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<p>After studying in-depth the health hazards of smoking, I was dumbfounded and furious</p> <p>Leisure Education as a Tobacco Control tool</p> <p>21/8/09</p> <p>By: Shaun Cavanagh</p> <p>For: Associate Professor Bob Rinehart</p> <p>Paper: Directed Study SPLS 590-09C</p> <p>Waikato University</p> <p>After studying in-depth the health hazards of smoking, I was dumbfounded and furious. How could the tobacco industry trivialize extraordinarily important public health information: the connection between smoking and heart disease, lung and other cancers, and a dozen or more debilitating and expensive diseases? The answer was it just did. The tobacco industry is accountable to no one </p> <p> C Everett Koop, Memoirs (Rongey, 2001).Introduction</p> <p>This excerpt from former U.S. Surgeon-General C. Everett Koop carries several themes in relation to health promotion from the perspective of Recreation Therapy. These themes include: Human responsibility and freedom of choice, Locus of control, Independence and dependence, Interaction between a person and their environment, and operation of commercial motives through regulatory frameworks. The existing conditions for sale and consumption of tobacco mean that New Zealanders aged 18 and over are able to purchase products identified as causing death and disability. The challenge for health promoters and medical professionals is addressing the smoking-related effects, occurring after the individual has developed a dependency on the product. Attention needs to be directed to consumer perceptions of the potential harm at the point of sale, despite the legal status of tobacco. On a community-wide basis, smoking is the health status factor most readily changed to decrease morbidity and mortality (McLean, Richmond, Lopatko, Saunders, and Young, 2002, p. 111). Tobacco has been described by the World Health Organisation (WHO) as the only legally available product that when used as the manufacturer intends, kills half its users (Anderson and Mathews, 2005, p. 9). A 1995 American College of Chest Physicians (ACCP) position statement stated: tobacco use is the single most important preventable risk to human health in developed countries and an important cause of premature death worldwide (Anderson, Jorenby, Scott and Fiore, 2002, p. 932). From a global perspective according to the United Nations Secretary General (2004), it has an adverse impact on health, poverty, malnutrition, education and the environment, and consequently, tobacco control has to be recognized as a key component of efforts to reduce poverty, improve development, and progress toward the Millennium Development Goals which seek to eradicate extreme poverty and hunger (WHO, 2002, 2). By 2030, 10 million people will die each year, with 70% of those in developing countries. If current trends continue, about 650 million people alive today will be killed by tobacco, half of them in middle age, each losing 20-25 years of life. A predominant focus for WHO is how tobacco control policies in a range of countries can take into account the specific characteristics and needs of women and girls, men and boys (WHO, 2002, 2). This is because marketing efforts for tobacco products target particular groups, especially in developing nations.Globally, an estimated 4.9 million people die each year from tobacco-related illness, compared with 3.1 million from AIDS, 2.1 million from diarrhoeal diseases, 1.6 million from violence, nearly 2 million from tuberculosis, 1.2 million from road injuries and 1 million from malaria (Chapman, 2007, p. 3). Fifty percent of all deaths from lung disease are linked to tobacco; Eighty percent of smokers live in low and middle income countries; and 520 million people will die from tobacco use in the next 50 years (www.tobaccofreeunion.org). In New Zealand, around 23 percent of the population smoke tobacco, and prevalence is much higher among Maori (46 percent) and Pacific peoples (36 percent). It causes significant morbidity and contributes to socioeconomic and ethnic inequalities in health in New Zealand (Ministry of Health, 2007, p. 1). Broughton (1996, p. 35) notes that the use of tobacco by Maori was widespread in New Zealand by the end of the 1840s, just 70 years after its introduction by Captain Cook, and a decade of the signing of the Treaty of Waitangi, and this caused a dramatic change in the population dynamics of this country. This was despite that in pre-European times tobacco cultivation and preparation was completely alien to Maori (Broughton, 1996, p. 12). He states that there was no doubt that tobacco use was implicated in the increased death rates of Maori over the latter half of the nineteenth century by exacerbating chronic illness, respiratory disease and poverty (Broughton, 1996, p. 93). An estimated 18,000 pregnancies and 9,000 preschool children annually are exposed to smoking in families. It is well understood as the biggest single factor undermining the health, development, well-being