco within our community, no longer pushing tobacco as readily as before? Are they more sensitive to the welfare of the youth of our community? If not, how shall we continue efforts to engage them? Perhaps we need to change altogether the approach that we used. Progress in this regard can be reviewed in the same way as before. At the end of this section it will be useful again to review the area covered as a whole. The objective here was to sensitize the community to the continual promotion of tobacco that is undertaken by a few people usually those who presently smoke. We hope that this will persuade people to try and minimize this happening.
Those who persuade young people to smoke are seen as a harmful influence 50
ASSESSING IMPACT If a few members of the community are better aware than before of these influences within our community, we should be able to elicit this fact. How should we find out? Just the impression of the community worker is one source of evidence. Does he feel that there is greater awareness about this in the community now? Does he feel that there is some feeling in the community that we should try to minimize or prevent this happening any more? Is there evidence that the promotion carried out by a few individuals has now I feel people are now become less? Even if there is no reduction in such more aware... attempts, are young people now more aware of, and resistant to, the people who promote tobacco use? Progress can be more validly assessed by using other sources of information too. If there are people in the community who will systematically look at evidence of progress we can teach them to ask a few people several key questions about the subject and them to check in a few months whether there is a change. It is not essential that there is progress on this subject to take up issues in another chapter. Progress on each of the areas can proceed concurrently. But we need to keep track of progress on different issues that we raise.
51
Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
52
6.4 Enable members of the community to understand how they can counteract influences that promote tobacco use. The emphasis in the previous four chapters was on raising certain issues and generating awareness and concern within the community about what is being done to it. We did suggest various things that people could do in response, but that too was mainly to consolidate the feeling that they needed to respond. The primary aim was to raise consciousness and concern. In this chapter we go more into detail about practical responses to prevent the spread of tobacco use. When we keep gently raising the right questions for some time people begin to understand how some individuals are gradually led into starting the habit of smoking. They will begin to see that there are many factors contributing to this process, operating from outside and inside our community. It is not as if tobacco is something that magically gets attached to people. Smokers have been taken along, through a gradual process of conversion, until they need tobacco to feel good or just to feel comfortable. Even though the effect of the first few cigarettes is unpleasant for most, they are persuaded to ignore their own experience and to continue use. Eventually they too begin to rely on the cigarette to feel good. The fact that a lot of work has to be done by others to make a person keep smoking, until they reach this stage, is often forgotten. Even when people have started to take a cigarette occasionally without direct outside persuasion, they don't all enjoy it. Most of the alleged enjoyment begins after a person becomes habituated or addicted after which he needs nicotine (from tobacco) to feel relaxed or comfortable. So a good deal of ‘preventive’ work is possible even with the occasional smokers, because they really aren't smoking in the same way as regular smokers. Approaches relevant to regular smokers are discussed later (in Chapter 7). Good prevention work will not stop at just warning people that smoking is bad for health. It will set out to counteract the influences that promote the uptake of smoking by people in the community. Again, the guidance on what should be done is set out in the form of questions that can be raised with members of the community. ! Can we recall the factors that promote the uptake of smoking by people in our community? (We identified these in sections 6.1 and 6.3) Which of these do we think are most important to counteract in our community?
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These are really preliminary questions. We can raise these with any persons in the community who we think will take an interest in working for a change. We can try to engage different groups from within the same community. Even one individual or 53
family that shows an interest in working to improve the lives of people in community is worth engaging.
that
And different individuals, families and groups will take up different issues as their priority. For the purposes of this manual, we can analyze and work through one example. That should serve as a basis for working on other issues. But the issue taken up as an example with any given group should be what that particular group chooses. Of the several factors we think are important to counteract, let us then take one as example. The same procedure can be applied to any other subject that is chosen. The example taken up here is the image created in the minds of young people that it is attractive or sophisticated (`cool') to smoke. If we think that this is an important contributor to young people starting to smoke, or experimenting with tobacco, how shall we try to reverse it? ! How many people have fallen for the campaign of the tobacco trade to make people see smoking as attractive? How many people in our community already recognize the effect on all of us, when we see popular or glamorous people smoking on television or in films? Does anybody in our community now point out to others how these scenes create a very positive image of smoking? How can we increase the number of people who recognize these kinds of 'unnoticed' ways in which smoking is made to look good - especially in the eyes of young people? Can we address the people who make these television shows and films to request them to stop such promotive or positive portrayals of smoking? Would it not be best if the young people, who are the most vulnerable to this kind of promotion, took up the task of addressing those who make such films?
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These are reminders of the content that were covered in section 6.1. To progress beyond the stage reached in that chapter we will need to make people see the process of changing attitudes and perceptions. A convenient starting point is how we see things. We can start looking at how we ourselves see tobacco, and examine whether it can be changed further in the right direction. ! Can we not examine our own perceptions about how attractive or unattractive 54
smoking looks? ! For example, do any of us see the act of lighting up a cigarette and inhaling the smoke as a rather an ugly, odd or peculiar sight? If there is nobody in our community who sees it that way yet, how can we help at least a few people to start seeing it this way?
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John’s Story
John works as an executive in a tobacco company.
At the start of his career he worked hard to promote smoking. He argued against those who were unhappy about tobacco advertising, and he made a joke out of medical reports of death caused by tobacco.
Now when John sees young people smoking it makes him uneasy.
What made John change?
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PROGRESS REVIEW Have I too begun to examine my perception of the act of smoking? Having come to examine it carefully has my perception changed? If I had previously not seen it as unattractive or stupid looking, do i see it that way now? On the other hand I may not have changed, even after looking at things carefully. If I still see smoking as even slightly attractive, I can examine more carefully how that perception is influenced.
I have changed....
I too may still be influenced by the numerous ‘unnoticed’ images that link smoking to g l a m o u r, n o v e l t y a n d ‘ a c t i o n ’ . T h e s e associations, once built up, tend to remain even if we don’t particularly approve of smoking.
I have not changed....
So I need to see how I react when an attractive person lights up a cigarette. Do I still see the smoking as attractive by association with the person’s looks? Or do I now see the person’s attractiveness separately from the act of smoking a cigarette? In fact, with time we should begin to see people’s attractiveness diminished the moment they light up a cigarette.
So here is a suggestion that we can try on ourselves. We may not have previously seen smoking as particularly ugly or silly looking. But it is possible to change our perception in that direction. If we do succeed in changing how we see the act of smoking we can disseminate that within our community too. Let us proceed with spreading the new 'view' of how smoking looks. Again, questions that may be useful are suggested. ! Can those who see smoking as ugly and silly show that this is how they see smoking now? What happens to people who smoked in a way that looked very 'posh' and pompous, when they see that there are now people in the community who think they look rather old-fashioned or comic? Can we get smokers too to see their own habit as rather brainless and the subject of amusement for some? Can we get smokers too to openly admit that they are continuing to smoke because of habit, and that they too see the habit as a burden? 57
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Can we address popular actors and actresses to point out how they are used to make smoking look glamorous by unnecessary smoking scenes being included in films or other shows?
These are just a sample set of ideas that can be shared with our community, whenever appropriate. We have kept to the theme of addressing the attractiveness or unattractiveness of smoking, as seen by our community. We can think of many other similar issues to raise in line with the factors that we identified in the previous section. The intent in addressing people outside the community who promote a positive image of smoking is not simply to stop them from doing so. Even if they continue to promote tobacco, our community is protected at least slightly, because we have started to take some action. The activity itself is good for the community to develop increasing understanding (and displeasure) about the way tobacco is pushed. And the effect of this is mostly on young people in our community. If it helps to curtail the underhand promotion of tobacco through the media, that will be an added bonus.
PROGRESS REVIEW Let us see what progress has been made in changing the perception of smoking, or other use of tobacco, as a result of what we've done so far. Have others in our community too begun to see the act of smoking as more repugnant and repellent than before, just as we have? We may notice that people in our community now tend to feel amused at some smoking behaviours. For example, when some less informed smokers proudly display their smoking in the ridiculous belief that it looks impressive. Or, is there no change yet in the way most people see smoking? If so, we need to go back to the things that we looked at, in ourselves, at the beginning. Our perception of smoking changed in the direction of seeing it as less pleasing because we looked at it critically. We need to see how this can be better shared among others in the community.
Change in the perception
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We can, for example, see whether children in our community find it amusing when anyone lights up a cigarette. Children and young people tend to take up a challenge faster than adults do. So their change may be a more sensitive indicator of progress. And when children start to see things in this new way, others too may begin to see that the act is indeed ludicrous. It was a child who helped others to see the reality of ‘the emperor’s new clothes’.
This task is difficult because we are looking at something very subtle. How can we determine whether people now see smoking as more unsightly and inelegant than before? The intervention is rather vague and difficult to implement. And the measurement of it is even harder. But it is worth continuing to look for subtle signs of a change. We can at the same time deal with other topics in this manual. Creating the accurate perception of smoking is though a crucial element of successful prevention work.
Ha ha you look funny
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John’s Story
continued
What made John change?
One of John’s school mates who is a doctor persisted in talking to John about the damage caused by tobacco. He would describe about patients who had died of heart attacks due to smoking and the devastation faced by the person’s young children. Or he would describe the suffering of someone who has had his leg amputated due to disease of the blood vessels caused by smoking.
Then John’s favourite uncle developed cancer of the lung which doctors attributed to smoking.
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We took up 'how the community sees smoking' as the example here, but we need eventually take up the other factors too that make people start, and continue, to smoke. These include persuasion by current users, the expectation that tobacco gives pleasure, the idea that it is a sign of sophistication or 'adulthood', and so on. We shall briefly take as an added example how to influence what the tobacco trade does to promote smoking. The questions to be raised with the community are suggested below. ! Can we not address those working within the tobacco trade to see how they too can discourage the promotion of tobacco, without necessarily leaving their jobs? What is the likely reaction of a person working in the tobacco trade when he or she sees a young person smoking? Are all of them likely to be pleased that a new young customer has been recruited? Could not there be at least a few people working for the tobacco trade, who don't feel happy when they see a young person smoking? If the majority is likely to feel happy that a young person has started to smoke, what is the reason for their feeling this way? Do they have to feel happy that a new customer has been found, or just show that they are happy? Is it not possible that there are quite a few people earning a living from a tobacco job, who do not feel good about their trade? Who are the people working in the tobacco trade who are likely to feel like doing something to minimize the promotion of smoking - those from our own country or those from outside? How can we help 'foreign' people promoting tobacco in our country and our communities, to develop some feeling for our people too?
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We should, as earlier, try to set down a few indicators by which to judge whether things are beginning to move in the right direction in our community.
PROGRESS REVIEW This is one of the more difficult areas in which to analyze progress. People in the tobacco trade, especially those who work for the larger tobacco companies, are often made to feel that their trade is not different from any other legitimate industry. They 61
are given the idea that some 'health fanatics' or extremists are unfairly targeting their good industry. So they would not want to show links with anyone who is trying to reduce the harm that tobacco causes. Thus it is difficult to assess whether all our attempts to persuade people working to promote tobacco are reaching them. We have to be creative in assessing the progress. The general principle is to Has John changed? keep some form of informal contact with the more enlightened persons in the tobacco trade. If we keep contact with some apparently good people within the trade, we can assess progress too through this channel. We must take care to ensure that the persons that we are in contact with are genuinely good hearted and interested in changing the ethos within the industry. There is the obvious risk that the person is not at all genuine in wanting to help.
ASSESSING IMPACT Let's check whether our community has made progress on the subject addressed in this section. Have we become more active in counteracting the positive image of tobacco that is deliberately as well as inadvertently fostered? The level of concern or interest within the community is an important way of measuring what to expect. If there is no interest whatever, there is unlikely to be a helpful change in the public's perception of tobacco use. After an interest is awakened within the community people may begin to take practical steps. Interest in doing something must be accompanied by knowledge of what is helpful. We can assess both of these. We need to take note of even the smallest action that is taken by the community to change the image of tobacco. Finally we can start recording any anecdotes that indicate a change in the community's perception of tobacco use. If there is evidence of more sustained or encouraging signs of progress within the community, we can look for wider impacts. A difference in the way the majority now looks at tobacco use, especially smoking, is an example. Changes in attitudes among people working within the tobacco industry is another.
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People have changed
People are more sensitive to positive promotions of tobacco
People are discouraged from promoting smoking
Former supporters of the tobacco trade no longer push tobacco
Tobacco promoters aware of changing trends
Smokers do not persuade the young to smoke
Current users aware of changing trends
Addressing those responsible for promoting tobacco on television
Others in the community see it as a positive action
People who attempt to persuade young persons to smoke are seen as a harmful influence in the community
63
Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
64
6.5. Help everybody to understand why they should counteract these influences, and encourage them to take all action that they can. If more people in our community start to smoke, why should this be a cause for concern? For us to feel like doing something to prevent the spread of tobacco use, there needs to be good enough reason. Although the process that we are describing here does not require too much effort to launch, there still needs to be enough reason to want to do it. A brief account of the harm that is caused by tobacco is given in the introductory chapter of this manual (Chapter 1). Justification for spending energy to prevent the spread of tobacco use is not really needed any more. It is generally well known that tobacco causes a huge amount of harm. And the level of harm that people are generally aware of is enough to justify extensive preventive efforts. But very few people recognize the real size of this harm. For instance few people know that about half of all smokers die of a tobacco related cause, or that it is considered the single most important cause of preventable death. And the diseases caused by tobacco not only lead to premature death but also carry a severe burden of physical suffering. And of those who die of tobacco related causes about half die in middle age, so resulting in major impact on still dependent families. Because people who die of tobacco related causes don't fall down dead as they light a cigarette, the cause is not readily noticed. This is why people who work for the tobacco trade are able to convince themselves that they are not responsible for so many deaths. For the same reason they try to convince the public too that the harm from tobacco is not really confirmed. So people are led to believe that the reports of harm are really due to an unnecessary fuss created by health agencies to get attention or to get funds to do prevention work. We can help our community to see through this kind of superficial deceptions. Again we can initiate discussion. ! ! Have you heard about the extent of harm that tobacco causes? Is it really no different from that caused by motor car exhausts fumes or eating unhealthy food? How have some people come to the conclusion that the harm from tobacco is trivial? Do people in our community know how much the tobacco trade is paying the states in the USA, as compensation for treating tobacco related illnesses? How is it that in our countries, there still seems to be 'controversy' about whether tobacco causes a significant number of deaths? 65
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How many of us recognize that tobacco is estimated to cause more deaths than AIDS, tuberculosis, maternal mortality, motor vehicle accidents, suicide, and homicide combined ? Is it not incredible that so little effort goes into reducing tobacco-related deaths, in spite of this horrifying scale of harm?
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PROGRESS REVIEW All of the information that we are communicating in the form of questions above takes a few visits to get through. It is not difficult to put these ideas across. But is there more concern about tobacco related harm or is there not? These can be checked out before we move on to the next topic. One reason that the real harm is not noticed is that there is a constant stream of propaganda aimed at making it look trivial. This we have referred to already. A joking line such as, 'It has been found that all smokers die.' is enough to keep smokers laughingly smoking a little longer. This strategy is complemented by familiar 'trick' arguments. A common technique is simply to point out to someone who is quite old and apparently healthy despite smoking for many years. Since everybody who smokes doesn't die young there have to be a few survivors. Such survivors are readily visible and are seen still smoking. Those who have died of tobacco are safely out of sight and often out of mind too. So the impression is easily created that smokers are doing pretty well. This is because all those don't do well die and disappear! Sometimes we take no notice, or preventive action, because we think that smokers are to blame for bringing trouble upon themselves. This issue should be addressed, as follows. ! Do we take little notice about tobacco related harm because we think that smokers are to be blamed for smoking, and that it is their own responsibility that they have to suffer these illnesses? Have we failed to realize that they had, at a very young age, been seduced into smoking?
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People tend to ignore things that they feel are beyond their control. So one reason for lack of interest about tobacco related harm may be the feeling that there is nothing we can do about it. This issue is addressed in the next set of questions. ! Who is responsible for creating the idea that we should do nothing active to stop the continued recruitment of newcomers into smoking? Have we too been made to feel that nothing effective can be done to reduce tobacco use? 66
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If people drop dead the moment they light up a cigarette...
If one out of every two people drop dead the moment they light up a cigarette...
yet 50% of smokers will die of a tobacco related illness 67
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Do people in our community feel that those who are concerned about tobacco related harm are creating an unnecessary fuss about a small issue? How are such impressions created and propagated? Should we allow more and more victims to be so seduced from a very young age onwards, or start doing something now to reduce the recruitment into smoking? If we think of doing something to stop more people being recruited into smoking, are some people in our community likely to be critical of us? Is it simpler to do nothing and allow the continued harm to people in our own community than to try to do something to protect them? Can we think of the things that we can do usefully, without being seen as interfering or trying to gain personal publicity or popularity? Should we not address the common tendency to criticize or condemn any attempt to do something for the public good?
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One step in creating concern is to help people to do something about the problem. If we simply become aware and do nothing, there is little concern built up. For concern to grow, we need to start taking some action. Let's therefore bring up again the subject of taking action. ! Shall we look again at items listed in the previous section (6.4 - on counteracting the influences leading to smoking), and see which of these we can start doing without any special effort or organization? Have we taken any action to do even a simple thing to reduce the artfully crafted allure of tobacco? If not what are the likely reasons?
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John’s Story
continued
What could John change?
