|Subject Code and Title||PUBH6008: Capstone A: Applied Research Project in Public Health|
|Assessment||Assessment 2: Literature review|
|Learning Outcomes||This assessment addresses the following learning outcomes:|
|Total Marks||100 marks|
The literature review should provide a basis for justifying a clear research question or hypothesis to be explored further.
You must also indicate the search strategy used for your literature review. For example, what were the key words you searched for, and which key databases or other sources did you use to conduct your literature review? (e.g. CINAHL, Proquest Public Health, Informit, Medline, Google Scholar).
PUBH6008: Capstone A: Applied Research Project in Public Health
Assessment 2: Literature review
Over the years, continuously increasing numbers of population are becoming exposed to the direct effects of smoking and tobacco use. From the year 2014, Been et al. gives a well-studied statement that the use of smoking and tobacco remains a major contributor to the rising numbers of deaths and disabilities across the world while increasing the possibilities for health inequalities. The health inequalities are increasingly observed among young adults due to prolonged exposure to smoking. The scenario is further driven by smoking uptake among youths, as well as socioeconomic inequalities. Once established, the habit of smoking become a long-lasting problem for individuals, creating difficulties to quit. Controlling the rising incidents of smoking among adolescents, therefore, becomes a significant aspect for achieving the global aim of promoting the generation of a smoke-free generation.
The work of Brown, Platt and Amos (2014) considers the harmful consequences of second-hand smoking (SHS) to provide emphasis on developing public litigations introduced across many countries to counter the ill effects. Further evaluation related to smoke-free public policies have numerous benefits to public health concerns, including the reduction of heart diseases among individuals of different age groups, as well as mitigating pregnancy-oriented complications. Additionally, the benefits of such policies are also explored in the context of bringing about positive health effects to children by linking policy guidelines to a reduction in childhood asthma hospitalisations as stated by Frazer et al in the year of 2016. However, a specific gap in current literature can be observed in terms of sparsity and inconsistency in developing evidence so as to determine the positive implications of such public policies on eradicating health inequalities, characterised by prevalence of smoking habit.
Moreover, the theoretical understanding is also limited regarding the inequalities driven by uptake of smoking habit among young individuals worldwide. In 2016, Katikireddi et al conducted a research which states however, studied smoking among adolescents aged between 13 and 15 years in UK to suggest a significant drop in smoking and tobacco use, especially among females, after the prevalence of legislative response. Nonetheless, the particular study also failed to address the need for examining socioeconomic inequalities associated with the particular situation.
The purpose of this paper, therefore, is to assess relevant literature discussing the nature and implications of policies addressing public smoking bans while developing a suitable theoretical framework, assisting in fulfilling existing gap in scholarly efforts. Although principally purposed with preventing ill effects of public smoking on individuals, especially non-smokers from SHS, consequences of such policies also intend to improve air quality across public places while reducing health risks for the citizens. Following sections of the paper, as a result, provides a useful foundation to theoretical knowledge by reviewing available scholarly evidence while disclosing issues related to the topic to provide a suitable direction of potential research.
The issues regarding SHS should be provided with substantial attention given the significant prevalence of the harmful effects of smoking on a considerable proportion of global population. Based on the report of World Health Organization (2013), smoking tobacco is responsible for around 6 million deaths annually, including the death of more than 600,000 non-smokers. Considering the overwhelming costs associated with smoking, it remains as one of the leading causes of preventable deaths worldwide despite the wide awareness related to detrimental effects of tobacco use. As a result, the steady rise in public policies restricting individuals smoking in public place can be observed throughout the past three decades. One of the major consequences of such a significant rise in legislative responses across many countries is based on facilitating normalisation of public places, such as worksites and restaurants free from the harmful impacts of smoking. However, such policy responses alternatively give rise to smoking at private places, such as homes and cars, which over the past few years have replaced public sites to increase exposure to SHS (López et al., 2012). Reviewing such a theoretical framework, therefore, provides a vital understanding that enactment of legislative bans or restrictions on smoking should address the growing issues related to voluntary smoking at private places, affecting individuals significantly.