and survival of this group (Cowan, 2007, p. 4). By reference to a legally available product that kills, what is implied is a person-environment interaction where the resulting health outcomes depend on lifestyle choices made in the context of that interaction. This bears relevance to the concept of leisure, and to leisure education on the basis of lifestyle, which requires humans to seek variety and to explore their surroundings. Examples of the interaction between leisure and tobacco include leisure-related themes on packaging, debate over retail tobacco displays, debate over second-hand smoke in public places and parks, the presence of smoking in movies, sponsorship of leisure related events and programmes, the relationship of tobacco and other substances such as alcohol, and the effects of illness on personal ability to engage in a leisure lifestyle. Learning and familiarization with personal surroundings is part of the concept of internalization, defined by a developmentalist (Vygotsky, 1978) as a set of social relationships, transposed inside, and having become functions of personality and the forms of its structure (Linzey, 1991, p. 242). It is during the young adult stage of life that leisure routines and lifestyle appear to become more stable and set for most people. If conscious awareness of leisure and a valuing of the phenomenon occurs, it most likely takes place at this stage of life (Peterson and Stumbo, 2001, p. 37). Drewery and Bird, (2004, p. 4) note that Human beings are dynamic, interacting with others and their environment at every moment. Leisure helps shape who we are as human beings. It is expressed through our lives and is revealed in our histories, life goals, growth and development, and behaviors (Russell, 2002, p. 1). Social behaviour is the reciprocal exchange of responses between two or more individuals (Peterson and Stumbo, 2000, p. 5, emphasis added). Culture is paideia, something you absorb as a child (de Grazia, 1962, p. 355). A sociological perspective known as symbolic interaction theory holds that people actively interpret each others actions and behave in accordance with the interpretation (Thio, 2000, p. 96). The taking in of the culture which surrounds by a developing person may be considered as a natural dependency, since the flow of resources (such as information) is from outside, independent of the person, inwards.As the environment is a central part of leisure experience, these examples demonstrate that the presence of tobacco in that interaction has the potential to undermine the quality of that experience. For example, regulations about retail tobacco displays (and the function of cigarette packets) have recently been debated in New Zealand. Cigarette pack design is an important communication device for cigarette brands and acts as an advertising medium. Many smokers are misled by pack design into thinking that cigarettes may be safer (Wakefield, Morley, Horan, and Cummings, 2002). A key tobacco control strategy is to develop an environment that prompts people to quit and that is fully supportive of people who are trying to stop smoking (Paynter, Freeman and Hughes, 2006, p. 7). Trends suggest that substantial and sustained efforts will be required to further reduce the prevalence of tobacco use and thereby reduce tobacco-related morbidity and mortality (American Legacy Foundation, 2007, p. 5).Following on from initial discussion of the relationship between Tobacco Control measures and the allied health profession of Recreation Therapy, this literature review investigates further examples of where the tool of leisure education can be of benefit to attempts to prevent smoking initiation, and aid quit smoking attempts. Attention to both aspects is essential due to the preventable nature of smoking-related illness. Tobacco use was described by C. Everett Koop in his tenure as U.S. Surgeon General (1982-1989) as the chief, single avoidable cause of death in our society, and the most important public health issue of our time (Taylor, 1984, xvii). This position on the effects of tobacco is supported by international evidence, and endorsed by major organizations such as the World Health Organisation, Centers for Disease Control, Department of Health and Human Services, National Cancer Institute, and the Royal College of Physicians. These major groups all make their own authoritative statements on the harmful effects of tobacco use that guide policy internationally. The potential relevance of leisure education is increased by the description that avoidable deaths result from tobacco use, as this suggests that there are lifestyle determinants that can be changed to reduce this scenario, and leisure education places a primary emphasis on the nature of lifestyle.Thesis Statement </p> <p>People making quit smoking attempts experience many challenges despite the outcomes of their attempt, and frequently experience a vacuum where they are required to find alternative activities to avoid relapse. These challenges can occur irrespective of the use or non-use of Nicotine Replacement Therapy (NRT) to aid the quit attempt.Research questions: </p> <p> How can existing strategies for prevention and for compliance with quit smoking attempts be effectively supported with the tool of Leisure Education? </p> <p> What support can the allied health profession of Recreation Therapy provide Tobacco Control efforts that no other discipline can?