John has no intentions of resigning his job. He has worked hard to get to his position. The company pays him well. John’s friend once made a chance remark which John could never quite forget. “You know, if you use the opportunities you have, you can probably save far more lives while working within the tobacco industry than I can as a doctor”. What seemed like a crazy idea at first began slowly to make sense. He began to feel uneasy whenever he saw a young person smoke. This gradually led to reluctance to implement some of the promotion strategies of the trade. He became sensitive to subtle strategies used by the tobacco trade to make smoking appear attractive to young people. The company kept saying that the target was adults and their strategy was only aimed at switching brands. He began to realize that the real intention was different to what the company was “officially” saying. When John is obliged to carry out promotions to induce young people to smoke, privately he carries out activities to undermine it. He waters down the various ‘informal’ promotions that are carried out by the company. John has realized that his living standards will not come down even if he does not recruit a single new customer. He is only carrying out in private what the company professes in publicpreventing the young from starting to smoke.
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PROGRESS REVIEW Let's see if there is some increase in the knowledge and awareness of harm that the community now possesses. Shall we look around for chance comments? We can also ask a few people deliberately. And if there is increased awareness we can also see if there is increased concern too. Are people a little unhappy about what is happening to their community? Or are they still unconcerned, even if they may be a little more aware? ! ! Do we want somebody else to organize us and make us move? Shall we see what each of us can do, without any special effort, to counteract the way in which tobacco (especially smoking) is glamorized? Shall three or four of us, who meet regularly anyway, check out things that each of us has done? Can each of us look at flamboyant displays of smoking with some disdain, so that others too realize that these displays are foolish? Can we not as a family take action to reduce tobacco promotions? Can we, for example, talk to the local trader who displays prominent tobacco promotions in his shop? How shall we respond if he initially dismisses what we say?
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These are mere examples of small things that an individual, a few individuals, or a family can start to do. It gets them on an active track. And getting on an active track on any subject makes life more interesting. In this case it also helps to save a few lives of people in our community. It prevents people getting stuck in a habit that impairs their enjoyment of life. And it saves a considerable amount of money that can then be spent on really enjoyable things.
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John’s Story
continued
What could John change?
His next plan is to see if a benevolent culture can be built among others working with him. This means building up support among his work mates. It means sharing the idea that ‘we must prevent young people from smoking’. If this displeased the higher ups then it would show everyone the nature of the trade they work for. They would then have to work out creative means for protecting the public. If the higher ups agreed, John could actively carry out activities that would genuinely prevent young people in his country from smoking.
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ASSESSING IMPACT The expected result of activities outlined in this section is that the community will begin to recognize the numerous ways in which tobacco harms them. The ideal impact is that the community gets onto a track where it actively learns to seek information about the extent of harm done by tobacco. The process should then be a continuous one of increasing awareness, from which we all learn. Has this process begun? If it has we should expect that those who are more aware will start informing and engaging those who are less aware. This trend should specially engage the smokers who are the members of our community who most need to respond to the information about the harmfulness of tobacco.
Look around for chance comments
ask a few people deliberately
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Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
73
6.6 Examining, from the start, whether the atmosphere is changing in the right direction. If our prevention work is succeeding, there should be a gradual shift in the way tobacco and tobacco smoking is seen in the community. The atmosphere should change towards one that doesn't encourage a new person to make the effort to learn how to smoke. So we should look for a shift in the way that smoking is seen. ! Are people who are concerned about the welfare of the community increasingly committed to reducing the amount of tobacco used in our community? Is everybody beginning to recognize the different ways in which the tobacco trade makes smoking look attractive? Do people see how they can counteract these influences? Are more people beginning to see the act of smoking as ridiculous and even somewhat repulsive? Do people see the act of smoking as rather brainless too? When people try to smoke in a showy or flamboyant way, do people in our community see it as an attempt to cover up a sense of insecurity? Are people, especially the young, sensitive to the ways in which films and shows on television serve to promote a positive image of smoking? Do they try to ensure that even their least intelligent friends will not be taken in by these portrayals?
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PROGRESS REVIEW These questions are intended to verify whether there is a change in how tobacco promotions are handled by the community. All of these are things that we expect to see being affected early. We should not wait until some action is over to check the results. In many formal 'interventions' there is an assessment at the beginning and one at the end, with some reviews in between. Our work with the community to which we belong is not like this. We have no fixed date to start 'a programme' or to end it. Things have to go on daily, everyday. So our way of evaluating impact has to be different. We need to work out a way for constantly looking at things in our community. And any improvement, or lack of adequate improvement, must also be noticed as we go along. 74
Our programme is not a formal ‘intervention’. It goes on everyday. Therefore evaluation has to be continuous too. We must look for early changes first. Is there success in making more people see tobacco use as inelegant and unrefined? Are people becoming more aware of the tricks and strategies that are used to make young people see it as fashionable? And is this number increasing? In any community some people will be easier to trick than others. They are the ones who will most easily be taken in by actions of the tobacco trade to make smoking look fashionable, strong, stylish and a sign of sophistication. We need to see whether even this group, which is the most gullible or easy to seduce, is also beginning to recognize how they are being manipulated. So our review of progress has to be a continuous assessment to see whether these less informed members of our community are also beginning to see things more clearly. There should be a continuous increase in the depth of understanding. There should also be a continuous increase in the number of people who begin to recognize how they are being taken in. We must remember that a particular group in any community often gets left out of our reach. They do not readily talk to people like our health worker. Some special effort and attention is needed to keep checking whether we have missed a particular group in our community. If so we have to think of ways to reach them, even if it has to be done gradually. 75
Those in our community who promote smoking or tobacco use must also be reached. Most of these are people who still smoke. This group is often missed in 'prevention' work. They are only addressed in efforts at 'cessation' or stopping use. It is worth focusing some specific attention on them. ! Are the people who previously encouraged others to smoke not doing so any longer? Are people who still smoke happy to discourage others from starting to smoke?
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PROGRESS REVIEW If present smokers are beginning to realize that they too should behave in a way that will discourage young people from starting to smoke, that is a sign of great progress. We need to reach out to those who still smoke, to see if they can be helped to understand why they should prevent the spread of tobacco use. They too are members of our community. For present smokers to join in the prevention effort, we need to keep open a dialogue with them. If we see no change of mood in some groups of people who are still smoking this is a sign that we have not done enough to reach and engage them. So we can continue to reach out to them until some impact is seen. There are longer-term indicators that too can be monitored, such as the number of people who have quit or reduced consumption, or the quantum of tobacco sales in our community. These are discussed later, in section 6.9 . Whilst longer term or final outcomes are to be discussed in detail later, let us just ask a question or two here, so as to get this idea across to our community. ! Have we succeeded in creating an atmosphere that discourages initiation of tobacco use? Is there any visible change in the tendency for young people in the community starting to smoke? Compared to an year ago, have less young people started to use tobacco this year? Should we keep a count among, say, students of a particular age groupso as to keep comparing the situation annually?
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The example used here was that of reducing the perceived attractiveness of tobacco in our community. There were other aspects dealt with in the first four sections of this chapter. (pages 38 to 88) We can add to these examples other things that we could monitor on a regular basis, to keep track of progress. 76
ASSESSING IMPACT The final result of our preventive action should be that, from now on, nobody from our community will start to use tobacco. In our examination of early results we want to see whether the atmosphere which leads to reduced initiation is getting established. If we check only the number of people who are starting to use tobacco, we shall have to wait for a long time to see that result. Should the result be unsatisfactory our corrective action comes rather late. If instead we keep checking whether the earliest changes that lead to a reduction in initiation have occurred, any necessary corrective action too can be taken early.
As in previous sections we can pause here to see if the contents of this section have got through to the community. This will not happen magically. We need to take active steps to ensure that all the ideas discussed so far are dealt with. Evidence that the ideas have got through will be the action that the community takes to combat all influences that give a positive image to tobacco.
Less young people take up smoking
Smokers give up their habit
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Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
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6.7 Create vigilance amongst all, about how our efforts may be undermined. If there are any indications that we are becoming successful in reducing the extent of smoking in our community, this will be noticed by the tobacco trade as well. This is not something special about the tobacco trade. Any serious business enterprise takes the trouble to monitor how they are faring. If the area that we have chosen to work in is relatively small, the changes in smoking are unlikely to be noticed. Sometimes the local tobacco agent may be unhappy when the sales come down. Sometimes there may be some people who smoke already, who feel a little unhappy that their habit is now seen as a weakness. They may then be interested in preventing the progress of the community towards seeing tobacco use in this negative or less attractive way. In a small community, those who try to prevent our efforts succeeding are mostly these kinds of less informed people, rather than people from the organized tobacco trade as such. There may rarely be local agents of the tobacco trade who may feel upset that the efforts of the community are succeeding. These issues can be raised with interested persons in our community. ! What are the things that someone who is unhappy about our efforts to reduce tobacco consumption will do? In what ways can they discredit our efforts to reduce tobacco consumption? What do they gain by criticizing the community’s efforts to reduce the spread of tobacco use? Does the person who sells tobacco at a stall or shop in the village or community make any significant profit from the sale? Would he get more profit if people bought other things from his shop, with the money they now spend on tobacco?
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Some people who try to undermine the community’s progress are doing so without thinking. The owner of the local shop is made to believe that he benefits greatly by selling tobacco too. So he does not want the sales to come down. Such traders have rarely stopped to think of the presumed benefits from selling cigarettes. In most countries, the margin of profit from tobacco sales, especially cigarette sales, is very low for the retailer. The trader does not want to lose even this small profit. But he does not realize that it will be more profitable for him if the consumer bought any other product with his ‘cigarette money’. 79
The tobacco trade is clever at convincing the traders that they are benefitted greatly by selling tobacco. Traders are targeted with many inducements, gifts and other offers to keep them pushing tobacco on people in our community. But in reality the local retailer is able to generate a higher percentage of profits from other products. We need to help the trader to see this. Should we try to persuade the local trader to reject tobacco sales, he or she will feel that the tobacco profits will go to a competitor. He will benefit only if he gets the consumer to ‘divert’ money away from tobacco into another product, on which he can get a higher percentage of profit. We are primarily interested in ensuring that the local traders do not actively collude with the tobacco industry and make their shops tobacco promotion venues. Some shop owners carry tobacco advertisements free of charge. There are others who go beyond just passively allowing the tobacco trade to use their premises as tobacco promotion sites. They actively help the tobacco trade to undermine the community’s efforts to reduce the harm caused by tobacco. ! Can we anticipate how someone paid by the tobacco trade will try to undermine our efforts, if he wanted to do so? Can we make the community aware of these methods? How can we win over the hearts of people who try to obstruct our progress? How can we neutralize or counteract their actions , if we can’t win them over?
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We want to make sure that people paid to promote tobacco will have little chance of undermining the community’s progress. As stated previously, small-scale efforts will most probably be unnoticed or ignored by the organized trade. But some local tobacco agents may try to undermine our efforts if there is a significant impact.
PROGRESS REVIEW
He is a right wing experiment, he is a communist, he is an anarchist, he is....
Have we noticed any attempts by people who work for the tobacco trade to obstruct or undermine our work? If not, we can carry on as before. But we need to recognize the rather devious methods sometimes used to hinder progress of prevention efforts. It may take the form of misrepresenting our work as that of opponents of the political groups in power. At other times there may be attempts to cast doubts on the integrity of the people who are working to prevent the spread of tobacco. Most of the time the biggest block to our progress is the creation of dissention among us. 80
If there is indeed significant obstructions or undermining we need to address the people who are responsible. Our objective should be to win over the people who are trying to obstruct our work. If they too are people from our community we should in time be able to win them over to the side of supporting the well being of the community rather than that of the tobacco trade. The undermining of our efforts is not only the result of the organized tobacco trade. This too needs to be raised with our community. What are the factors, other than deliberate undermining by the tobacco trade, which lead to our interest becoming less after some time? How can we start things in the right way, to ensure that our interest will not disappear quickly? Here we want to address the factors within ourselves that lead to reduction of efficiency. Many efforts stop because we started in the expectation of a quick action that ‘solves’ the problem fast. Very few things in life are won that way. Our expectations at the start should be realistic. For real progress to be achieved we need to sustain the activities that we initiate with great enthusiasm at the start. To start with too grand an expectation often leads to a rapid decline in interest. So let us begin with realistic expectations about our own capacity to sustain an interest. Small regular actions are better than one large event. A group of interested people, for example a few members of a clinic’s staff, meeting to discuss the subject once a month or so is another useful strategy for sustaining interest. After a few months of dialogue with various members of the communities we want to work with, we shall be able to find a similar group of interested persons in each community too. In many interventions, there is a recommendation to start by creating an ‘action group’ or core group of people to take the initiative forward. But many people who initially come forward drop out fast. It may be better to wait a few months and form an informal interest group a little later. It can then be constituted by people who demonstrate a capacity to work steadily to achieve a lasting result.
ASSESSING IMPACT A good indicator of whether our efforts are being undermined or not, is the level of enthusiasm shown by the groups collaborating with us. Evidence that deliberate attempts have been made to undermine us will not be easy to come by, even if such attempts are made. Loss of interest among those who were enthusiastic previously is the kind of insidious undermining that happens from within, and which should be recognized early. 81
Anticipation that this can occur, and early recognition when it begins to occur, are the best remedies. When we do recognize a block, or a lack of enthusiasm, it is useful to remind ourselves of the reasons that motivated us to start this initiative. It will also be useful to see whether we have moved too fast or too slow so far, and to remedy that too, if necessary. Things fizzle out when the correct tempo is not maintained.
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Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
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6.8 Strengthen the community to deal with problems and ensure sustained progress. Our actions for improving the community are not intended to be just a short-lived gesture. We want to see persistent benefit. To make this happen we must recognize the factors that lead to prevention work becoming ineffective, or fizzling out after some time. Our own loss of interest and enthusiasm with time is a powerful factor that undermines our activities. We discussed in the previous section that one reason for such loss of interest is starting too ambitiously, expecting to produce quick and magical results. Most activities that start off with a big noise or grandly find it difficult to sustain the pace. It is probably better to start small, with realistic expectations, looking for small but definite gains. Unlike people who work to spread tobacco use, we are not motivated by payments for the results that we achieve. When we work for a result that is benevolent, and which we believe is worth working for, the attitude created is quite different from working for payment or profit. So it is not difficult to keep working. The real work required for preventing the spread of tobacco is not energy consuming or strenuous. We discussed the example of helping people to see that the act of smoking looks old-fashioned, inelegant and stupid. This is effortless and generally quite fun. Sustaining progress is then a simple matter. following questions. ! We might try to find answers to the
If we start to make changes in our community, how long will we have enough interest to continue? Who are those amongst us who will quickly lose interest, or try to discourage us after some time? Why are they likely to do this? What can we do now to ensure that some people amongst us will not discourage us after some time? Are there people who are opposed to our efforts to reduce tobacco use in our community? How can we prepare for the various ways in which they will try to undermine our efforts? 84
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Anticipating the phase when the initial interest becomes naturally less, is a good way of making sure that we will not be disheartened. Improving our community is not a ‘project’ or a ‘programme’ that we do for a time and then stop. We want to improve our setting continuously. And tobacco is a good example of the things we need to address, so that our setting becomes a better place in which to live.
PROGRESS REVIEW Is there better understanding now about the need for a steady and sustained process to benefit our community? Some people are interested only in doing things that have a big appeal, and draw much attention even for a short time. They should be encouraged to take on this longer-term responsibility too. Our community will progress in many ways when we learn that we can make a significant change by persistent interest (not necessarily strenuous work) for a reasonable length of time. If this idea gets through to a few interested individuals, our community will definitely progress. Until a fair number start taking action, we will have to work as one or two individuals, to stimulate progress. For a noticeable change to occur, about six months of work is usually needed as a minimum. We need to recognize the people who are likely to lose interest after a short time. They too will be among people who are initially receptive to the ideas that our community health worker has shared. ! Shall we speak to those who want to reduce tobacco use, and explain the need to sustain a response? Shall we anticipate and plan what to do, when some people among us lose interest or try to discourage us? Are there people within our community, whom we have not yet reached, who can advice, encourage or support us to continue our work? Are there people outside our community, whom we can reach out to, who can advice, encourage or support us to continue our work? How can we use their advice to make sure that our efforts do not fizzle out after a time?
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People with commitment, from any field, are a useful resource to help us sustain our activities. They can be from within and outside our communities. Simply having such a person or persons to contact occasionally is a useful way of ensuring steady progress. Another possibility is to keep looking for even the slightest signs of progress. ! Can we learn how to detect small changes, so that we can see the results of our actions as we go along? 85
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Is there a forum to discuss signs of progress? Shall we set up a system, for example a regular meeting, to discuss observations, and the steps we should now take?
‘Regular meetings’ do not have to be formal events with an agenda and a special meeting place. ‘Meetings’ happen day to day. All we need do is to talk about the state of the tobacco issue in one or two such existing meetings. Our group can be a few people who regularly wait for a train, come to a playground to relax or exercise, come across each other in a library canteen and so on. We can gently raise the tobacco issue at such a meeting and bring it up again in a week, and later perhaps agree to discuss the situation in a week. The initiative proceeds steadily in this way. When there is some progress we need to look at what is appropriate to aim for next. While we refine our interventions to be more effective as we progress, we can look at ways of sharing our positive experiences with others outside our community too. This is not only a help to others, but also a means of improving our interest.
