Health Policy
Health policy embraces courses of action that affect the set of institutions, organizations, services and funding arrangements of the health system. It includes policy made in the public sector as well as policies in the private sector (Buse et al 2005). Health policy is broadly defined as ‘goals and means, policy environments and instruments, processes and styles of decision-making, implementation and assessment. It deals with institutions, political power and influence people and professionals, at different levels from local to global (Leppo 1997, cited in Lee et al 2002, p. 10).
Tobacco Consumption
Tobacco consumption is a key concern for health policy makers around the globe as a cause of disease and death. It is a particular concern in the Asian region where the prevalence of smoking is high (Gauld 2005). Traditionally, efforts to control tobacco consumption around the world focused on three strategies to diminish the toll of smoking: preventing the initiation of smoking by children, reducing nonsmokers’ involuntary exposure to environmental tobacco smoke (ETS), and encouraging adults who smoke to stop. The first of these is necessary to avoid future smoking-produced illness in the youngest generation and to break the seemingly endless cycle of childhood addition followed by premature adult death. The second is essential to protect the innocent, nonsmoking victims of ETS. The last is crucial to minimize the near-future damage on smoking adults caught in the cycle of addition and disease decades ago (Rabin and Sugarman 2001).
Tobacco is considered as one of the two major causes of death worldwide whose effects are now increasingly rapidly (HIV being the other). According to Boyle et al (2004), If current smoking patterns persist, there will be about 1 billion deaths from tobacco during the twenty-first century, as against to 100 million during the whole of the twentieth century. About half of these deaths will be in middle age (35-69) rather than old age, and, those killed by tobacco in middle age lose, on average, more than 20 years of non-smoker life expectancy.
According to the Hong Kong Council on Smoking and Health (2009), there are 676,900 daily and occasional smokers in 2008, or 11.8 percent of population aged 15 or over. In 2006 population, 20.5 percent of men and 3.6 of women are everyday smokers.
Health Effects of Tobacco and Cigarette Smoking
The Health Policy instituted in Hong Kong and elsewhere in the world is founded on the research and scientific studies that point to the negative health impacts of Tobacco on health. The medical literatures in the past decades abound with the dangers of tobacco and cigarette smoking to humans. According to Kong (1986) there are over 4,000 substances from a burning cigarette. These are grouped into 4 namely: cancer producers, irritants, nicotine, and carbon monoxide. The cancer producers are aggregates of particulate matter composed of polycrylic hydrocarbons, known to most people as tar. Other substance like phenol and fatty acid esters are co-carcinogens. The irritants include hydrocyanic acid, formaldehyde, acetaldehyde, ammonia and oxides of nitrogen. They have direct irritant effects on the mucous membrane of the mouth, nose, throat, trachea, bronchi, pharynx and esophagus. They further cause increased bronchial mucus secretion and mediate acute and chronic diseases in pulmonary and muco-cilliary function. Nicotine, when inhaled and absorbed into the blood stream, increase heart rate, blood pressure and workload to the heart. It also increases catecholamine release causing cardiac irritability and enhances platelets stickiness through altered prostaglandins production thus predisposing to clotting in diseased vessels. It is also the major constituent responsible for smoking habituation and dependence. Carbon monoxide is a toxic gas which interferes with oxygen transport and utilization. Its build-up in blood stream may reduce oxygen available to myocardium. The combination of effects produced by nicotine and carbon-monoxide could and does precipitate sudden death and myocardial infarction in cigarette-smokers with a compromised coronary circulation.
Cancer
Many research and scientific findings point to tobacco use as one of the factors contributing to many forms of cancer such as lung, urinary tract (renal, pelvis, bladder), upper aero-digestive tract (oral cavity, pharynx, esophagus) and pancreas. Smoking tobacco is often linked to cancers of the nasal cavity, paranasal sinuses, and nasapharynx, stomach, liver, kidney, cervix uteri and myeloid leukemia (Yarbro et al 2005).
Heart and Circulatory Diseases
Two chemicals in cigarette that stand out as the biggest problems when the heart and circulation are concerned – these are nicotine and carbon monoxide. Nicotine, aside from being highly addictive, has potent effects on arteries throughout the body. Nicotine is a stimulant, quickening the heart by about 20 beats per minute with every cigarette, it raises blood pressure, is a vasoconstrictor which means it makes arteries all over the body become smaller, making it harder for the heart to pump through the constricted arteries and it causes the body to release its stores of fat and cholesterol into the blood.
The heart has to work harder to overcome all these effects. To work harder the heart, like every other muscle in the body, needs extra amount of oxygen for the additional workload. The oxygen has to be transported through the blood. But carbon monoxide from tobacco smoke literally poisons the oxygen carrying capacity of the blood. So this results in the heart having to work harder to get more blood to itself to work harder (Spitzer 2003).