Concerning the issue of SHS, it is also known as passive smoke, tobacco smoke pollution or involuntary smoke, mainly includes a combination of several contaminants, which are mostly associated with smoking a cigarette. While smoke emitted through both ‘side stream smoke’ and ‘mainstream smoke’ continuously leading to the issues of SHS, it becomes the third leading cause of preventable diseases, disabilities and deaths across the world (Andersen et al. 2006). As SHS is increasingly affiliated with adverse health effects among non-smokers, such as acute respiratory disorders, cardiovascular disease, mortality and morbidity among children, low birth weight among babies of non-smokers, and several types of cancer, there is no safe level of exposure to SHS. It signifies the harmful impact of SHS at minimal exposure, suggesting the need for developing feasible response mechanisms by global bodies. Harmful effects of tobacco smoking in private places, for instance in home, increase the health hazards among the people who don’t smoke because of SHS, as Farkas et al stated in the year 2000 that an adult smoker at home can make the children adapt the habit of smoking accordingly.
The research on the efficacy of legislative policies barring smoking while preventing exposure to SHS has been conducted positively over the years. However, these attempts do not come up with straightforward implications. A review paper, prepared by Callinan et al. (2010), has combined 50 articles published before 2009 to find the reduced exposure to SHS among a large proportion of the population across public spaces. However, the paper presents no change in prevalence or reported duration of exposure of SHS at private spaces, such as the home after the implementation of particular legislative bans. Given the duration of time spent by non-smokers within the public residences per day, the particular scenario poses an inevitable challenge for the global legislative environment in the course of forming suitable policy response. Based on the theoretical propositions of collected literature, it can be argued that the spill over effects of both macro-environments (i.e. public smoking policies) and microenvironments (i.e. anti-smoking policies for private smoking) can be determined through two main theories, such as social diffusion and displacement.
The theory of social diffusion indicates that restrictions imposed on smoking at public places are usually affiliated with increases in bans or restrictions in voluntary home smoking. Such a theoretical model encompasses two specific ideas related to social norm and behavioural susceptibility theories, where the former involves perceptions of normality or typicality to influence social behaviours, the latter argues the tendency of a particular behaviour to decline gradually if it becomes difficult or inopportune (Gritz et al., 2003). It can be argued that legislative response related to prevention of smoking habits at public venues may alter social norms by reducing perceived acceptability and visibility of smoking at those places while influencing individuals to shift their attitudes, beliefs, practices and awareness related to smoking. In fact, potential research in the chosen area can demonstrate the ability of smoking bans across public places in informing individuals about the constantly evolving social norms related to smoking alongside the wider perceived unacceptability in the society involving reduced tobacco consumption.
The second theoretical model, i.e. displacement or ‘last refuge’ is a highly pessimistic concept, positing that restricting smoking in public places will displace smokers to adopt smoking behaviours at the private venues, such as homes. Haw and Gruer (2007) notice that the particular scenario can majorly lead to producing undesired results, which mainly include the dramatic increase in SHS exposure to non-smoking members of the families. It raises significant social concern for children who are more vulnerable to harmful impact of SHS. In the year 2010, Kaufmann et al mainly indicates that the level of SHS exposure to children by finding out that approximately 98 percent US children are living with a smoker, compared to 40 percent not living with the ones if cotinine levels used in cigarettes were maintained above .05ng/mL. The numbers of cigarettes smoked in private places like homes essentially determine the cotinine levels in children. The particular scenario becomes more problematic given the lack of choices available to children in their home environment regarding their willingness to be exposed to SHS.
After the imposition of smoking bans across public places, especially since 2004, a significant decline can be observed in exposure to SHS while supporting improvement of health of both smokers and non-smokers. Due to the increased risks of deaths and illnesses, a number of international health organisations take the onus of introducing several legislative actions in a mean to reduce exposure to tobacco use and SHS to promote quality of life and support public wellbeing. It has been studied that various workplaces across the world have combined their efforts to prevent smoking by supporting smokers to quit their smoking habit. Services, such as nicotine replacement therapy (NRT) and counselling support, sanctioned by various workplace environments have proved to be effective in countering the negative impacts of smoking to the society (Bauer et al., 2005). However, a significant gap in existing theoretical framework can be observed in determining the effectiveness of policies, which seek to prevent smoking at the institutional level. Despite banning smoking across various public establishments, the prevalence of tobacco use can be still evident in some universities, healthcare organisations and prisons.