ASSESSING IMPACT Are we ready for a sustained series of actions? At the end of this section we should have become sensitive to the need to plan for the longer-term strategy to sustain our interest. If some recognition of this has occurred, and if practical measures to anticipate and handle a possible decline in interest have been taken, the content of this section has been well used.
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Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
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6.9 Encourage at least a few persons to look for more remote or longer term indicators of progress. Changing the way people see tobacco, making fun of the sly and devious measures taken to make it look special and alluring, and working out new ways of overturning these cold-blooded attempts are all quite enjoyable activities. So we don’t need special effort to keep such activities going. It is not too difficult to observe whether the opinion in our community is slowly changing as a result. These must, however, eventually impact on the amount of tobacco consumed in our area and in the numbers who are persuaded to start smoking. To measure these remote results is more difficult, and less interesting, than monitoring day to day progress. It is often quite boring. For our work to be sustained and for our own education though, we need to measure these ultimate impacts too. Thus we should try to set up a few ways of looking at changes in total consumption, changes in the number of new recruits and changes in the number of current users. This is a little more difficult to measure than the previous things. So it cannot be expected of the whole community group. More success is likely if one or two people agree to take on the task of monitoring longer-term impact. They can get the support of the others too, of course. Some questions appropriate to getting the process going are as follows. ! ! How many of us would like to study the longer-term impact of our work? How shall we measure the changes that occur in our community by next year? Shall we record a few indicators now, for later comparison? For example, how can we assess whether the number of cigarettes sold to members of our community has increased or decreased? Similarly, is it possible to record some other indicators of consumption, for annual comparison? How can we check whether the number of new recruits becomes less, say, next year? Will it be possible to check the proportion of people in different age groups in our community who smoke regularly? What are the tobacco related problems for example, worsening poverty or deaths and diseases caused by tobacco that we should monitor, to see if these too come down in the longer term? 88
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We should keep a record of the way we used different indictors to measure the present status, so as to help us make a valid comparison with a repeat assessment. Such an assessment may occur only an year or two later. What we have listed are things that could be considered the ultimate goals of our tobacco prevention initiative. There are numerous other things that can be monitored usefully. But the problem is in finding the resources to monitor all of these. We have discussed the indicators that can be looked at by people who are working daily in our communities. These are the more immediate indicators of progress. A few other indicators fall in between. For example, responses by people who want to spread the tobacco habit will be an indicator of how we are doing. If there is opposition, hostility or some other visible reaction to our work from the tobacco industry, that may be a sign that we have become effective enough to be noticed. If they fail to stop us, that’s even better news. If they come round eventually to quietly helping us, that is great news. Our community groups in each locality can choose to monitor indicators of this nature, depending on their interest.
ASSESSING IMPACT To assess the impact of this section we must check on the data that the community is gathering. A fair amount of information should be available to help the community make valid comparisons of the situation in the longer-term too. The degree of success is indicated by the amount and usefulness of the information that is gathered.
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Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
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6.10 Join the community in celebrating successes and working out new ways to get more exciting results even faster. If we find that someone has stopped smoking in the last month, this is really happy news for the community. It should be cause for celebration that at least one person is more free and comfortable. It is as well an example to others, that such freedom is not so hard to achieve. For the whole community this should be a symbol of success, and evidence that people can overcome strong social influences created to keep them tied down in suffocating habits. Rarely though does a community celebrate the victory of a smoker or smokers against the various insidious influences that serve to keep them on a treadmill. This is probably because such a change is not seen as being the result of the community’s efforts. Or it may be seen as too small a change when the whole community is considered. Underestimating the progress made is common. Let us now imagine that community. are only two assume a particular situation with a hypothetical community. Let us an average of six to seven young people began smoking every year in that If the community takes action to prevent the spread of tobacco, and there or three new users every year now, what will be the result?
The likely result is that even those who are responsible for this reduction will not realize that things have improved. Even if they do, they will probably not feel that they have won a significant victory. This happens because many people are looking only for a final outcome of `eradicating' tobacco. This tendency is common. Results of ‘treatment’ or ‘cessation’ work are more visible and noticed than a much larger ‘prevention’ result. And this lack of sensitivity to the results of prevention work is not just found among ‘outsiders’ critical of our work. It is a tendency even among the people doing the prevention work. If a young person in their community starts to smoke, they will notice it and feel bad too. The fact that three more young people previously started to smoke in the same period is not realized or recognized. To ensure real progress we must learn to detect these ‘hard’ results. But we must learn even more to detect the changes that precede these hard results. A small change in the atmosphere in our community, towards being less encouraging of smoking, is therefore a sign that should be noticed. Improvements may be noticed in passing or because we have looked carefully for signs to monitor our progress. When we get used to looking deliberately for pre-determined signs of progress, it becomes a habit after a time. Signs of progress or decline are then noticed early. The more sensitive we are to early signs, the more likely that we will progress and build upon small successes. 91
For success to be celebrated and for it to serve as a stimulus for greater success we need to get into the habit of sharing the signs of progress that we see. ! Have we seen any improvement in our community in the last week, or last month? If not, what can we try to achieve in the next week, or next month? Have we noticed some small encouraging sign but failed to respond to it? What can we do to share news of even the slightest progress, without letting it go unnoticed ? Shall we all take the trouble to report to each other any sign of progress that we see in the next week? Can we start by sharing something that we said to somebody yesterday for example to spread the idea that smoking looks rather boring and oldfashioned? Are there other positive examples of this kind that we’d like to share? How can we teach everybody in our community too to notice these kinds of signs, and to share the good news with as many others as possible? Do people understand how major an achievement it is to counteract the widespread attractive image of smoking, which is constantly crafted by the industry? Do we give ourselves enough credit for our achievements?
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Let’s pause to consider what we are trying to achieve. The idea is that people must ‘engage’ in the process of doing simple and effective things to improve our community. And they must then engage in looking at any impact they may be having. The whole community begins to change when this process is in operation, even among a few, for long enough. The process of engagement is greatly enhanced by seeing even the slightest impact. It is further enhanced when those who’d feel good about such a change see it and celebrate it together. Celebration may simply be the sharing of the good news and the resultant good feeling. If the success is a major change after an year or so of work, our celebration too can be appropriately bigger! Celebrations are a good occasion for us to learn how various commercial interests have programmed our lives. Just the mention of the word ‘celebration’ makes us think automatically of certain things as obvious accompaniments. Alcohol is a prime 92
example. The tobacco trade has not succeeded as much as the alcohol trade in making its drug an automatic association of happy and celebratory events. But they are making enormous efforts. These provide us with a good challenge to overcome.
ASSESSING IMPACT Are the ‘natural’ groups who have now taken on tobacco as part of their agenda, sensitive to progress that is taking place in the community? This is what we are looking for here. The more such groups that are looking with interest at the way things are proceeding, the better. Secondly there needs to be the means of feeding these groups with news of successes and challenges. This mechanism will perhaps need to be maintained by whoever initiated the community response. Eventually, the community will learn to notice and monitor things more effectively. Thirdly, there should be sufficient feeling for the welfare of the community among some groups within it. This should be evidenced by expressions of joy when even the slightest progress is made in counteracting the onslaught that tobacco has quietly carried out against our community. These need to be tempered by feelings of concern for failure to progress.
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IMPLEMENTING COMMUNITY CESSATION RESPONSES CHAPTER 7 “Cessation” of smoking is understood in different ways. Many people understand it as a difficult process that a person who is a regular smoker has to undergo, to stop smoking. Most of those who see it in this way feel that the smoker needs help from experts to assist this process. Medical and non-medical experts are often seen as having a role according to this way of understanding cessation. Others see cessation as a natural process that smokers can go through relatively painlessly, and without special help. There are several other shades of opinion between these two extremes. We are interested in examining ways in which an ordinary clinic or hospital, without special expertise, can facilitate these different routes to cessation. In our region there are a large number of people who use tobacco in ways other than by just smoking it. Chewing tobacco, often with betel leaves, or inhaling it as snuff are examples of these other kinds of use. Our efforts should encourage cessation by these other users of tobacco too. Harmful consequences of tobacco use are seen with all forms of tobacco consumption. Formal ‘cessation’ efforts do not often target forms of tobacco use other than smoking. Those who use tobacco in ways other than by smoking, are left to get over it by themselves. In community efforts a mood must be created that makes all tobacco users feel like quitting. Part of the task of implementing cessation activities through our local health facility is to help people 94
In This Chapter Factors that promote or prevent cessation Learn to enlarge these forces Local influences that promote tobacco use Counteract harmful Why should we act? Is atmosphere changing? Be vigilant Deal with problems Measure progress Celebrate success 128
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understand the process of cessation more accurately. Most of those in our community probably now see cessation as just the act of ‘giving up’ smoking. They may think that a person gives up smoking as a result of concern for its harmful consequences. This common understanding sees cessation as an act requiring a good deal of will power, to overcome immediate discomforts that accompany the withdrawal of nicotine. The ‘urge’ for nicotine has to be suppressed or overcome. The user is expected to undertake the cessation effort in the expectation of longer-term good namely, a reduction in the risk of various diseases and premature death. As a result of this way of understanding cessation, people often miss the important fact that cessation leads to comfort, not suffering, in the shorter-term too. People who want to stop smoking can choose to focus on the discomfort that they anticipate will occur every time they experience an urge for nicotine, or tobacco. This is usually how people approach cessation. They could instead focus on a completely different idea. Namely, the fact that the life of a smoker is one of recurrent waves of discomfort even at present. A smoker’s life is indeed a series of uncomfortable spells. The discomfort is relieved only by the next cigarette. Giving up smoking can therefore be an experience of great relief and freedom. Cessation is experienced as freedom when the idea of smoking is relinquished. This broader understanding of the benefits of cessation is not generally prevalent. It is useful to help smokers contemplate the benefits of cessation, which occur from the beginning itself. The first step in this regard is to help the community of smokers appreciate the fact that cessation should be an experience of freedom. When people decide to give up for the sake of experiencing freedom too, not just for health benefits in the distant future, they realize that cessation is not a great fight to ward off immediate discomfort for the sake of some later gain. Such persons are able to overcome their urges rather more easily. Most people who quit do so with no professional help. Our community efforts must strengthen people’s ability to do this. For those others who are not able to appreciate this or reach this state, help to overcome withdrawals will need to be provided in some other form perhaps through a clinic.
Initiating activities through the clinic or hospital PEOPLE WHO WANT TO QUIT In implementing a cessation effort, we have to reach current tobacco users. One way of reaching them is through our clinic itself. Rarely, there will be people who come along and ask for help to stop smoking. They should be given support to reaffirm the fact that they can indeed quit. And they can be provided the necessary guidance too. A few simple guidelines to follow, in helping such persons, are given in appendix. 95
PATIENTS WHO USE TOBACCO There are large numbers of smokers who come to health facilities seeking help for physical conditions, but who do not mention their smoking. It is now recommended that doctors ask all patients about their smoking habits and use the opportunity of the consultation to simply advise their patients to stop smoking. This intervention takes less than one minute, but a few smokers stop smoking simply on this advice alone.
A). PATIENTS WITH TOBACCO-RELATED COMPLAINTS Some conditions, such as respiratory problems, heart disease and sexual problems (erectile impotence) are clearly related to smoking. In these cases we can emphasize that the patient’s problem is at least partly due to smoking and he should stop smoking immediately.
B). PATIENTS WITH OTHER COMPLAINTS Any patient who is found to be a smoker should be advised strongly to give it up, even though his symptoms may not be directly related to smoking. The symptoms that the patient complains of do not necessarily have to be related to his smoking for us to ask him to quit smoking.
SMOKERS AMONG FAMILY MEMBERS Smoking among family members of patients is generally ignored by doctors. When a child is brought to the clinic with some illness, it can be an opportunity to ask the father to stop smoking. Some childhood illnesses, such as asthma, are made worse by inhaling smoke from others’ cigarettes. This is commonly called ‘passive smoking’. Similarly, husbands of pregnant women who come for antenatal care need to be reminded to stop smoking, as even passive smoking causes harm to the foetus. In poor families, smoking leads to a significant financial burden on the family’s meagre resources. So in all families where there is significant poverty, smoking by any member of the household is worth checking for. Alcohol is another source of heavy expenditure in poor families. Tobacco and alcohol use often go together.
SIMPLE ADVICE Asking current smokers to stop smoking is a highly cost-effective intervention, and clinic staff other than doctors too should be mobilized where possible to reinforce this message. People are more sensitive to medical recommendations when they come to a clinic or hospital with a problem. Studies conducted in western countries have shown that a significant number of smokers stopped smoking just on one simple recommendation of their family doctor. We often think that smokers do not listen to medical advice, but this is not true. Because we see that the large majority does not stop with just a simple recommendation, we miss the opportunity of influencing even the ten per cent or so who do. 96
REINFORCED ADVICE If our advice can be backed up by a ‘follow up’ reminder, the numbers that quit tobacco can be increased. And those few that stop are more likely to continue off tobacco if they are contacted again. If we want our clinic intervention to produce greater results we can try to find an interested person in the clinic to speak to all those who say they smoke. This person can ask smokers to quit and to inform the clinic in a week how much better they feel. If we have enough resources we can ask people to write back and keep in touch with them through the post, or by telephone. Ongoing contact by letters, telephone or asking the person to visit the clinic again are all ‘extra’ interventions that are possible only with added effort. Giving smokers a short pamphlet or document about quitting is yet another possibility. But asking every smoker to stop is something that should be done wherever possible. Additional help, other than simply asking or encouraging the person to stop smoking, can be offered to those who seek it. Details of how this can be done are found in Appendix.
Initiating activities in the community In addition to contacting and helping people through the clinic, we will need also to reach the much larger population of smokers among the public served by our clinic. We can do this through any interested persons or group. We discussed ways of reaching our community in the earlier chapter on prevention too. Our cessation work can also reach the community through the same group, combined with their prevention activities, as part of a comprehensive approach. Or we may need to start by developing some link anew. And for each setting we must work out the locally appropriate way of reaching the relevant communities. Let us assume that we have a way of talking to people in the community through a 'community worker'. It does not matter whether we have a person who has this designation. Anyone from the community concerned can fulfil this role. Or it could be someone who has enough interest to visit a given community from time to time. For convenience we shall name this person the 'community worker'. The community worker can be male or female. ‘Field health staff’ are an appropriate channel for reaching the people. But those working in our hospital or clinic too can still reach out to the wider public. They can, for instance, use contacts that that they develop through the work of the hospital or clinic. Interested clinic staff do not have to spend a great deal of time outside to achieve successful results in the community. If we work in a clinic or hospital, we need only to develop a channel to reach out repeatedly and regularly to the wider public. 97
It will be easier to understand how this can be achieved, once we have understood the process that we want to create within communities. This will now be discussed in relation to the items listed in the following ‘model’ for community cessation work. We shall start with the first.
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A Model For Cessation Action at Local Level
Learn about the forces that promote or prevent cessation of tobacco
Engage these forces
Community understands how vulnerable members are being led to continue tobacco use
Community understands why they should counteract these influences
Community understands how to help smokers to quit
Community takes action
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Is the atmosphere in the community beginning to change in the right direction
Join the community in celebrating successes
Strengthen the Community to deal with problems
Create vigilance amongst all, about how efforts may be undermined
Work out new ways to get more exciting results even faster
Ensure sustained progress
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7.1 Learn all about the forces from inside and outside our small community that promote or prevent cessation of tobacco use We can help people to discover the different factors that influence cessation of smoking by directly pointing out the relevant factors. We can also do so by helping people to find these out themselves. For either course of action we too need to learn about the factors that have an influence on cessation. If we keep our eyes and ears open from today, and start reflecting on the things we discover, we will develop increasingly accurate understanding of the things that influence continuation or cessation of smoking.
‘Biochemical factors’ In a ‘medical’ approach, the reason that people smoke is seen mainly as a condition called ‘dependence’. This refers to the fact that the body and mind of a smoker has got used to having a chemical (nicotine) in their system. When people are dependent on a chemical they want to have it on a regular basis, especially because they feel uncomfortable when the substance is lacking. These symptoms are called ‘withdrawal effects’. In the medical approach, the help that is offered is mostly to overcome the ‘dependence’. But we need to understand many other factors too. For example, a person’s withdrawal discomfort can be almost unbearable in one setting and almost unnoticed in another setting. The way other people in the environment react can make the withdrawal symptoms better or worse. So we need to understand these other things that are necessary, to support any medical help that a person gets to overcome his smoking habit. The large majority of people who have given up smoking have done so with no medical help at all. The help that is required by the minority who need it is outlined in Appendix.
Other factors One task then is to see whether we can create a climate in our community that makes smokers want to quit. Such a climate should help those who want to quit to actually do so. It should also ensure that those who quit are continually encouraged to continue off tobacco. Those who quit should continue to persuade and help other smokers to quit. To encourage the community to learn the other factors that influence continuation or cessation of tobacco use, we can follow the same method that we followed in the ‘prevention’ approach. We can see how certain issues can be raised with people in our community, so that they’ll be encouraged to find ways of helping the whole community to progress. 101
Let us list some questions that we can raise with a few members of our community, and see how they respond. Our community worker needs especially to speak to groups of people who smoke already. The approach again is one of asking a few questions and leaving them to answer, or think about, these. So there should be no difficulties of the kind that arise when people feel that somebody is trying forcibly to make them quit. ! ! ! Why do you think people who smoke regularly continue to smoke? Do you think that all smokers really like to go on smoking? What does someone who smokes do when the idea comes to him that he should quit?