</p> <p>The methods used to answer these questions include taking Recreation Therapy and leisure education core principles and looking for examples of crossover situations where they apply to Tobacco Control measures. It is anticipated that these examples will not just exist in intervention contexts, but will exist in areas such as regulatory frameworks, cultural influences and social activities, education, and also in the comparison of existing models that are shared by both disciplines. Accounting for these aspects could benefit the clients served in treatment contexts, and serve to reduce smoking prevalence. These core principles are what guide practitioner activity, and most likely exist in other disciplines in some form. Core principles as they currently apply in Recreation Therapy, and have application to Tobacco Control are:- Learned helplessness vs Mastery or Self-Determination</p> <p>- Intrinsic Motivation, Internal Locus of Control, and Causal Attribution</p> <p>- Personal Choice</p> <p>- Flow</p> <p>(Peterson and Stumbo, 2000, pp 9-12).</p> <p>In New Zealand, there are three key objectives of tobacco control activities: 1) to reduce smoking initiation, 2) to increase quitting, and 3) to reduce exposure to second-hand smoke (www.moh.govt.nz). According to Aguilar and Munson (1992) many adolescents may consume their first drink or drug in the context of leisure activities, and ongoing drug and alcohol use may occur during social activities including parties, other social gatherings, or concerts (Nation, Benshoff, Malkin, 1996, p 15). Contained within this statement are the themes of youth (with all their healthy potential) and use of leisure (often filled by choice of activities that harm, rather than enhance heath). The expression of the Therapeutic Recreation principles above (with the exception of learned helplessness) in the leisure lifestyles of people are inconsistent with the behavior and effects of smoking, as indicated by the symptoms that result. This is because the very nature of the substance works to undermine health, and the extent to which these principles are expressed in a persons leisure lifestyle, defined as the day to day behavioral expression of ones leisure-related attitudes, awareness, and activities revealed within the context and composite of the total life experience (Peterson and Stumbo, 2000. p. 7). This concept relates to the determinants of health, due to the cumulative effects of given behaviors over a lifespan. The essence of leisure is freedom (Mundy and Odum, 1979, p. 4). This is a central point in considering the relationship between smoking and leisure, and accounting for the effects on a sustainable basis.The role leisure education can play is preventive as well as rehabilitative. Many people who make the initial decision to smoke seek something immediate, as indicated by Burkeen and Alston (2001, p. 81) who endorse the use of recreation in the lives of youth who might otherwise choose to fill their time with negative leisure activities, thereby undermining their potential for growth and personal development. Smoking is also linked to socioeconomic status, lower income and poorer education being strongly linked with current smoking (Bittoun, 2007, p. 17). With emphasis on lifestyle choices and leisure awareness, leisure education can teach people to stay away from, or to quit smoking. Programs that tend to be effective in reducing substance use and abuse problems address a number of relevant individual, social, and cultural factors (Durrant and Thakker, 2003, p. 219). The acquisition of favorable attitudes toward leisure during formative years lays the foundations for satisfactory socialization in later stages of the lifespan (Iso-Ahola, 1980, p. 163). The intention of leisure education is to instill a leisure ethic within people, so that they may freely and willingly take part in activities that can bring them satisfaction and enjoyment, with the ultimate goal of enriching and enhancing their lives (Dattilo and Murphy, 1991, p. 8).</p> <p>This report takes the stance that the harm done by tobacco occurs by stealth, and that it is usually not detected by the smoker until well after an addiction has formed, making it extremely difficult for the person to quit. The association of smoking with leisure has been acknowledged as a non-traditional example of adult leisure involvement (Peterson and Stumbo, 2000, p. 47), indicating that many people will trade off the long term maintenance of health for the immediate effects of cigarettes...</p>

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