Frazer et al. (2016) have studied the impact of banning smoking at the institutional level from the perspective of quitting behaviour and exposure SHS to find that imposing restrictions across universities and hospitals drive smokers to quit their habit while generating wider awareness regarding reduction in smoking. After the introduction of policies banning smoking at the public institutions, a significant reduction in the number of people died from smoking-related diseases and exposure to SHS can be observed across the prisons. However, the particular study also has a significant gap, as it does not find any feasible evidence that conveys a substantial decline in smoking rates. Based on the particular theoretical investigation, it can be argued that developing settings-based smoking policies offers a significant contribution to minimising smoking rates across public institutions, such as hospitals and universities. While the impact of policy responses at the institutional level is attributed to reduced mortality rates and exposure to SHS, the quality of fundamental evidence requires more improvement. Such a research gap can be fulfilled by carrying out more studies assessing vital evidence related to policies of smoking bans across specialist settings.
Studies contrasting smokers and non-smokers essentially revealed notable advantages of smoke-free homes. These reflected that current smokers are more likely to allow smoking in private spaces, in their homes particularly both before and after the enactment of legislative actions to restrict smoking. These studies also specifically focused on smoking populations, which did not participate effectively on home smoking restrictions. Studies contrasting smokers and non-smokers, on the other hand, found out the increased incidents of home smoking restrictions after the imposition of public policies banning smoking across public places. As per the study of Rayens et al in the year 2007, it is observed suggested that variations in restrictions in-home smoking depend on smoking status, indicating the need of harsher rules and guidelines in response to bringing change in the behaviours of smokers taking longer to adapt with home smoking bans. Particularly, Hahn (2010) noticed that legislative bans on smoking over the years evolved to hasten or accelerate normalisation of unfavourable stigma associated with smoking and exposure to SHS, especially in the private residences, thereby enabling smokers to specific changes voluntarily in their smoking habit within the home. Concerning the review of literature concentrating on non-smokers, significant growth in voluntary home smoking restrictions during pre and post-bans can be observed. Therefore, the importance of findings related to diffusion is important because non-smokers are more prone to suffer from most health consequences of SHS exposure (Monson & Arsenault 2017). Such a scenario consistently creating concerns for the policymakers seeking to prevent potential displacement of smokers in private places, such as homes or cars after the enactment of public bans.
Studies have specifically hypothesised children as the most vulnerable population cohort, affected by prolonged SHS exposure, as they do not have the same agency as the adults. Such exposure is essentially observed if their parents are smokers. Therefore, the theory of diffusion plays an important role in pointing out the benefits of public smoking bans, which can be eventually extended into the homes of children with their smoking parents. The particular theory goes in line with the finding of Lee, Glantz and Millett (2011), which considered adult population to gather data while gaining response that individuals living with children were more likely to adopt smoking bans after the implementation of legislation, addressing smoking bans across public places. Such an understanding implies the need for changes in anti-smoking legislation in line with overall decline in prevalence of smoking habit throughout Western societies and increase in smoke-free private residences (Mills et al. 2009). Therefore, results of the selected study essentially signify the trend towards shifting attitudes regarding smoking after the imposition of public smoking bans driven the incidence of significant declines in proportion of population to adopt a smoke-free approach. For instance, Kairouz et al observe ban under examination as one of many strategic actions undertaken by the government in the year of 2014, concurrently introduced with the aim of minimising exposure of non-smokers to SHS.
The overall review specifically conveys the need for understanding the related context comprehensively to overcome the challenges of contemplating any changes in the public smoking ban policies while overcoming modifying the potential consequences. The need for developing superior understanding is mainly observed for tracking and determining the potentially salient factors, which highly likely to change over times.