The idea behind asking these kinds of questions is to help people recognize that a person who smokes regularly thinks from time to time that he should stop. If there are smokers in the group they will be able to say from their own experience about occasions where they have felt like quitting. But the feeling passes off and they continue to smoke. When these questions are initially raised there may not be any real response. But these are important questions to get on people’s agendas. So our community worker should not rush these questions. Leave these thoughts and ask them again, later. ! ! ! Did you think about my question the other day? Do people just go on smoking ‘automatically’? What answers did we reach?
The likely response, even on repeating these questions, is that they have no real comment. To get things moving we have to go on for some time with these, and other, questions. We need to build up our link with different smokers and groups of smokers. And we should strengthen the idea that we want to talk to them about tobacco use.
PROGRESS REVIEW Let’s check whether we have made any headway. Are we getting closer to individual smokers and groups of smokers? If we have now a fair acquaintance with several that is good progress. If not, we just continue. Not all groups are equally easy to access. With time we will find that some people are becoming more accessible. Secondly we need to see whether we have got people thinking about their tobacco use. People go on using tobacco partly because they have never really stopped to think about it. If our groups have begun to think about, and talk about, tobacco we’ve made great progress. 102
Some groups may slowly take up the idea while others don’t. The key to success is to keep a dialogue going. One or two minutes’ conversation is adequate to keep things moving. Our work can go on for years. So we don’t need to give up after a few weeks. Let’s just keep checking periodically whether tobacco users have begun to think about why they should go on in their habit indefinitely. Some will progress faster than others. Once we manage to get a few people thinking about whether they should forever continue to smoke, we can proceed to build on that. At least a few will eventually report that they do get the idea that they should quit tobacco. Why most people don’t act at once on these ideas is worth exploring. ! ! ! ! ! When someone feels like quitting, what does he usually do? What may happen if he says to his smoking friends that he wishes to quit? Are some smokers more likely to encourage a colleague who wants to quit? Are some smokers more likely to discourage a colleague who wants to quit? Who are the smokers who are more likely to encourage a colleague to quit smoking? Who are the smokers who are more likely to discourage a colleague from quitting? What then should someone who wants to quit smoking do about the influence of his smoking friends?
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Again we hope that these kinds of questions will help a smoker recognize at least one of the external influences that contribute to his decision to continue, or to quit, smoking. A major ‘external influence’ is the effect that a user’s natural group has on him. It is not easy to go contrary to the prevailing mood in one’s usual circles. The person who wants to quit tobacco has to address this factor. Because we cannot suddenly do something different to what we always did, we tend not even to consider the possibility of change. Many transient impulses to quit tobacco remain just transient impulses because we know that our environment does not allow us to implement them. This is one reason why the smoker who feels like quitting ‘forgets about’ the idea quickly. Anybody who wants to benefit from the impulse to quit must learn to address the group that keeps him from quitting.
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An individual’s decision to quit or continue smoking is also influenced by his external environment
Some will encourage him to continue smoking
Some will encourage him to quit
Many won’t care at all
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Even when helping individuals to quite it is effective to carry out interventions that change the community
These should specially be directed at the promoters of smoking
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One way to do this is for one person in the group of users to raise it with his colleagues. The other is for our community worker to directly raise these issues with the group of current tobacco users. ! ! ! What is the prevalent influence in our group (of smokers)? Do most of us try to discourage someone who wants to quit? Is this a reason for many of us not even thinking about quitting?
PROGRESS REVIEW Have any groups of tobacco users begun to examine whether their group tends to keep all its members bound to tobacco use? If they have learnt to examine the prevailing ethos in their group, that alone will help change it for the better. If they have not, we need to keep encouraging smokers to raise this issue with their smoking colleagues. Keeping an eye on the prevailing mood among groups of people who are still using tobacco is one component of our community cessation effort. There are other matters too that we need to influence and to monitor. One of these is the mood that prevails in the world beyond our small group of smokers. We refer here to the mood in wider society and the country as a whole. Let’s see how this matter can be dealt with. Relevant questions are not only for the people who use tobacco but all other interested parties within our community. ! What is the mood in our community, in wider society and in our country as a whole, about smoking? Is it one which makes people feel like quitting or continuing to smoke? How is this mood generated and maintained?
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As in the prevention exercise, we can look at the numerous influences from outside our community that too have a bearing on whether people are encouraged to go on smoking or to quit. Particularly important is the fact that advertising and promotion of tobacco tends to keep current smokers smoking. Low cost of tobacco is another factor that promotes continuation of use, or even an increase in consumption. Many people who quit tobacco, especially in middle age, do so when they become concerned about the serious risks it poses to their health. Unlike young people, older persons are more sensitive to the risks to their life (even though they have a shorter span of life left!). Any influence from inside or outside our community that makes people recognize the real extent of risk from smoking is therefore useful. Similarly any influence that makes the harm appear trivial is likely to hinder the desire to quit. 106
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Do smokers know the real extent of harm from smoking? Have they recognized the impact that the cost of tobacco has on the family budget (especially if they are very poor)? Do they know, for example, that half of those who smoke die of tobacco related diseases? Do they recognize that a heart ailment that they may already suffer is probably due to smoking? Do they recognize that any sexual weakness they may already suffer is probably due to smoking? Have people noticed in the media articles, cartoons, jokes or other contents that appear to make the harm from tobacco appear trivial? Have we noticed any other things in the media that too could influence the decision of people to quit smoking or not to quit? When people see smoking portrayed as a common or ‘normal’ thing in films and television, what is the likely influence on their decision to continue smoking? What can we do to minimize any harmful impact of such influences?
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As we get progressively more sensitive to the issues we will be able to recognize the less obvious factors that make a person want to continue smoking or to quit. We will then stop attributing the decision only to the ‘dependence’ on the chemical and learn to recognize all the other factors that also contribute. The more sophisticated we become in such recognition, the more effective we shall be in moving people in our community towards escaping their habit.
ASSESSING IMPACT A wide range of influences that impact on the decision of tobacco users to quit or to continue use were dealt with in this section. Our assessment of impact from this section is to see whether this wide range of issues has begun to be appreciated by the people in our communities. Particularly important is the need to reach people who are still using tobacco. Whether they just go on using or not, should become a matter of thought and discussion. And in this section we were trying to sensitize them to the different factors that influence that decision. So we need to see whether they’ve begun to recognize, for instance, the part played by others in their tobacco-using group. If people who smoke are now 107
beginning to question whether they should continue smoking the rest of their lives, that indicates significant progress. Movement of the prevalent mood among current users is the second aspect to examine. Any incidents that point to a change among them shows that the work done has produced the desired result where it matters most. The third area in which to look for progress is in the mood in the wider community. Is that one which encourages or discourages quitting by people who still smoke?
108
Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
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7.2 Do all we can to influence the external and internal environments to improve If we find that insertions in the media and the way smoking is shown in dramas and films and on television is likely to induce people to continue smoking, what can we do? An example we discussed was the presence of regular insertions in the media to make the harm from tobacco use appear trivial. Another is the portrayal of tobacco use as the norm or as something desirable. There are many useful things that we can do. What is actually done depends upon the interest and level of enthusiasm in our community. As in the chapter on prevention, we want to create awareness of the way these insidious influences work, by stimulating our community to respond to them. The community worker can raise the questions. ! If certain magazines regularly contain pictures of popular film stars depicting smoking in a very positive way, or as the `done thing', what can we do to prevent this influencing our people to continue smoking? Can we as a small community influence the way smoking is shown in foreign and national films or TV shows? How can we minimize their harmful impact, at least on our community? Can we minimize the tendency of some members of our own community, to dissuade people from quitting?
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As with the first task, we need to see if people in our community will be induced to take some action. They need to reduce the harm that is done to the community, especially by these outside influences. They may fail to have any impact on how the outside world chooses to target them. But they will become more effective in there work locally, because of their actions to address the outside forces.
PROGRESS REVIEW We have not gone into detail here about the various positive depictions of tobacco use that are aimed from outside at communities like ours. These were dealt with in much greater detail in the chapter on preventive action (chapter 6). Our assessment of progress here is simply to find out whether the positive depiction of tobacco use is recognized. And for the cessation effort, those who must recognize this are people who presently smoke. Have they begun to see how they are made to think that their habit is attractive? Is it because it really looks good or is it through clever manipulation of public impression? If at least a few of those who presently smoke see how they too are influenced in a subtle way to continue smoking, that is sufficient progress for the present. 110
Influences that make people who smoke feel that they are not really at major risk must be recognized and counteracted. The way smokers are made to feel `we are going to die anyway, so why bother?' is very subtle. This feeling is spread unwittingly by those who are unable to give up their tobacco habit, as a way of rationalizing their behaviour. Such a response is easy to understand and perhaps even to accept or excuse. But attempts by those who make money from tobacco to hide, cover up, or trivialize its dangers is inexcusable. As we begin to spot the ways in which the damage from tobacco is made to look trivial or negligible we should try to prevent or counteract these too. If we cannot prevent forces from outside our community, for example those operating on a global scale, we should try at least to minimize their impact on our community. Let us approach it in the usual way of raising the issues with concerned people, with whom we are in contact. ! Who are the people who want us to think that smoking is not really a serious risk to our health? How do they create this impression? Whom do they use to propagate these ideas?
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People in our community should readily be able to answer these questions. But their answers may need to be made complete. What is a complete answer today will be incomplete by tomorrow. That is especially so if the tobacco trade chooses to counteract the perception that tobacco causes major harm. In that event they will continue to devise new ways to make a joke of its risks. We have to work in the expectation that the tobacco industry will subtly continue to deny or counteract efforts to help people recognize the harm caused by tobacco. It cannot be easy to go on producing, marketing, and persuading innocent people to use, a substance that one knows will cause enormous suffering and premature death. So those in the trade will have to convince themselves that the harm is indeed trivial. If not, they have no way of escaping their conscience. People in the trade do this by producing propaganda and rationalizations that they themselves then believe. They have to convince themselves that the harm from tobacco is, for example, no different to that caused by excessive intake of fatty foods or by exhaust fumes emitted from vehicles. What they then do, with conviction, has to be counteracted at all levels. A person in our community who postpones the decision to quit tobacco because of subtle propaganda of the tobacco trade will otherwise be an unnecessary extra victim. And very few people even recognize the fact that they are victims. 111
We need to use our intelligence too, to understand the ways that people are persuaded to go on smoking. So let us ask our contacts in the community to examine more carefully the different things that are done to make a smoker go on in his habit, without contemplating quitting. ! What are the strategies that we spotted, which are used to make smoking appear a trivial risk? Are we able to spot the theme of certain jokes that make fun of the dangers of tobacco?
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The smoker is made to feel clever to continue smoking, and to laugh at those who are concerned about health risks of tobacco. And the feeling that he has `chosen' to continue to smoke, having considered the risks and found them negligible, is strengthened. A major reason that tobacco users do not recognize the damage that is being done to them is that they can see people around who have been smoking for long years, who still appear well. And they are reminded of such persons whenever the subject comes up. There is a problem here about helping people to recognize risk. About half of all smokers die of tobacco related illnesses, and about half of them die in middle age. This is an enormously larger risk than that associated with most other behaviours. But the degree of risk is not really felt. All that the smoker sees are people around him smoking, apparently without any problems. He does not realize that all of tobacco's victims who have died prematurely are out of sight, usually underground. So the tobacco trade is able to hide all its victims and display only the survivors. Even if ninety percent of smokers died prematurely of it, that would not strike us, as they'd all be well out of sight. The tobacco promoter will still be able to point out triumphantly a single elderly smoker who still survives.
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Ashok is 55 years old. He rarely exercises, eats a lot of fatty food and smokes 10 cigarettes a day. He was diagnosed as having hypertension one week ago.
He would be sensitive to advice regarding cessation of smoking
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PROGRESS REVIEW This dialogue with tobacco users is to help them see the risks. And the most important factor in helping users to recognize the risk is to help them see how they are prevented from recognizing it. Let us see whether our people are now able to recognize the ways in which tobacco is made to look a trivial risk. If smokers have begun to see the different ways in which this is achieved, we have made good progress. But they need to be told that there are still other ways in which they are made to trivialize the risk, which they haven't yet recognized. The next time we see an article in a newspaper casting doubt on, or making a joke of, the deaths that are caused by tobacco we will be more careful. We will look at the source of these and learn how these references `happen' to appear. If the recognition is still weak, we need to go on with this theme. People don't pick everything up with equal enthusiasm. And subjects like harm and risks are often not very stimulating or interesting. Public attention to harm occurs only if the harm is manifested in a dramatic way. A few thousand people being killed quietly from apparently `natural causes' does not attract any attention compared to just two or three people dying in an accident, for example. So the effort to prevent the trivialization of the harm will need to be sustained. Did we recognize that one strategy for trivializing tobacco-related harm is to make anyone who tries to prevent the spread of tobacco appear a moralistic or fundamentalist opponent of `pleasure'? This strategy is used even more effectively in preventing alcohol-related harm being recognized. But let us raise the issue with regard to tobacco, as follows. ! When the harm from tobacco is made to look like a joke, won't those who try hard to reduce the harm appear to be gloomy propagandists? Who tries to spread the idea that people trying to prevent the spread of tobacco are exaggerating the harm, or trying to punish smokers? What are the other ways in which any effort at prevention is made to look boring or serious or an attempt to interfere with the freedom of people to do what they like? Why is it so easy to spread this view?
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This theme needs to be developed further. People should begin to see the way in which they too have been trained to look at things. The view propagated is usually that which is in the interests of the tobacco trade. Not everything that is done to make health promotion look boring, serious and against `fun' is done by the tobacco trade. We all contribute to create this image in different ways. We are generally guided to do this without realizing that we are being led. 114
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Do smokers realize that they too are being used to create a mood that makes the harm look trivial? Have we heard of the way `smoker's rights' groups are formed to ensure that smokers continue to smoke? How can we counteract subtle external forces designed to make people want to continue smoking?
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We will not have any convenient way of assessing the impact our action has on those outside our community. It is easier to see changes in the influences within our community, that encourage or discourage quitting.
ASSESSING IMPACT We'd like to see our community better informed on the ways that tobacco users are made to feel like continuing their habit. They should become increasingly better informed on how some of this is carried out through deliberate manipulation of public opinion at almost a global scale. They should also become increasingly aware of how the same result occurs due to things that we ourselves do, without quite realizing the impact. We want this increased understanding to be accompanied by action to prevent or reduce these influences. Let us therefore look at changes of the influences from within our community. Those coming from outside are emanating from powerful sources, and we may not find it easy to prevent these reaching our community. But we expect our community to do what they can to address this external influence too. Doing so should at least increase our awareness of, and concern about, these outside manipulations. And it should help build resistance. The main change to look for is whether the prevailing mood in the community is moving towards countering the forces that discourage users from quitting. We can see whether simple things, such as people's chance remarks and comments, are changing. Do they speak to smokers in a way that encourages quitting? Are they concerned about the welfare of those who use tobacco, and the welfare of their families? Do they address those who promote tobacco and persuade them to join the move to help our community develop? A second area of progress is resistance to various insidious ploys. These ploys are aimed at making tobacco users justify or minimize the risk that they are taking with their own lives. Are smokers now becoming aware of how they are cleverly converted into becoming the agents that prevent themselves from quitting? Do they see how those who are concerned about their welfare are 115
made to look like antagonists, while those who are keeping them tied to tobacco use in the most immoral way are made to look like friends? The ideal outcome from understanding the issues dealt with in this section is that all tobacco users who still continue its use will do so with complete insight. Insight should be into all the external forces, deliberate and unwitting, that keep them tied to the habit. They should also develop insight into the clever manipulations, which had made them believe until now that they freely `chose' to continue smoking. We will concentrate a little more, in the next section, on the influences from within our own community, which persuade users to continue.
Outside influences may emanate from powerful sources
116
Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
117
7.3 Ensure that everybody understands the local influences which promote continued tobacco use. In our preventive efforts, we learned how to understand the different local factors that we have to counteract successfully. The same principles apply to cessation as well. ! ! ! Who, within our community, are the strong promoters of continued smoking? Can they be helped to see the harmful influence they have on all smokers? Should they not reconsider whether it is a good thing or bad to influence others to continue their tobacco use?
Some people who promote tobacco use, or continued tobacco use, may not ever come in contact with our community worker. So she may not be able to identify the people who keep a group of smokers, from ever thinking about quitting. But we need to reach these persons. In nearly all settings there are groups of people who smoke. We are looking particularly for the `influential' members of those groups. They may not be very visible or powerful but could still be a force in keeping the others always tied to tobacco use. Who are these people? Some people are influential in preventing others in their group from developing or advancing. This does not apply only to tobacco use. Such people are often the least capable of understanding issues. They just carry on doing what they have always done. Any attempt to change the existing pattern makes them uncomfortable. They are comfortable only when they can exist doing just the things that they already know. Such people may be limited in their ability to understand how their habits can sometimes restrict the full enjoyment of life. People who are limited in their ability to understand or perceive things may, strangely, be the most influential in keeping a group tied to a particular course of action. So there may be two or three people who feel very insecure if their group tries to examine their smoking habit critically. They will then try to block any serious thought on the subject by making a cutting remark, showing annoyance or criticizing someone. As a result the larger group too quickly learns to avoid the subject because they don't want to upset their less intelligent colleague. Our community worker needs to understand this influence. Any discussion with groups of smokers is likely to be undermined by the few who do not understand that it is in their interest to look at their habit critically. The tobacco industry too tries to foster the feeling among smokers that they should get together and fight the world to win their `rights'. They may, in our country too, be working behind the scenes to 118
create `smokers' rights groups'. The net result is that a few smokers at least will be prevented from seeing how they are being manipulated by the industry. And the least perceptive are most likely to be duped. There will be people in our community who prevent any chance of smokers they know from even discussing the need to stop smoking. These people may not have any links with the organized tobacco trade. But our community worker must work steadily to counteract the influence of this small unenlightened group. The discussion with smokers, about those in their groups who are reluctant even to talk about tobacco, has to continue for long. In this way we can prevent the initial resistance from leading to dismissal of the subject for all time. Our worker must understand that someone in the smokers' group will always make light of the subject and prevent any serious consideration of it. Anticipating this is essential. Our worker must see how the groups of users can be helped to recognize the people in their own groups who prevent any serious discussion of tobacco. Once this is achieved, we can go on to addressing the commonest objection raised by the less enlightened users. ! Is it good or bad for the community to do nothing - and let smokers whom we know just go on smoking? If we try to help them think about quitting, why is this seen as interference in their personal affairs or freedom? How is it that inducements to make people start or resume smoking, or influencing people to continue smoking, are not considered an interference in their freedom?
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Most people don't realize, until it is pointed out to them, that persuading or forcing others to consume tobacco (or alcohol) is a very common and accepted practice. It is never criticized or condemned as an interference with another's rights. But any attempt to discourage use of these substances is immediately condemned as interference in people's `freedom of choice'. Even to talk about quitting is portrayed as an interference with another's rights. If the general mood in the community is one that discourages smoking and gently persuades smokers to consider quitting, it will encourage more people to take action to quit tobacco. This mood needs to be created among groups who already smoke.
PROGRESS REVIEW Have we started to reach groups of smokers with the question we want them to think about? Namely, who are the members of their groups that prevent the others from thinking seriously about whether they should or should not continue to smoke? Many 119
tobacco users will be able to understand quickly the benefits of becoming free from the constant cycle of discomfort and temporary relief of discomfort. But we want to check whether the groups have begun to discuss openly the subject of who keeps them tied to tobacco? For a group to develop as a group, they need to see the influences that undermine progress. In community efforts we have to create changes among groups of smokers too. So the development of understanding within a group, as to who keeps others tied to smoking, is of great benefit. The result we are now looking for is the development of understanding within the groups of users that we reach, about those who obstruct progress on achieving freedom for the group. We said previously that a factor which induces smokers to continue smoking is the general image of smoking within the community. The image that smoking has among groups who already smoke is even more important. Our community worker has to address this too. ! What are the things that make smoking appear, especially to current smokers, as something that is positive or attractive or something that ‘should be done’? Who are those, among smokers, who strongly reject any efforts by any of the group to question their own habit ? Do they use any prohibitions on smoking in certain places, or public opposition to smoking, as a tactic in making other smokers determined to continue? Who are the people, in our group of smokers, who are likely to do this? What are the methods they use to make smokers see continued smoking as a defiance of unfair ‘restrictions’ or ‘interference’? Do they know how the tobacco trade can influence them, without their even being aware of it, to take up this attitude? How can more enlightened members among a group of smokers counteract the influence of those who are less perceptive? If the people who make others continue smoking are not even paid by the industry, why do they continue to persuade their smoking colleagues to continue? Can we explain to current smokers why they should actively work to help each other quit, and to prevent newcomers being recruited into their habit? 120
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We have to win over the few smokers who do free propaganda for the tobacco industry. They may not be aware of how they are kept on the side of the industry that cynically sells them a product that is known to be lethal. The tactics that are used currently in our own area have to be monitored regularly. Only then can we help people to see how they are taken in. We can remind people of the various types of things that we already know are being done by the industry. These are relevant to raise with smokers. We need to update the examples given below with newer tactics that we discover as we go along. ! Have smokers participated in competitions and contests where they can win prizes for smoking, or sending empty packs? Have they entered competitions after which they are sent tobacco promotional materials in the post? Why do we not feel that this is an ‘interference’ with our freedom? Have any people had invitations to parties and concerts sponsored by the tobacco trade? Do they realize how these are designed not only to recruit new smokers, but also to make them feel like continuing to smoke?
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We have used a small range of examples to explain how the influences within a group of people who smoke together can interfere with individuals liberating themselves from the tobacco habit. The prevailing ‘culture’ within the group needs to be targeted in many ways. A smoker may belong to several smoking groups and the culture in all of these has a bearing on his ability to quit.
If the people who make others continue smoking are not even paid by the industry, why do they continue to persuade their smoking colleagues to continue? 121
ASSESSING IMPACT Has the ‘local’ influence (of the culture within tobacco using groups) begun to be addressed? The measure of success of interventions described in this section is the extent to which groups of smokers are no longer dominated by the influences that keep them tied to tobacco. Progress can be recognized when smokers are able to identify the individuals in their groups who keep others tied down to the habit. These are the individuals who are not able even to allow rational discussion of the subject of continued tobacco use. Liberation from this influence too may become visible, sometimes rather rapidly. Evidence of such liberation is the gradual loss of authority of the kind of people that we described. When everybody recognizes the people who obstruct any attempts to diminish the power of tobacco over their lives, they have made progress. And when they identify the individuals who habitually do this, the power of those individuals to obstruct progress is also diminished as a result. As with all previous sections, we need to keep at this until the relevant groups are reached and take on the task. And we need to work with them until they begin to overthrow the dominance of the people who (often unwittingly) keep the group smoking.
122
Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
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7.4 Enable members of the community to understand how they can counteract these influences, and help smokers to quit. Having created a better understanding about the influences that keep people tied to tobacco use, we must promote more active steps to counteract these influences. And the counteracting must happen where it matters. Namely, among people who already smoke. So the community effort must focus on producing changes among groups of tobacco users. We have to create a movement among those who smoke. This requires building a partnership with their groups. Most work on tobacco cessation and prevention is led by people who do not smoke. This will probably be the case with our community teams as well. This can result in current smokers being distanced. Our cessation efforts so far focussed on those who presently smoke. For the best results, people who at present smoke should lead these activities or be active participants. If people who do not smoke led the community initiatives, they should contact people who smoke and work with them until they are willing to collaborate in a cessation activity. What needs to happen among smokers? First, they must see the potentially great benefit to them of the cessation initiative. They should realize that those who care about them are those who will help them reduce or stop tobacco use. They need to be careful about those who persuade them to see themselves forever as smokers. And they need to recognize the small gains that they can make from today itself. All of these should lead to advancement. There may be a person who finds even the idea of giving up smoking too unpleasant to think about. If such a person becomes able to contemplate quitting some distant day, that is advancement. Another may want to stop some day, but take no action. If such a person decides that his desire to stop smoking should be implemented, that too is progress. From the point of view of the community, or of the group of people who smoke, even small changes constitute progress. Many people are unable to see this kind of small progress, and fail to recognize the early impact of their work. So what are the ideas for action that we could discuss with a group of current smokers in our community? ! What is the general opinion in our group about all of us continuing to smoke the rest of our lives? Can we as a group even think about reducing the control that tobacco has over our lives? Are some of us so completely controlled by their need for tobacco that they are anxious that they may be pushed to give up smoking? 124
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Smoker’s thoughts
Do I want to continue smoking for the rest of my life?
Do I intend to smoke 100000 more cigarettes?
Maybe I should think of giving up smoking
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This takes up the theme that we began in the previous section. A few sessions on these lines will be needed to get a group thinking about taking practical steps about their smoking. Within the group there will be people who do not like the idea of attention being focussed on smoking. They may try to prevent further discussions on the subject. But progress occurs if the majority realizes that they should look at their tobacco use, out of self-interest. There will be no progress if they feel that they are being pushed by some interfering `outsider'. Possible progress by a group can be raised next. ! ! What progress can we make as a group? What does the tobacco trade do to make us smoke more, or to prevent us quitting? What can we do about our colleagues who are influenced by these actions? What can we do about those of us who do not understand the reasons why we should seriously think of quitting? Can we change the opinion in our group towards more actively supporting a reduction or cessation of smoking?
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We are trying here to consolidate the progress begun in the previous section. Resistance starts when we start actively thinking about doing something about our smoking. We have already discussed the possible opposition. The group should by now be sensitive to the likely opponents of progress and the tactics they may use. So it may be possible soon to start talking about practical steps that can be taken. Let's raise some of these issues. ! ! ! What progress is possible even if we don't stop smoking immediately? Are there some of us who will make fun of those who try to quit tobacco? How can we engage them too, rather than leave them behind and progress as a separate group? How can we make sure our group continues to progress? What are the signs that will show us that we are progressing? 126
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And the group can be assisted to work out signs that they can use to monitor progress.
PROGRESS REVIEW We are seeking progress or advancement of the group, not just of one individual. Has this particular group begun to change? Do they see the idea of taking control over their tobacco habit as something worthwhile and possible? Have we succeeded in engaging a group of smokers in a discussion about indicators of their progress? If they can be engaged in such a discussion, that is itself an indication of great progress! Let us continue the discussion on signs of progress of the group. ! ! ! What progress should we look for in our own group? Have we made progress, at least in the way we talk about tobacco? Where do we stand, as a group, in discouraging young people in our community from starting to smoke? How shall we assess whether we have reached a better state in a month's time?
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We are trying to see whether it is possible to think of areas in which to progress. And one way of ensuring progress is to decide what we will look for, as a sign that we have indeed made progress. We can start with something that does not appear too difficult. For example, it is possible to imagine a situation when none of us will do anything to encourage another person to start smoking. This is a good example then of something we can agree to look at, as a sign of progress. It is not impossible to conceive of a situation where nobody in our group of smokers tries to recruit a newcomer into smoking. We can similarly imagine a situation in the future where someone in our group of smokers will object, if another of us tries to persuade a young person to start smoking. We should search for ideas like this, on which there is a chance that most members of our group of smokers will agree. If we can get agreement on this kind of relatively simple step, we can arrange to check for progress with time. We can later take up other items, which may perhaps be more difficult to handle openly. For example, the way in which some people in the group obstruct others from gaining freedom from their tobacco habit.
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How aware are we of the ways in which we discourage each other from contemplating quitting? 127
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PROGRESS REVIEW We are trying to achieve a change in the mood in our group. Any progress that the group makes in the way it sees tobacco must be noted. In these early days, we are looking for small changes. So any reduction in the tendency to justify continued tobacco use, or to belittle attempts to quit, should be noted. And our inputs should go on continuously, all the while working to change at least the way we talk about tobacco. To stop seeing tobacco use in a positive light is progress. So also is a reduction in the feeling that we have no control over it. There will be an appropriate time to talk about reducing tobacco consumption too. Reduction in consumption will have to be preceded by discussing the things we anticipate will happen when we try to quit, or reduce, tobacco consumption. ! Can we try to encourage each other to reduce the number of times we consume tobacco each day? How shall we keep track of the reduction in smoking that we achieve? Can we save the money that would otherwise have been spent on tobacco, and use it for some really enjoyable or fun activity?
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This is simply an anticipatory phase. We can learn how different members of our group react to the very idea of reducing use. The idea of quitting too can similarly be discussed. It is useful sometimes to see who our real enemies are, when we try to take control over our lives. With constant attention to the habit, a few may already begin to reduce or quit use. Quitting does not always have to be preceded by a reduction of use. It may be easier to quit in one go than to struggle with each reduction. ! Will the tobacco trade be happy if every smoker in our country began to think about quitting? If not, how will they try to prevent this happening?
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PROGRESS REVIEW There must be continuous progress, in these discussions. The best evidence of progress is real action resulting from discussing tobacco in the right way. Increasing depth of understanding of the forces that keep us tied to smoking is a stimulus to action. For the majority though, insight alone does not result in action. Some collective preparation for action is needed. 128
We need constantly to monitor the mood in our group. Has it made a significant move towards seeing the benefits of quitting, and wanting to quit? When we sense that there is indeed a change in the feeling of the group, we can start discussing the possibilities of collectively stopping the habit. And the group must understand that cessation of smoking is for the sake of making our lives freer and happier too, not only for the longer-term health and economic benefits of stopping smoking. ! Are we already feeling more in control over our smoking, and beginning to feel freer? Do we recognize that smoking makes us less free and less able to enjoy the usual pleasures of life? Do we realize that a major benefit of quitting is that our lives will become freer and more enjoyable right away? Do we recognize that, when we are in the habit of regular smoking, we are constantly fighting off a feeling of discomfort or an urge for another cigarette? Have we realized that we are `on edge', and a little uncomfortable, most of the time that we don't have a cigarette? Have we noticed that this urge, and the resultant discomfort, spoils the full enjoyment of many nice things in life? Would it not be a joy to escape the constant need for another cigarette, and to feel free?
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It is worth reiterating this point several times. The fact that quitting tobacco should be for the sake of experiencing immediate freedom too is often not recognized. People don't readily understand this point that quitting tobacco is an escape from quite an uncomfortable life. During the smoking phase, a person's life is dominated by the need to keep getting repeated doses of nicotine (from tobacco) to feel relaxed or comfortable. This is like being on a treadmill a constant struggle to postpone withdrawal discomfort. And smoking a cigarette only puts off the discomfort for a very short time. So the day to day life for a smoker is an unending battle with a selfimposed, additional, thirst. Smokers who quit generally say that they have done so for the sake of their long-term health, and usually because of the impact of that on their families or children. But they generally don't see the short-term benefit. So they see quitting as a struggle to overcome present discomfort for the sake of some far away gain. But the reality is that there is a major short-term gain too. And that is the benefit of becoming free of an unending struggle with repeated waves of discomfort. 129
PROGRESS REVIEW Is there recognition of the aspect of freedom in the act of quitting? We have spent a considerable amount of time on this because it underlies successful and stable quitting. We can check progress on this understanding by asking a few of our smokers directly. And if we find that the idea has still not got through, we can use a different entry as follows. How can we help smokers to see that quitting is not really a sacrifice of immediate joy for the sake of longer-term benefits? Can we help them to realize that the life of a smoker is a constant and unpleasant struggle? There are a few questions the community worker can raise with our tobacco users, once the correct mood and relationship have been established. What do you feel about your life as a smoker? ! Are you generally more relaxed and comfortable than non-smokers or are you more tense most of the time that you don't have a cigarette? Is tobacco use a pleasure only because it gives relief from the tension that you feel, when you are in need of another cigarette? Is tobacco adding to your enjoyment of life or spoiling it? Is it really a great pleasure to have to fight off discomfort continuously? Do you remember the days you started to smoke that you smoked mostly because of others? Do you remember that you didn't really enjoy tobacco itself, in your early smoking days? Do you see that the `enjoyment' then was created by others? How do you understand your own wish now to smoke cigarettes, which you didn't really like very much at the start? Is the basis of your present `enjoyment' of tobacco mainly the fact that you are now uncomfortable when you haven't consumed it for a time? Does it make sense to go on being trapped in a habit, in which the `joy' is mainly the relief of a self-imposed thirst for tobacco? Do we now recognize the cycle of feeling tense for a cigarette, then smoking, soon feeling tense again for a cigarette, then smoking again, soon feeling tense again..., and so on? 130
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PROGRESS REVIEW Has our group of smokers started to see this new angle? When a person sees clearly what his life as a smoker is really like, that alone provides a strong impetus to change. The reasons for quitting include not just the longer-term gain but also immediate relief from a life of recurrent unease. If our group has not tuned into this angle yet, we have to work on it further. It is useful for people to see the quality of their lives now, before they actually quit. If not they only notice the discomfort experienced when they quit. They should now, while still smoking, examine their current difficulties. They experience right now all the discomforts that they will experience when they quit. The only difference is that the current discomfort is repeatedly extinguished by the next dose of tobacco. Another way of focussing on this is to examine the experience while we are still smoking. A few more questions will be useful. ! ! Shall we look at our state the next time we feel the urge for tobacco? Can we describe to each other how we feel when we need a cigarette, for instance? Let's remind ourselves that we are tense and uncomfortable right now, while we are still using tobacco. The tension is really experienced recurrently now, while we are still hooked, but we fail to recognize this.
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We asked about the plans that our smokers' group had, to overcome this recurrent cycle. Making plans is easy. Making plans that lead to real change requires more thought and energy. Embarking on actions without really understanding the longer-term implications is a waste of energy. We save time and energy by making a little effort for proper understanding and planning at the start. ! ! ! How shall we plan for our liberation from tobacco? What do we need to aim for in the first few weeks? Is it realistic to expect that all of us will quit smoking right away, even if we all do understand now why we should do so? 131
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Can we see what we can all do together for instance, creating a mood that allows people to quit or at least reduce consumption? How shall we make sure that those who are not ready to change do not hold back others? How can we make sure that even the weakest person in our group is not left out? Can we try to ensure that everybody makes at least a tiny amount of progress for example, even in what they say that they hope to achieve? Can we set a date to see how much progress everybody has made?
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The process whereby groups of smokers join the community-wide effort to minimize tobacco use proceeds on the lines indicated above. Our community worker who is facilitating the process needs to give the occasional input to ensure that progress continues. If even slight achievements are recognized, the process is likely to keep going forward. Simply creating a forum in which smokers can discuss their progress is a useful measure.