Throughout the review of available literature, it is clear that tobacco use has consistently become a global epidemic to give rise to a considerable degree of burden related to premature deaths and diseases. Based on the report of World Health Organization (2017), more than 1 billion people are smokers, leading to an increase in societal costs at over £1 trillion annually. From past few years, usage of tobacco is considerably related to child wellbeing from several perceptions, as there comes a situation where an unborn child face difficulty when the mother smokes tobacco or make use of tobacco products at the time of pregnancy. The statement of Wagijo et al (2017) explains that such exposure to tobacco smoke is fundamentally associated with birth defects, stillbirth, premature birth and intra-urine growth restriction among children before their birth. Additionally, epidemics such as neonatal and infant deaths, respiratory tract infections (RTIs) and asthma attacks are prevalent due to increased exposure to SHS after the birth of children. Therefore, controlling the prevalence of tobacco epidemic has become a necessity across modern societies worldwide.
Concerning the implications of international treaties, the Convention of the Rights of the Child, in particular, the important convention is based on right of every child to grow in an environment free from any adverse health consequences associated with tobacco use (Toebes et al., 2018). Children, especially during their young age depend entirely on the decisions made by their patents concentrating on tobacco and exposure to SHS. The importance of tobacco control policies can be essentially observed in the particular area, like these, for example, play a useful role in guiding parents to make informed decisions by developing greater awareness of harmful effects of smoking. The policy responses with the aim of prohibiting smoking in public places and in-car alongside reducing parental smoking can be formed via an increase in prices of tobacco products, as well as restricting marketing of such products (Reitsma et al., 2017). The treaty, known as International Framework Convention for Tobacco Control (FCTC) is used widely used by the governments and supported by the WHO to allow countries participating in developing proper control policies (World Health Organization, 2017). Based on the advocacy of WHO, the participating countries need to follow an MPOWER model to consider six key areas in their course of developing tobacco control policies. As part of the particular model, M refers to developing prevention policies based on monitoring tobacco use while P indicates protecting individuals using smoke-free legislation. O involves offering assistance to quit smoking where W implies warning population about the harmful effects of smoking (Wolfson, 2017). E means enforcing restrictions or bans on advertising, promotion and sponsorship of tobacco products, whereas R finally reveals the need for increasing taxes on tobacco.
Consequences of smoke-free regulation
A recent study, conducted by Faber et al. (2017) provides emphasis on carrying out a systematic review by identifying 35 well-structured studies from different countries, such as North America, Europe and China to evaluate the impact of smoke-free legislation on health consequence of children. The result of meta-analysis confirms the substantial association between smoke-free policies and considerable reductions in adverse health consequences during the early-life stages. While the preterm birth was lowered by 3.8 percent, severe asthma attacks and severe RTIs were minimised by 9.8 percent and 18.5 percent. Given the primary roles played by preterm births and RTIs in increasing the global burden related to adverse health outcomes of childbirth, the particular consequences highlighted by the previous study is highly important (Kyu et al., 2016). Drawing the on the evidence obtained from the study of Tan and Glantz (2012), which considered adults, the greater benefits from the imposition of smoke-free legislation can be retrieved if these are applied comprehensively to cover a wide range of public places. Smoke-free legislation typically appears to emphasise more on reducing exposure to SHS among children and pregnant women while minimising the tendency of parental smoking prevalence via modifying social norms, individuals developing their efforts to make smoke-free homes, for example. Moreover, the evidence from UK helps Katikireddi et al. (2016) to suggest that the implementation of smoke-free legislation helps the society to reduce the tendency of taking up smoking habit at the school age.
Tax System And Other Policies
As stated by WHO, taxation involving various tobacco products is one of the most effective ways to minimise the prevalence of smoking throughout various societies. In the course of achieving such objective through taxation, it proves to bring significant benefits related to prenatal and child health (Faber et al., 2017). The study of Patrick et al. (2016), for example, has observed a consistent reduction in child mortality rates in the US after the decision of increasing tax or prices of tobacco products. Hawkins et al (2016), on the other hand, come up with the findings that governmental provisions related to smoking cessation services play a significant role in lowering the incidences of severe RTIs. The implementation of tobacco control policies also contributes importantly based on the evidence of US, where improvements in child health can be observed dramatically. Furthermore, public policies, which greatly contributes to increase the legal age for cigarette purchasing, provide positive implications in reducing the events of low birth-weight among infants.