PROGRESS REVIEW At this stage we are looking for visible changes in tobacco use. Have any of our smokers quit already? (if two people quit that is equivalent to saving one life!) if anybody has already quit, is that applauded by others who have not yet quit? Expressed intent to quit too is a sign of progress. Those who set a date to do so may need only a small amount of support to implement their resolution or even bring the date forward. Have some in our groups reduced their consumption? Is the group taking the trouble to record the reductions that some of its members are achieving? Do people who have not as yet reduced consumption still show improvement in the way they react to others who are making progress? Smokers who are less able to understand how their lives are being impaired at present may be slow to make progress. It is important that they contribute to the progress of others, and of the community in general, even if they make no change in their own consumption. A positive attitude towards others liberating themselves is also a sign of progress. Eventually, the tobacco trade should find that they cannot find unpaid tobacco promoters in our community, even among those smokers still unable to think about ever quitting. 132
We shall find that, in a supportive environment, the majority of smokers are able to make progress that they previously would not have believed possible. For those who are slower and less able to take control of their lives, special help may be needed. These people too make better use of such help when the situation in the community, and among the smokers that they spend time with, changes in a liberating direction. We are at a stage where some people have begun to make changes in their consumption, while others have not gone that far. This is when we need to have the strongest inputs. If we leave things at this stage, just a small number benefit and the others continue their tobacco use. What has begun here is a process . A few people quitting is only a sign that the process has begun, not the end result of it. To derive maximum benefit from the work we have undertaken with the community, we need to keep moving things along even more actively now than before. Groups of tobacco users should see that some of their number are developing well, while others need a little more push to join them. The rest of the community too should all be facilitating and encouraging the process. Let us see what can be done to further consolidate the process of growth. ! If even one member of our group has made the slightest progress, what shall we do to make it a stimulus for the rest of us? Shall we see what we can do to help him make further progress? Is it not good that at least one of us is less tied to tobacco? Can the group try to set further goals for all members or a few others?
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There is no end point in this initiative. Community cessation work is a continuous process. We keep moving the wider environment in a direction of discouraging smoking. And we keep the thrust alive, among groups of users, of continuously promoting each other’s liberation from the grip of tobacco.
ASSESSING IMPACT Is the cessation process in motion? Our community worker and team have to understand what we want to achieve the beginning of a continuous process. It is one of people moving away from tobacco use. And the process has to take root among all groups of users. Our community effort can only be considered partially successful if it just manages to pick up a few users and stop or reduce their use. The final impact that we seek is a community wide change in mood especially among tobacco users. Reductions in use and quitting should occur continuously, once the correct mood sets in. 133
Many groups find it easier to stimulate their members to quit when they recognize how they are being duped. Tobacco users were not just duped into starting use. They are even now duped into continuing use. They are duped into underestimating the harm. And they are duped into believing that they ‘choose to smoke’. When users recognize who really has chosen that they smoke, they can make great strides forward to overthrow the manipulators.
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Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
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7.5 Help everybody understand why we should encourage tobacco cessation. Why we should be concerned about tobacco use in our community, and by any person outside our community too, was spelt out in chapter 1 and in section 6.5. We do not spell out that content here again, but touch on a few additional aspects relevant to cessation. The harm that tobacco is known to cause is so great that any normal human being should feel persuaded to take action to stop its spread. Most people probably find it difficult to understand, or believe, that some human beings can justify promoting tobacco. People are perhaps able to promote tobacco in good conscience because they deny or minimizing the harm. The tobacco industry too probably takes the line of subtly dismissing the suffering that tobacco causes, so as to retain self-respect. There are though some persons whom we meet in our own communities who appear to be determined to get everybody smoking tobacco. And some of them find it inexplicable that there should be people who are concerned enough to want to reduce the spread of tobacco. `Why is it a matter of concern to you', they ask, `if adults choose to smoke? They have the right to choose.’ This argument is not a denial of the harm. It questions why anybody should want to do something for the public good. And it also shrewdly introduces the confusion of any effort at improving the society one lives in, with attempts to interfere with other people's freedom. We must be very clear in our response. Community efforts to promote cessation, or prevent the spread, of tobacco are not intended to interfere forcibly with people's freedom to smoke. Some prevention strategies are indeed aimed at restricting certain freedoms. But certainly not the freedom for people to smoke in a way that does not harm others. The `freedom' that prevention work does wish to interfere with is the freedom of tobacco promoters to seduce newcomers into the habit, especially children. One reason why usually concerned human beings do nothing to stop the spread of tobacco is this kind of deliberate confusion that is put about by the tobacco trade. We mentioned in a previous section (6.5) that justification for spending energy to prevent the spread of tobacco is not really needed any more. The problem is that few people are aware of the real size of this harm. That about half of all smokers die of a tobacco related cause, and that tobacco is considered the single most important cause of preventable death, is not generally known. Diseases caused by tobacco not only lead to premature death but also carry a severe burden of physical suffering. And of those who die of tobacco related causes about half die in middle age, so resulting in major impact on still dependent families. 136
Let’s see whether we can remind people of the scale of harm caused by tobacco. ! ! Have you heard about the extent of harm that tobacco causes? How many of us recognize that tobacco is estimated to cause more deaths than AIDS, tuberculosis, maternal mortality, motor vehicle accidents, suicide, and homicide combined ? Is it not incredible that so little effort goes into reducing tobacco-related deaths, in spite of this horrifying scale of harm? Do we take little notice about tobacco related harm because we think that smokers are to be blamed for smoking, and that it is their own responsibility that they have to suffer these illnesses?
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Our community worker can continue on the themes related to this subject from previous discussions. Let us here try to focus a little more on aspects that were not dealt with at depth previously (in section 6.5). ! Have we noticed more subtle harms from tobacco that smokers are less productive, often tense, and unable freely to enjoy happy occasions without nicotine? Have people who've begun to smoke regularly become very different from what they were like before? Are people who smoke generally more irritable especially when they are without a cigarette? Do people who smoke look different from their peers after they have been smoking for a few years?
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We do know that tobacco smoking interferes with blood supply to all parts of the body. This is how it leads to increased occurrence of sexual weakness in men, `heart attacks', `strokes' and loss of limbs from gangrene. Loss of blood supply affects the skin too. So people who smoke look older than their peers do. Appearance and attractiveness is impaired due to other reasons too. When people are not in a relaxed or happy mood they look unattractive. And the mood of people who are dependent on tobacco is often impaired every time that they are in need of nicotine. Attractiveness is dimmed not only by nicotine staining of teeth, discoloured lips, bad breath and repeated coughing. Not only does smoking make people less attractive and less pleasant, it also similarly affects places where it occurs. Let's raise this issue too. 137
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PROGRESS REVIEW We hope that people in our community will begin to recognize the pervasive impairment that tobacco, especially smoking, causes to people and to places. These subtle harms are not readily recognized. Success here is measured by increased sensitivity to these less readily noticed damage caused by tobacco. Pollution of the environment is an aspect that too is not readily recognized. We could awaken people's awareness on some of these issues too. ! How many of us think about cigarette butts as the likely cause when we hear of fires that devastate a row of houses or a large forest? Do we realize that tobacco users dump tons of butts, empty packets and other debris, without any feeling of responsibility for the pollution it causes? Have we considered the bad odour that tobacco leaves in houses, offices and other buildings and on the clothes of all who happen to be close to a smoker?
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A different kind of harm that smokers suffer is the beguiling to which they succumb. Smokers are handled like puppets and made to do what the tobacco trade wishes. And they do not even realize that they are being manipulated. So they defend the trade that cynically exploits them. Let's briefly touch on this with our community. ! Have we recognized how smokers are continually given the idea that smoking is harmless, and a great pleasure? Who is responsible for creating the idea that we should allow people already beguiled into smoking to continue to smoke? Have we too been made to feel that smokers can never give up? Have smokers been made to fight for the `right' to smoke? Have they been made to feel that efforts at tobacco prevention are a move against them? 138
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Have they been targeted in ways that will increase their consumption e.g. by competitions that encourage them to buy packs instead of singles?
The range of subtle harms is wide. And their collective impact in diminishing the quality of life of tobacco users and of non-users is considerable. We have only itemized a few examples.
PROGRESS REVIEW Are people becoming more sensitive to the wide range of impairments of the community’s well being caused by tobacco? As before, we need to check informally for increased awareness of, and concern about, this extensive damage. We should look also at the benefits of quitting tobacco. Many tobacco users feel that they have now damaged their health and there is no point in quitting. But the risks of developing several tobacco-related illnesses begin to come down after quitting. There is a tendency to make people continue to smoke by creating the impression that they are already harmed by tobacco use, so there is no need to try to quit now. This tendency is generated seemingly unwittingly, but we need to be vigilant about how this impression is fostered. Let’s raise some of this with our allies in the community. important for discussion with our groups of smokers. ! ! ! ! Is there any real benefit of quitting now? Don’t some of us say, ‘won’t we die anyway, whether we quit or not’? What do arguments like this achieve for us? Who really is interested in promoting such arguments? These issues are most
People who stop smoking benefit from the moment they stop. The greatest benefit is probably the feeling of freedom. When people quit without ambivalence they begin to experience a sense of freedom from the moment that they quit. The sense of achievement for having quit a habit, which they had previously felt was not within their power to stop, is also a great good feeling. And it too starts from the moment of quitting. The economic benefit too operates from the moment of stopping. This gain is especially important for people who are economically underprivileged. But this is often not recognized. We can draw attention to it. ! ! How much money did I spend on tobacco every day? How much do I earn daily? 139
How is it that we paid no attention to the numerous benefits from quitting?
Are there outside influences which tend to make us underestimate the benefits of quitting?
Is there a tendency to underplay the benefits of quitting and to exaggerate its ‘difficulties’?
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Other apparently trivial benefits too are important. Simple things, such as the fact that the person who smoked no longer smells offensive, are still important for the well being of the individual as well as of others in their lives. Improvement in the taste of food, freedom from constant irritation and clearing of the throat, and increased exercise tolerance are all to be experienced from the earliest days of tobacco free life. These are worth raising with our tobacco users. ! ! How is it that we paid no attention to the numerous benefits from quitting? Is there a tendency to underplay the benefits of quitting and to exaggerate its ‘difficulties’? Do we too do this because we are not ready to quit? Are there some people among us who tend to do this more than others? Are there outside influences which tend to make us underestimate the benefits of quitting?
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ASSESSING IMPACT At the end of this section, there should be greater awareness of the harm that is caused to our community by the use of tobacco. And we expect that people would have become more aware of the subtle forms of harm too. A question or two in passing may be enough to check whether this realization has indeed occurred. If the appreciation of the different types of harm is still minimal that is no bar to proceeding with other issues. We can increase the awareness of the community even as we learn more about tobacco related damage.
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Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
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7.6 Examine from the start whether the atmosphere is changing in the right direction In our ‘prevention’ work we checked whether there was a gradual shift in the way tobacco and tobacco smoking was seen in the community. Here too we want to know whether the atmosphere is changing. We are now particularly interested in finding out whether it is moving in the direction of encouraging smokers to think about quitting. It should also make tobacco users feel that quitting is something that they can and should undertake now. We must look for a shift in this direction. We can raise the questions that need to be answered. ! Are people who are concerned about the welfare of the community becoming increasingly committed to reducing the amount of tobacco used in our community? Is everybody beginning to recognize the different ways in which the tobacco trade too contributes to making smokers continue to smoke? Do people see how they can counteract these influences? Do smokers realize that they have been seduced into an unpleasant habit from which they should try soon to escape? Do they see how the tobacco trade has deliberately got them into a killer habit, well aware of what they were doing?
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The changes that we are looking for must happen among our tobacco users. They need to be weaned away not only from tobacco use, but also from the covert propaganda of people they see as their ally the tobacco industry. How the industry has taken over the hearts and minds of their victims has to become evident to these very victims. Let’s continue with the issues that we need to examine in relation to our smokers, and other tobacco users. ! Do smokers in our community no longer smoke in a showy or flamboyant way? Are smokers sensitive to the ways in which certain insertions in newspapers, magazines, films and on television serve to dissuade them from quitting? Do they try to ensure that even their least perceptive friends will see the need to devalue smoking, and to try to escape the habit? Do smokers make sure that they do not encourage others to smoke by word or deed? 143
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PROGRESS REVIEW These were some issues that we discussed in previous sections. We want to check here whether early signs of progress are to be seen among groups of people who currently use tobacco. The indicators listed are easier to achieve than, say, quitting smoking as a group. We want our groups to start moving. Results will continue to flow when movement starts. We can add to these examples other things that we want to monitor on a regular basis. There were other areas in which we expected to make gains. These were changes that were likely to follow the initial awakening of awareness of tobacco users about the damage that was being done to their lives. Such steps included tobacco users encouraging each other to give up or reduce their use. Along with this we expected to see at least some of them giving up their tobacco use or reducing the quantum of use. We can monitor progress on this line as well. Is the mood among tobacco users now different? ! ! Are they encouraging each other to quit? Do they speak of smoking in a way that shows that they see it as a burden to be got rid of ? Have people begun to reduce consumption? Have people begun to quit? Are those who have not made any change happy with the progress made by their more advanced colleagues? Are they too in the process of moving towards taking control over their tobacco use?
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There are longer-term indicators that too can be monitored, such as the number of people who have quit or reduced consumption or the quantum of tobacco sales in our community. These are discussed later, in section 7.9.
ASSESSING IMPACT The result we expect from sharing the content discussed in this section is different from the previous sections. We are not seeking to change any specific tobacco-related 144
mood or behaviour, but rather to stimulate the community to look more broadly at the changes that have occurred. So we should look at whether the community has begun to look at the changes within it. Are they looking at movement in the attitude of current users? Will they recognize progress when it occurs? Can they keep giving the relevant inputs according to the progress that they find? As in the prevention effort, a continuous movement or change is the most important result. Quitting, and reductions of use, are the anticipated spin-offs that should continually result as the process proceeds.
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Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
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7.7 Create vigilance amongst all, about how our efforts may be undermined. A community can make great strides in helping its tobacco users to quit. And it may then falter after some time. Our communities must make continuous progress for the maximum benefit. The likely reasons for their efforts to falter should be recognized, anticipated and handled correctly, from the inception. This should make uninterrupted progress more likely. Among the reasons for our successes slowly fizzling out is the natural tendency for any endeavour to gradually lose momentum with time. Another is the deliberate undermining of it. Parties interested in undermining the community’s efforts on tobacco cessation could include some current smokers or people in the tobacco trade. Rarely, there can be opposition from existing ‘leaders’ in the community who did not join the move to defeat tobacco. Their opposition could simply be the result of not liking to be left out of the leadership of any community activity. Preventing or minimizing the opposition from these quarters should be a consideration from the start of our activities. Even as we work with smokers and help them to see the fact that we are working for them and not against them, we could encounter some resistance or displeasure from some. Not all smokers are likely to be completely enlightened and perceptive. Those who are not able to appreciate the efforts to reduce tobacco-related harm may want to undermine the whole process, simply because they are not yet ready to quit. Such persons can feel threatened by the change in the community. How can we minimize this risk? We can raise this with our communities. ! ! Are there still people among us who’d like to undermine our successes? How can we minimize the number of smokers who wrongly see our efforts as a threat to them? Who are the people who currently smoke, who feel that the cessation endeavour is a move against them? What mistake have we made to give them this impression? How can we win over the hearts of smokers who may try to obstruct our efforts? Can we make a special effort to get the cooperation of those tobacco users who feel threatened by our activities? How can we neutralize their efforts, if we can’t win them over? 148
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We should recognize that there could be some unenlightened persons who are unhappy when others move away from the tobacco habit. This awareness alone should enable us to detect any minor displeasure that exists. The displeasure that some people feel is not openly expressed. So we need to be sensitive to ‘soft’ expressions of opposition. We must be particularly vigilant about unhappiness among people who currently smoke. And when we spot such a feeling we should quickly and repeatedly reach out to the people concerned. Among ‘opponents’ of the cessation drive there may be the local trader or traders in tobacco. They may be unhappy when sales come down, because they believe that their earnings are then likely to fall. Those who make their money only, or mostly, by selling tobacco are indeed likely to suffer a loss in profits. But this is not always the case for small traders in our communities, who sell other goods too. If they are perceptive enough, these traders will realize that the percentage of profits that they earn from tobacco sales, especially cigarette sales, is generally much lower than what they earn by selling any other commodity. So any move of consumer spending away from tobacco into another product gives the trader greater profit. Local traders who are not sharp enough to understand this may even team up with the few smokers who feel unhappy that their habit is now seen as a weakness. They may be inclined to try and prevent the progress of the community. In a small community the force that tries to prevent our efforts succeeding are mostly these kinds of less informed people, rather than the organized tobacco trade as such. Often though there are local level dealers of the tobacco trade who may feel upset that the efforts of the community are succeeding. These issues can be raised with the interested persons in our community. ! What are the things that someone who is unhappy about the community’s efforts may do? In what ways can they discredit the efforts of reducing tobacco consumption?
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PROGRESS REVIEW Are we sensitive to the possibility of our efforts being undermined? If the community recognizes the most likely sources of unhappiness, it can forestall most of the undermining. Although there may not be open hostility, opposition can exist ‘under the surface’. Should our community recognize this, and the ways in which such displeasure may manifest, we have made the required progress. We can then turn to the other major reason for activities fizzling out after a time. The issue of our enthusiasm declining can be raised directly. 150
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What are the factors that lead to our enthusiasm declining after some time? Is it not ‘natural’ for interest in anything to decline after a time? How can we start things in the right way, to ensure that our interest will not disappear quickly?
There is no magic solution to this problem. Anticipating a gradual loss of interest is part of the remedy. Another is working out different means for ensuring continuity. One safeguard against rapid loss of interest is to start with the longer term in view. A big `crusade' to root out tobacco may attract a lot of attention. But it is unlikely to produce a sustained result. Whatever we do should be possible to sustain without spending unusual energy. The method recommended for getting our community to move is simply asking a few questions repeatedly. This requires no special `campaign' or planning or organization at all. It is to be undertaken as a part of our day to day life.
ASSESSING IMPACT Have our communities recognized the ways in which their work may be blocked? We can check at the outset whether they are sensitive to the different possibilities. If they are not, this longer-term perspective has to be raised with them, until they include it in their thinking.
151
Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
152
7.8 Strengthen the community to deal with problems and ensure sustained progress. We discussed the issue of sustaining progress in relation to the prevention efforts too. So we will here refer briefly to just the considerations that apply to populations of tobacco users. Sustaining progress in promoting cessation is not an energy consuming or strenuous activity. It is simply helping smokers to discover that their attachment to smoking is a hindrance to the free and full enjoyment of life. If they can see that it looks ugly and silly, and help others to see this too, that would make things proceed even better. All of this requires only gentle probing, to assist people to see beyond the smokescreen put up by the tobacco trade’s overt and covert marketing. The challenge is to make our groups of tobacco users constantly examine the effect that their use has on their lives. It is easy to raise this issue. It is similarly easy to create recognition of the restriction that tobacco use imposes on their free enjoyment of life. Although all smokers will not be able to recognize this, the majority can be awakened enough. But the subject is not going to remain on their agenda. So the group will go on smoking whilst at the same time being aware of its restrictive impact. And after a time this too will be ignored or forgotten. Let’s see what our groups say to this. ! Although we recognize how smoking spoils the full enjoyment of life, will we not continue to smoke out of habit? If we continue using tobacco from habit, or for the need for nicotine, will we not soon ignore the fact that it imprisons us? And are we not likely then to be taken along by the rest? How can we keep reminding ourselves of these issues, for long enough to make an impact?
!
! !
We want to keep reminding ourselves about how we have now begun to think. This has to be kept up long enough and not quickly pushed into the background. Of the people in our groups of smokers, the least advanced will be unwilling to dwell on this subject. Let’s see how we can keep them engaged for long enough. Some of us will have to take the lead to keep reminding each other and asking about progress. Perhaps we can get help from outside too? Our community worker may be happy to engage in a dialogue for as long as it takes to make a noticeable change. 153
Wake Up
Morning Tea
Go to the toilet
At the bus stand
154
Arrive at office
10 o’ clock tea
Lunch time
I am stressed
Giving up smoking is freedom from all this 155
PROGRESS REVIEW Are members of our groups, primarily tobacco users, thinking about the need for sustained reminders and stimulation? If they are, have they thought of how to organize this? Thinking about the likely course that our initially enthusiastic endeavour may take, is necessary at this stage. Sustained action is more likely when we have thought about it at the beginning. Keeping up the interest of our community worker too has to be thought about. She or he too may lose interest after a time. Although our initiatives do not require a great deal of organization they still have to be remembered. And even that effort can slowly atrophy. We can learn from other initiatives how such gradual atrophy may be avoided. ! ! ! What kinds of activities do we know to be sustained? What kinds of activities last only a short time? What lessons are available to us from the answers to these questions?
Activities that are driven by availability of continuous resources or funds generally continue. But our approach so far has been to see how we can manage without having to raise any funds. Other activities that continue are those which are part of the `responsibility' of an existing stable organization, such as a government agency or a private company. `Voluntary' or non government activities less often continue in a stable way. Voluntary activities are likely to persist under some special conditions. Enlightened commitment by people who understand the need for sustained action is one condition that leads to persistent beneficial activities. Another is selection of activities that do not require special effort or a large amount of resources. A third factor promoting sustained efforts is linking up with larger entities that can provide us with regular stimulation and guidance. ! Are there people outside our community who can advice, encourage or support us to continue? How can we use their advice to make sure that our efforts do not fizzle out after a time? Can we learn how to notice even the small progress that some make, so that we can see the results of everybody’s actions as we go along?
!
!
And it is useful, after we have made some progress, if we can help a neighbouring community which has taken no action at all about its tobacco use. This serves two 156
purposes. If we give the proper kind of guidance, another community too can begin to grow. More importantly, the offer of help to a neighbouring community or just another group or smokers helps us sustain our progress. ASSESSING IMPACT We are not looking here for evidence that the community initiative has sustained itself for several years. We want to see evidence that the foundation has been laid for sustained action leading to results. How well are our groups already addressing the question of ensuring long-term continuance, even in these early days?
157
Write a letter to those you advise to give up smoking
Those who are contemplating quitting may need some encouragement. Follow up appointments or maintaining contact by letter or telephone is a good idea.
Dear Sunil, Following our discussion last week on smoking I hope you have had success in your efforts to quit. I would be happy to see you next week and discuss your progress. I have left Wednesday afternoon to meet up with people who are making progress in taking control over their smoking habit. Yours truly M. Anthony Dr M. Anthony
158
Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
159
7.9 Encourage at least a few persons to look for more remote or longer term indicators of progress Changing the way smokers see and experience tobacco use, helping them discover how they have been duped in the past by the tobacco trade, and developing new ways of overturning the forces that promote tobacco, are all quite challenging and enjoyable activities. So we don’t need special effort to keep going. And it is not too difficult to monitor whether the opinion in our group of smokers is changing. These immediate outcomes must, however, eventually impact on the amount of tobacco consumed in our area and in the numbers who are persuaded to start smoking. Monitoring these remote results is more difficult and less interesting than measuring day to day progress. For our work to be sustained, and for our own education, we need to measure the ultimate impacts too. Thus we must set up a few ways of looking at changes in total consumption, changes in the number of new recruits and changes in the number of current users. This is a little more difficult to do than the previous tasks. So we cannot expect our whole group to become happily involved in assessing long-term impact. If one or two people agree to take on the task of monitoring longer-term impact, that should suffice. The approach here is similar to the one described under this heading in section 6.9. But we emphasize here the elements relevant to cessation activities. A few questions have to be raised with the groups that we are in contact with. ! Are there some among us who would like to study the longer-term impact of our work? How shall we measure the changes that occur in our group by next year? Can we not record a few indicators now, for later comparison? For example, how can we assess whether the number of cigarettes smoked by members of our group has increased or decreased?
! ! !
These are relatively easy and straightforward things to measure. All we need do is to keep a record so that we can compare with the situation some time later. If there is someone who shows enough interest in this kind of task, it is worthwhile for us to keep track of what we’ve been able to achieve. More elaborate measures include total consumption of tobacco in our village or other community. ! Is it possible to record some indicators of sales in our community? 160
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How can we check the number of people who have quit, other than those in our small group? What are the tobacco related problems such as worsening the impact of poverty or deaths and diseases caused by tobacco that we should monitor, to see if these too come down in the longer term?
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ASSESSING IMPACT If the community as a whole, or groups of smokers, take up the issues covered in this section we’d be able to see recorded information. They will have some assessment on the total consumption by a given number of users in their group. They should have some note on how this information was gathered, so that we can follow the same method later, for comparison. Should there be no records at all, we can ask them whether they wouldn’t like to know later how much of a change they’ve achieved. But our community worker should not try to press them too hard to keep gathering data and recording it. Such activities are not very interesting to most people. The idea that we should try to quantify the impact can be shared. It should be left to each group how they choose to do that.
Groups of smokers keep record of consumption over time
161
Learn about the forces that promote tobacco
Is the atmosphere beginning to change in the right direction?
Engage these forces
Strengthen the Community to deal with problems
How are vulnerable members influenced? Create vigilance amongst all, about how efforts may be undermined Why should we counteract these influences? Work out new ways to get more exciting results even faster How can we counteract these influences?
Ensure sustained progress Community takes action
Measure progress
Join the community in celebrating progress
162
7.10 Join the community in celebrating successes and working out new ways to get more exciting results even faster. Progress is easier to recognize, and therefore celebrate, in cessation work than in prevention. If we find that someone has stopped smoking in the last month, this is really happy news. And it will now be a cause for celebration even among smokers. It becomes an example to other smokers that freedom from tobacco is not so hard to achieve. For the whole community too this should be a symbol of success. It serves as a reminder that we can overcome strong social influences created to keep us tied down to suffocating habits. More notice than now should be given to these kinds of successes. Let’s raise this with our groups. ! ! Do we recall anyone who stopped smoking in the last month? Did we think it was a special achievement and pay due attention to it, or did we ignore it?
Communities do not celebrate enough a smoker’s victory against the various subtle and unseen influences that serve to keep them on the treadmill. This is probably because it’s seen as too small a change in relation to the large number of people who still smoke. Underestimating the value of achievements made is common. For small successes to serve as a stimulus for further achievements, we must learn to recognize at least the progress that members of our own group make. ! ! ! Have we seen any improvement in our group in the last week, or last month? Have we noticed even a small encouraging sign but failed to respond to it? What can we do to share news of even the slightest progress, without letting it go unnoticed in future? Shall we try to report to each other any sign of progress that we see, in every member of our group, in the next week?
!
All of us could be making small gains, too small to be noticed. Let us focus on such small steps that we can all make. ! Can we start by sharing something interesting that we said to somebody yesterday, which made him think? Are there examples of this kind that we’d like to share, where we have got a positive response? 163
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How can we teach everybody in our community too to notice these kinds of signs, and to share the good news with as many others as possible?
We are trying here to create a habit of noticing small gains. Along with this we want to encourage each other to make even a small gain, and never to stagnate. This is why we’d like all members of our group to work on making even a minimal gain. Encouraging each other to simply say something positive is a simple start. Events such as somebody quitting are great achievements. They should be given more attention than less significant gains. If two people stop smoking, that is equivalent to one life being saved such is the mortality associated with tobacco smoking. People do quite often quit smoking, but usually only after they’ve survived a heart attack or developed cancer. Until then the propaganda of the tobacco trade is too strong for them to consider quitting. Do people understand how significant an achievement is for someone to quit smoking, before he gets cancer? ! ! Why is it such a significant achievement? How do most people manage to quit smoking without too much difficulty after they get a heart attack?
It is indeed an achievement for someone to break through the smokescreen that keeps him smoking until he gets a heart disease or cancer. A good deal of insight is needed to recognize the tactics that are used to keep the smoker laughing at the risks of smoking. And a good deal of support from other smokers helps the individual smoker to break free of the clutches that have been created to keep him tied to the habit. There are always successes to celebrate in the cessation effort. If we are sensitive we can see the tiny achievements that our smokers are posting daily. And there are major achievements that occur from time to time, to celebrate more vigorously. One of our group quitting, another reaching a month off tobacco, and yet another reaching an year of freedom from tobacco, are instances.
ASSESSING IMPACT Are there many groups of smokers who have now begun to monitor their progress in freeing themselves of tobacco? The more such groups there are, the more there is to celebrate. Do they notice small and large achievements by their members? There should also be a means for groups to exchange information among each other. 164
Sharing ideas and informing each other about different kinds of successes that have been made is then established. Finally, there should be recognition, throughout the community, of the progress that several groups of smokers are making. When a community has cause to celebrate the air of freedom that is blowing through it, it has come a long way. And, if people in it are wise, they’ll learn to apply the lessons they’ve learnt dealing with tobacco to other scourges too.
Groups of smokers monitor their progress
Groups of smokers exchange information
165
MEASURING PROGRESS CHAPTER 8 Throughout this manual, we have emphasized the need to look at progress as we go along. Signs of progress to look for have been included in detail, in connection with each activity. This short chapter is simply to bring some of these ideas together. Our work with a community is not a project that starts today and ends on a given date. The community will need to continue to work, even if nobody now smokes. Preventing tobacco use is a continuous activity. So there is no real end point for measuring results, but rather a continuous process of assessment, and modification as necessary. And vigilance is needed as long as the organized trade that promotes tobacco survives. Quitting tobacco too is not just an end point. All those who have stopped smoking need to come further alive not just remain passive and vulnerable. They have to take the initiative of continuously working on others who still smoke. So measuring progress too is a continuous activity. Because we are serious about producing a change in our communities, we will pay adequate attention to assessing whether there is any response to our efforts. In each of the steps that were described above, there is a component of looking for results. These are as relevant to someone from the community as to our field worker. The intention is to make them look for changes as they work, rather than wait for the end to look at results. 166
In This Chapter Different ways of measuring Purpose of measurement Recalling measures already suggested 212
214
216
If we wish to be more rigorous in evaluating our efforts, we need to add to the measures that people in the community have used to assess progress. This is in order to increase the validity of the results. We can then with confidence continue with the approaches we are using, or choose to make changes. Our work with communities is not to satisfy some outside agency that wants us to ‘evaluate’ our work. We want to know whether we are doing the right things. So the assessments that we do should be adequate for our purposes. Our main purpose here is to find out whether we are wasting our time and energy doing things that are not effective. There is no need to measure changes that are being achieved if we are not prepared to learn from the information that we gather. We measure results because we are prepared to change our approach should we find that it is ineffective. Some people go on doing the same thing without looking for appropriate impact, even if it has no signs of benefit. This is partly because they are committed to a particular approach. Or they continue the same strategy because they cannot now learn anything new. Those who have learnt to go to communities or schools lecturing to children about the diseases caused by tobacco may spend all their lives doing this. And they may go on despite there being no indicators suggestive of a beneficial impact. Others may decide that something needs to be added to the activity to make it more effective. Or they’ll change some aspect to see if there is a greater impact. Those who have learnt to go to communities or schools lecturing to children about the diseases caused by tobacco may spend all their lives doing this. And they may go on despite there being no indicators suggestive of a beneficial impact. Others may decide that something needs to be added to the activity to make it more effective. Or they’ll change some aspect to see if there is a greater impact. Commitment alone is not enough to defeat the tricks used by the trade to get our people hooked on tobacco. We have to be prepared to learn from our experience and that of others. If we are indeed prepared to learn, and to change, then there is a point in assessing the impact of our work. If are not prepared to learn and to change, there is no need to assess impact. We should look for impacts appropriate to the inputs that we make. We should not give a few lectures in a school and then check whether tobacco use in our community has come down two years later. We must look for changes that are appropriate to the size or power of the action we have taken. To get a proper idea of whether our work is on the right lines we need to do rather systematic studies. Such formal research is often boring for some active people who are interested in making a change in the world. Such people should not be persuaded to spend most of their time making assessments or making their measures absolutely reliable and valid. They should only be encouraged to look for appropriate indicators, relevant to their day to day work. 167
Measures of progress
The level of involvement of high risk groups in our prevention work
The level of understanding of factors that promote the spread of tobacco use amongst staff
Qualitative improvement in the work of these groups
168
Formal assessment of results includes looking for the changes that we described in the preceding chapters on activities. If a few people can be persuaded to look at longer term results they should set down indicators, at least of total consumption and the proportion of smokers in different age groups. This can be used to compare with the situation that emerges at selected intervals. We may set up a means of checking results independently of the people who are working in the community. Short and long term changes that are useful to assess were described throughout the preceding chapters. Members of the community will be sensitive to the factors that lead to cessation of smoking or reductions in consumption by current smokers. These factors too were dealt with in detail in the preceding chapters. We can try to document systematically the factors that different communities and groups choose to monitor, along the lines indicated in the previous chapters. We list below a sampling of the kinds of things that were suggested for communities to monitor. Improving their understanding of the relevance of these indicators is also necessary. The ‘indicators’ listed below fall into a model for understanding how tobacco is spread and how it can be prevented. And they allow communities to look for more immediate evidence of progress. The list of indicators is picked up from the content of the preceding chapters, on prevention and cessation, and is given simply as a reminder of the range of things we should look for. The examples are not presented in a particular order of priority. We referred to measures of how our work is going and to measures of changes that have taken place in the community. The following are indicators of how our work is progressing. ! ! The level of interest and involvement of our community worker or workers The level of understanding of our staff or community team (for example, regarding factors that promote the spread of tobacco use) The way in which smoking by members of our team is seen by them and others The level of involvement of active and rebellious youth in our prevention work The level of involvement of smokers in our work The interest and commitment of the community groups The qualitative improvement in the work of the community groups 169
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Measures of consumption
The number of times the tobacco delivery van visits our town
The amount of cigarettes sold in a shop in our village last month
The number of people seen smoking in a public place
The number of smokers who have quit
170
A list of selected indicators of impact at community level follows. ! ! ! The number of people who have quit The number of people who have reduced tobacco consumption The number of people who express unhappiness about their own smoking habit The number of people who say they want to quit tobacco use Smoking being seen as a sign of gullibility or weakness Smoking being seen as a sign of being old fashioned Smoking being seen as a sign of insecurity or poor self esteem Smoking being seen as ugly and unattractive Changes in the way tobacco is perceived Changes in the way that the tobacco trade is perceived Changes among persons engaged in promoting tobacco The community’s understanding of overt and covert tobacco promotions e.g. In films or at dances and youth concerts The community’s resistance to overt and covert tobacco promotions Changes in intensity and quality of tobacco promotions Changes in the amount of publicly visible smoking Changes in the way people smoke e.g. With embarrassment not flamboyance
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This list, of changes that we can look for in the community, is just a selection from the things that we discussed in the previous chapters. Since these issues are to be monitored as part of the intervention itself, there is no great extra effort needed to keep monitoring how things move. Measurement of progress is most useful when the people conducting the activity do the monitoring themselves, so as to make sure that there is adequate progress. For systematic assessment, the observations made by the community as part of the ongoing interventions need to be rather carefully recorded and regularly checked. 171
Long term measures
Reduction in sales
Reduction in consumption
Reduction in disease and death
172
Measuring change in an individual
Select a variable
eg. attitude about smoking
Draw up a scale
Attractive
Silly
Record your results
Attractive
Silly
Re set after some time
Attractive
Silly
173
Measuring change in the community
Number of people who think smoking is silly
None
Few
Many
Amongst all
174
REACHING NEW HEIGHTS CHAPTER 9 For the work in our community to progress and prosper in the long term, there will have to be a constant move to reach new heights. And this means going beyond the ideas in this manual. It also means going beyond just our local community. An important contributor to reaching great heights is the willingness of people now in the leadership of the prevention work to allow active and honestly committed newcomers to become part of the effort, as equals with the rest. This will allow an increasingly larger segment of the population to be informed and involved. The wider the ownership of the prevention effort the greater the heights it will reach. Success is achieved when the population at large understands how people are being influenced and recruited into smoking, and takes the initiative in preventing or counteracting these influences. But there is a special problem in applying this principle to tobacco prevention. The prevention of harm from tobacco is not the same as, say, preventing the spread of HIV infection, reducing suicide or combating some other public health problem in a community. With regard to these other problems we need only to understand the causes accurately and counteract them. But in tobacco prevention or cessation work, the situation is different. There is a very influential agency working constantly to promote uptake and prevent cessation of tobacco. Such an influence does not operate in cases such as HIV infection or most other health problems. 175
In This Chapter Broadening the ownership Special challenges and difficulties Undermining by tobacco trade Changing industry behaviour 221
222
223
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Effective tobacco cessation or preventive action requires constant vigilance about the new strategies that will be used to promote tobacco. And most of these are insidious and often not noticed at all. Reaching new heights requires a high level of vigilance about, and good understanding of, the ways of the tobacco trade. What is effective today will not be effective next year because the tobacco trade will have changed its strategy for promoting the uptake of smoking by young people and of preventing smokers from quitting. We need to be sensitive to the measures that are used to counteract the activities that are successful today. This difficulty of having always to be vigilant to new threats is what makes the prevention of tobacco related problems more of a challenge than most other public health initiatives. There is no quick solution to this challenge. The most important response is for the community to discuss from time to time the things they see in their own community and in the various external influences that reach their community. A second problem faced in tobacco prevention or cessation work is that the trade may well try to undermine, obstruct or deliberately stifle any efforts that are successful. This again one does not face in most other arenas in public health other than perhaps in trying to reduce alcohol related problems as well. To achieve success we need to be aware of the methods that could be used to stop or undermine our efforts, and be prepared to accept this too as part of the challenge. Great heights can be reached if the tobacco trade too can be induced to reduce or stop its promotions. This may appear a futile or meaningless task. But some tobacco companies in the region have already claimed that they want to prevent children starting to smoke. Whether this is genuine or a ploy to increase the attraction of smoking to young people will be visible from the action they take in the name of prevention. But the fact that they have stated this is an indication that the tobacco trade has been pressurized enough to make at least a cosmetic response. If the actions taken are only cosmetic there is room to press them for action that will genuinely lead to the objective of stopping children smoking. This requires action beyond the limits of our local community. We should then try to persuade the trade to prevent cheap ‘starting brands’ being marketed, for instance. Similarly the tobacco trade should be persuaded to look at the ethics of ‘covert’ or hidden advertising, or the use of youth entertainment as a vehicle for spreading smoking. This means that the people in charge of marketing tobacco should feel some loyalty to the people of our country. In that event they should attempt to persuade their external employers to scale down the promotions in our country, at least. Or they should try covertly to minimize the impact of their marketing. This should not be too unrealistic as the people who now implement the marketing of tobacco for foreign agencies are still nationals of our own country. 176
People in our community may not be able to reach the powerful members of the tobacco trade. But we can try to address those that we can reach. Even the ‘representative’ from the trade who comes to distribute tobacco to the local sellers can be addressed. It is unrealistic to expect employees of the tobacco trade suddenly to achieve an unusual level of enlightenment. But they may gradually begin to realize the potential they have for saving a large number of lives. If they do, and begin privately to support the country’s tobacco prevention efforts, unprecedented heights will be reached.