Effect of novel guidelines
Given the impact of MPOWER model is well established by the literature, the future need for formally assessing the efficacy of newer approaches to tobacco control policies must be fulfilled to enable promotion of population health, including that of the children. This mainly comprises of estimating the judicial response in order to decrease exposure to SHS from public areas, for example schoolyards, play area and gardens, frequently visited by children, and few private areas, for instance, vehicles. Specifically, the study of Elton-Marshall et al. (2015) finds out that smoking in cars can have severe health consequences, especially in terms of increased exposure to SHS among non-smokers, suggesting the need for smoking prohibition policies by considering both public and private spaces, such as cars and homes. Additionally, the policies related to banning display of tobacco products across shops or using plain packaging of tobacco products can noticeably help adolescents by reducing attractiveness of smoking cigarettes or using any other tobacco products. As per the research of Edwards et al in the year of 2017, it is all about the studying and findings of reduced smoking experimentation and initiation among the young population in New Zealand driven by the country’s public policy banning the display of tobacco products through marketing or in stores. Additionally, Australia’s plan of introducing plain packaging of tobacco products was followed by a response, which was greater than the expectation, as it favourably contributes to quitting behaviour and initiation of smoking among adolescents. Therefore, these primary observations must be based on the application of increased theoretical efforts, attempting to evaluate and address similar policies undertake by other countries, such as the UK. Furthermore, policy assessments should consider the initiatives prohibiting the use of flavoured tobacco products since Huang et al. (2017) identified that these products particularly create an appeal among the younger generation, making them perceiving those as less harmful than the non-flavoured ones.
Tobacco control in low and middle-income countries (LMICs)
One of the significant knowledge gaps in terms of available literature can be observed in terms of the stark insufficiency of studies concentrating on health consequences of children and non-smokers associated with tobacco prevention and control policies in LMICs. This has become a pressing issue since increasing numbers of tobacco companies are targeting these countries, which are already encountering the ill effects of tobacco-related premature deaths and morbidity (Reitsma et al., 2017). The urgency in assessing the public policies related to tobacco uses in LMIC, therefore, can be observed in terms of developing a suitable theoretical framework. In relation to the situation, it can be anticipated that the bonding between the organizations from high earning countries and lower middle income countries, reinforced by social agencies and in this case, you can take the example of Global Challenges Research Fund that offer a good chance to cover up the gap of the present knowledge.
Third-hand smoke (THS)
So far, the potential consequences of THS have been overlooked. As per the views of Been and Sheikh in the year of 2018, THS is acknowledged as the components of tobacco smoke remaining on the exposed exteriors, such as clothes, hair, and skin, and even curtains, walls, and floors. Children, as well as non-smokers, are growingly exposed to the potential risks of THS through ingestion, inhalation or dermal absorption. The study of Matt et al in the year of 2011 directly focuses on examining the lingering characteristics of THS exposure by considering a significant proportion of non-smokers for two months after making them moving into a house owned previously by smokers. THS is also associated with environmental pollutions, which are prevalent in homes and families consisting of young infants (Northrup et al., 2015). The particular traces of THS can also be found in neonatal intensive care environments, including the incubators and parents’ hand, regardless of washing the hands. Smoking outside, therefore, is ineffective in reducing the effects of THS or normalising the risks of respiratory disorders among non-smokers and children alike. As a result, investigating the potentially harmful effects of THS while examining the prevention policies available to overcome the issue forms an important area of research for developing the existing knowledge.
It is a significant concern for the modern society that the highly promising MPOWER policies are only comprehensively implemented by only a few countries worldwide, given the large evidence-based research supporting its effectiveness in preventing and controlling tobacco use and SHS exposure, alongside the ratification of the TCTC by 181 countries. In order to accelerate the formation of proper tobacco prevention and control policies at the global level, it is highly significant to communicate the findings of most relevant scholar works to the policymakers around the world. The control and prevention initiatives across different economies can be strengthened through shaping evidence-based policies in the future. Such an objective can be achieved via developing greater awareness by the researchers regarding their responsibility and seeking opportunities to engage with policymakers, as well as media, to develop a highly informed response mechanism. Evidence from developed economies suggests the importance of advocacy by health professionals in accelerating the imposition of public policies in creating smoke-free public, as well as private spaces, such as cars. It serves as a vital example for others countries, where policy responses lack the particular direction.