177
APPENDIX Guidelines for helping individuals who seek help to stop tobacco use These guidelines refer to the kind of help that we can offer through a local hospital or clinic. These are not a form of ‘specialist’ intervention that has to be left to ‘experts’ to deliver. All the interventions described in this appendix are appropriate for implementation through any clinic or helping service, however small or simple. Many things can and need to be done by our community, in our community, to help people quit tobacco use. The vast majority of people who have quit smoking throughout the world have done so with no medical or other formal specialized support. A small minority needs some special help - and how this can be provided is outlined in this appendix. There is a small risk too, that exists in providing a special helping service for people to give up smoking. The risk is that all smokers in our community could be given the idea that they cannot stop smoking without some special help from our clinic. We must guard against this risk, while still offering the benefits that we can deliver through our clinic. When even one person in a community gets some special help to stop smoking, other smokers in the area may begin to think that they too need special help to quit. The impression is then strengthened that one cannot stop smoking easily, and people are not encouraged to give up on their own. We must make sure that we don’t unwittingly send a ‘hidden’ message, that people must have special help from a clinic such as ours if they are to quit smoking. So our helping should not appear to be something that people must get, to help them quit. Our help really is meant for the few who are not capable of giving up on their own. In many cases, the people who find that they have not enough strength to give up on their own, despite good support from the community and family, are the ones who are not quite sure that they want to give up just yet. So we should offer help through our clinic without in any way taking away the power that smokers already possess, to take control over their habit. The majority should not be ‘disempowered’ (made to feel that they do not have the control or strength to make the relevant change in their own lives) because of our special support for a small group. We should always remember, and remind others, that the vast majority of people who have successfully quit smoking have done so on their own. With this caution in mind the following guidelines are suggested, based on experiences of centres in our region and from outside it. A supplement in the journal ‘Thorax’ in Dec 1998 (Volume 53, Supplement 5 Smoking Cessation Guidelines and their Cost Effectiveness) is still a most useful resource on the subject. These need to be modified according to local circumstances. The suggestions below are based on an understanding of the realities in a Primary Health Care setting or a small local hospital or clinic in the South East Asia Region. 178
The following then are guidelines for practice through our hospital or clinic. Always ask about smoking (and other tobacco use). This should be done at every practicable opportunity. Health staff who are genuinely interested notice, and even create, many more opportunities than those who are not. If any patient smokes and we have not realized this, we should see this as a failure on our part. In some countries this may soon be seen as amounting to negligence. All patients who smoke should have an entry in their medical notes. A patient who has previously been noted as a smoker should always be asked at subsequent visits when he stopped smoking. If he has not, what efforts he made to stop. Whose support did he seek? Did he not let his family and friends especially those who smoke know that he was quitting? Why is he still continuing? All smokers should be asked why they continue to smoke. Have they not tried to stop? Do they not realize they are being seduced into continuing rather a foolish habit? Do they know about the contribution smoking could be having to their current illness? Do they know that smoking causes numerous cancers, heart disease, sexual weakness, wrinkling and premature aging of the skin, and loss of blood supply to the limbs leading sometimes to amputations? Ask whether family members of patients smoke. This is a health hazard for all members of the family. In addition, tobacco may be responsible for worsening other problems resulting from poverty. The proportion of poor people that smokes is larger than that of rich people. This is connected with education too. Smokers among family members who accompany a patient can also be persuaded to consider quitting. This should be part of the public health role of a health facility. Others in the patient’s household who smoke could also be reached. Those who attend the clinic could be asked to convey the message from the health staff that other members of the patient’s household who smoke should be encouraged to quit. Such persons can be asked to contact the clinic if they feel they could benefit from further encouragement and help. Continuous questioning and attention helps change the mood among the public too. The idea that smoking is an important health problem then gets reinforced in the community. The benefit of such questioning is not only that some smokers will quit as a result. There is the added benefit that such questions influence the mood in the outside world as well. Alliance building with any smokers who come as patients or who accompany patients is beneficial. The person must feel that you are interested in his welfare. The only way to convey the idea that you are concerned about his welfare is to be genuinely concerned. Where there is no real concern it is best not to try to pretend that there is. 179
When there is a bond that gets established, even in a two minute interaction, any advice or suggestion you make is likely to be taken seriously. And people usually recognize genuine concern quite easily. This is not dependent solely on the time that is spent. It depends mostly on the feeling that is present. If the person carries back with him the feeling that you were concerned, the alliance may continue even if he does not visit you again for years. Advise all smokers to quit. This advice should be clear and firm. People are more likely to act on advice when they recognize it as personally directed at them. When people visit health facilities, they are open to personal communication. So the advice giving should also be directed to the person specifically. It takes only a few seconds to give a specific, personally directed and firm message to the patient to quit smoking. A minority stops with just this advice. We should realize the value of this apparently small success. The number of lives directly saved makes this one of the most cost-effective health interventions. We may like to try and increase the proportion that complies, by investing a little more energy if we are so inclined. In that case, it is useful to remind the patient of the possible relevance of his tobacco consumption to his current illness and the other hazards known to be associated with it. Most importantly he needs to be informed that these risks start coming down when he quits. Assist smokers who like to stop, to the extent that you practically can. Measures to assist people to stop smoking do not have to be very complicated. But you may need to invest more than five minutes to follow the suggested additional steps. Always strengthen the fact the smoker has control over his life. Stopping smoking is about expressing the fact that we, and not tobacco pushers, are in control of our lives. Work on clarifying the reasons for stopping and the strength of the desire to do so. Explain that the smoker should not pretend to want to stop, to please somebody else. When people say they are not able to control their habit, they may be missing the fact that they are not really committed to the change. We can suggest the following ideas too, as means of strengthening the resolution to quit. If we have enough extra time and interest we can work out, with the smoker, ways to ensure that they are carried out. Just sharing ideas from the list should be helpful.
Some recommended steps for someone quitting smoking completely ! Set a date to stop completely. 180
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Engage significant others in the decision for example the person can announce to his smoking colleagues that he will be quitting next Monday, or to his daughter that he will be quitting a month before her birthday so as to invest all his tobacco money to get her a present. He can tell his friends about the problems he may encounter with a few unenlightened smokers, and ask for their support and advice on handling them. Learn from others who succeeded and those who failed. Examine the reasons they give and see how many of them are likely to be genuine. He can learn from the results of his own past experience of quitting or contemplating quitting.
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Anticipate the problems ahead. He needs to recognize that the craving for a cigarette is strongly influenced by fluctuations in the strength of his own decision not to smoke. This decision is undermined by the influence of forceful friends who still smoke. Deliberate ploys of the tobacco trade to make tobacco appear innocent, pleasurable, cool and desirable can undermine the resolution to quit. Situations and moods that were previously handled by lighting up a cigarette can also pose a risk. ! Plan how to handle social occasions where smoking is combined with alcohol use , especially where there are people who put pressure on others to consume alcohol or tobacco. Help him recognize these influences and discuss with others how the influence of a few such individuals should be counteracted collectively. Arrange appropriate responses, with family and friends, for successful liberation. Plan what may be appropriate for the first day's abstinence, the first three days, the first week and so on. Recognize that the experience of freedom from constant craving and tension for a cigarette is the greatest immediate benefit of quitting. This persists forever. At the beginning, the feeling of winning over a challenge is important. But with time the person needs to reflect on the freedom he enjoys as a result of no longer being on the treadmill. For people, who are not able to gather sufficient support from outside or within themselves to quit and sustain it, the use of `nicotine replacement' products (NRT or Nicotine Replacement Therapy) is specially useful. It gives the person a dose of nicotine to reduce the craving for another cigarette. Nicotine is most often provided in a special chewing gum or as a `patch' to be worn on the skin. Nasal spray and inhalators that deliver nicotine are available too. NRT is not freely available in most parts of the countries of our region. Nor are there specialized `cessation services'. But this should not really be a major bar to success of our efforts. If a person in our community feels that such specialized help is needed, we can locate the centres where such a service is available. 181
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Freedom from smoking
Set a date to stop completely Arrange appropriate responses, with family and friends Engage significant others in the decision Anticipate the problems ahead
Learn from others who succeeded and those who failed Use ‘nicotine replacement’ products appropriately
Plan how to handle social occassions
Recognize that the immediate experience of freedom is a major benefit of quitting
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Arrange a date to meet again, and to continue meeting at increasing intervals. After some time the novelty of having quit and the sense of achievement becomes less. Some people relapse, and there is a trend to create the impression that all smokers are at risk of `relapsing'. The idea that is constantly put around, that smoking is difficult to quit and that even if people quit they will soon `relapse', can itself lead to pessimism and failure. We should check carefully how these ideas have spread. The person who has quit can, and should, be an influence on others to consider quitting soon. The ex-smoker should not see himself as a vulnerable person who is constantly struggling to fight off the risk of returning to smoking. He should rather see himself as a force for persuading all remaining smokers to question the wisdom of continuing the habit. It is really for the smoker that life is a constant struggle with tobacco. He has to deal continuously with the recurrent waves of nicotine hunger. All people who quit smoking are a wonderful resource for helping others to do so too. Our responsibility to the community at large is to ensure that those who have quit are given as much opportunity as possible to spread the word about their success. We need to combat the widespread pessimism about smoking cessation that has been fed to smokers. They are made to believe that they have no control over their habit, and then they live out this belief. People who quit are the best advocates to smokers that they have the power to give up the habit. All smokers who have quit should be encouraged to see that they have an obligation to spread the trend of quitting.
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FURTHER READING A few useful sources to refer are listed here. They are intended just as a sampling of the things that we can read. Newer ideas keep emerging and we have to try, even if we work with a small remote village, to keep up with such developments. The mass media sometimes carry news items about tobacco. We must learn to read these critically, as the global tobacco trade has much more influence over mass media than those who’d like to reduce tobacco consumption. So apparent ‘news’ may be slanted to benefit a line that the tobacco trade wants. So-called ‘scientific’ journals are more likely to be independent. But there is strong evidence now that some of these too were influenced by surreptitious payments to a few scientists. One useful journal that covers tobacco is Tobacco Control. It offers the advantage of giving access to ‘scientific’ studies as well as to useful snippets of news and current developments. A regular monthly ‘Bulletin’ of use is the IATH Bulletin (admin@iath.org). There are many organizations devoted to tobacco control, whose websites offer a wealth of information and linkages for example ASH, UK (ash.org.uk). There are also numerous websites that give a positive, and often ‘sexy’ image of tobacco. Such portrayals are not really ‘official’ tobacco sites, but they serve to promote tobacco. A selected few of the sources that were used in the preparation of this manual are listed below. This is not in any way a comprehensive list, but intended as a sampling of the different kinds of sources that could be accessed. ! California Department of Health Services (1998). Tobacco Control in California: Who's winning the war? An evaluation of the tobacco control program. (Available through the Cancer Prevention and Control Program, University of California, San Diego) California Department of Health Services (1998). A Model for Change: the California Experience in Tobacco Control. (Available through the Tobacco Control Section, California Department of Health Services, Sacramento, California) Cochrane Tobacco Addiction Group. Nicotine replacement therapy for smoking cessation: A systematic review . Cochrane Collaboration, 2000. Edwards G. et al. Alcohol Policy and the Public Good. OUP, Oxford. 1995. Ferrence R, Slade J., Room, R and Pope M. Nicotine and Public Health. A m e r i c a n P u b l i c H e a l t h A s s o c i a t i o n , Wa s h i n g t o n . 2 0 0 0 . (http://www.apha.org) 184
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The International Agency on Tobacco and Health. issues) IATH, London. (admin@iath.org)
IATH Bulletin.
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Raw M., McNeill A. and West R. (1998) Smoking Cessation Guidelines and their Cost Effectiveness. Thorax, Volume 53, Supplement 5 Saffer H. and Chaloupka F., (1999). Tobacco Advertising: Economic Theory and International Evidence. National Bureau of Economic Research Inc., Working Paper 6958, NBER, Massachusetts. (www.nber.org) Stratton K., Shetty P., Wallace R. and Bondurant S. (Eds.) Clearing the Smoke Assessing the science base for tobacco harm reduction. Institute of Medicine. National Academy Press, Washington. 2001. Tobacco Control. (All issues) (http://www.tobaccocontrol.com) BMJ Publishing Group, London.
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Victoria Smoking and Health Program, 1997. VicHealth, Victoria.
Quit Because You Can.
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World Health Organization. Tobacco or Health A global status report . WHO, Geneva. 1997. World Health Organization. Leave the Pack Behind. WHO, Geneva. 1999. World Health Organization. The Framework Convention on Tobacco Control: An advocacy guide . WHO, Geneva. 2000.
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