Local Hong Kong studies that have been published internationally show that smoking is associated with lung cancer, esophageal cancer, liver cancer, ischemic heart disease, poorer outcome after recovery from myocardial infarction, peripheral vascular disease, Buerger’s disease, cardiac arrhythmia, ischemic stroke, peptic ulcer, multiple duodenal ulcer, poorer duodenal ulcer healing rates, upper gastro-intestinal hemorrhage, osteoporosis, impaired ventilatory function and diffusing capacity of the lungs, and respiratory symptoms (Lam 1998).
Tobacco Control Office and Smoking (Public Health) Ordinance
The Hong Kong government has set up a Tobacco Control Office, which aims to nurture a smoke-free culture in Hong Kong by collaborating with different sectors and mobilizing communities in the battle against tobacco. The Tobacco Control Office is primarily concerned in the enhancement of compliance with the Smoking (Public Health) Ordinance is assisting the Food and Health Bureau in reviewing the tobacco control legislation (Hong Kong Department of Health 2008).
The Smoking (Public Health) Ordinance was first enacted in 1982 with the aim of prohibiting smoking in certain areas, restricting the packaging, sale and promotion of tobacco products. It forms the major part of the legal framework on tobacco control in Hong Kong. The legislation was amended in 2006. Included in the amendment is the expansion of statutory no smoking areas which prohibits smoking in all indoor workplaces and public places; the indoor areas of all restaurants, karaoke establishments and bars open to all age groups; the indoor areas of residential care homes and treatment centers: the entirety pf child care centers, schools, hospitals, approved institutions, placed of detention or refuge and reformatory schools. The amendment also requires that the package/container of tobacco products to bear health warnings with pictorial contents and the increase in the are containing the health warnings of any tobacco product packet/container to at least 50 percent of the principal display surfaces.
Health Promotion
Let us look at the different definitions of health. Let us view health from three different perspectives. First is the Medical Model of health. The medical model of health is based upon the perspective of illness, disease and proper functioning (Larson 1991). Initially, the medical model defined health as simply the absence of disease. In the absence of disease, health exists (Chen and Bush 1979). Disease according to Blaxter (1990) is defined as deviations of measurable biological variables from the norm, or the presence of defined and categorized forms of pathology. This definition can be considered as the foundation of health and illness. However, this definition may be found lacking. Health is not merely the absence of illness. The Wellness Model is concerned with ‘better than normal’ states, as well as subjective feelings of health. Health is conceptualize as a state of feeling, the layman’s intuitive notion of health as physical wellbeing – comfort, energy and ability to perform (Greer 1986). It is optimal personal fitness for full, fruitful creative living (Goldsmith 1972). The third model is the Holistic Model. The holistic model encompasses the whole person, including physical mental and social health. The holistic model defines health as the health of a whole person including physical but also extending to mental and social aspects of health (Larson 1991). Health, as defined by the World Health Organization (1946) is a state of complete physical, social and mental well-being and not merely the absence of disease and infirmity. Lalonde (1974) presented a new and comprehensive perspective on health that is consisting of human behavior, environment, lifestyle and healthcare organizations. Lalonde believes that health an individual’s health is greatly affected by his or her lifestyle. The World Health Organization (1986) defined health as the extent to which an individual or group is able, on the other hand to realize aspirations and safety needs; and on the other hand, to change or cope with the environment. WHO added that health must be seen as a resource for everyday life and not merely the objective of living (cited in Macdonald 1998, p. 25).
Health promotion is considered as a vital part of public health. Health promotion is a unifying concept that brought together different fields of study. Today, health promotion is a part of the health services of most industrially developed countries. Health promotion addresses health care issues of today by contributing to newer approaches to health improvement, whole population programmes, health impact assessment, investment for health projects, capacity building, community planning and involvement, and evidence-based practice.
Health promotion, broadly defined, is a strategy for promoting the health of whole populations. Health promotion strategies are greatly affected by individual and structural elements. The individual approaches to health promotion aims to identify and reduce behavioral risk factors associated with morbidity and premature death. The structural approaches focuses of macro-social and political processes of health promotion (Macdonald and Bunton 2002, p. 10).
Legislation
To further protect the public from the hazards of second-hand smoking, the Government introduced the Smoking (Public Health) (Amendment) Bill 2005 into the Legislative Council to expand statutory no-smoking areas to all indoor workplaces and public places, to strengthen the regulation of advertisement, promotion, packaging and labeling of tobacco products as well as to strengthen the law enforcement efforts. The amendment bill was passed by the Legislative Council on October 19, 2006 and gazetted on October 27, 2006. The Amendment Bill has significantly enhanced the tobacco control regime in Hong Kong and its compliance with the Framework Convention on Tobacco Control (FCTC) of the World Health Organization (WHO) of which China is a signatory and which therefore applies to Hong Kong. With effect from January 1, 2007, statutory no-smoking areas will include indoor workplaces, indoor areas of restaurant premises, bars open to all age groups, karaoke establishments and other indoor public places, indoor and outdoor areas of child care centers, schools, hospitals, escalators, parks, swimming pools and beaches (Center for Health Protection 2006).
Implementation and Enforcement
To coordinate the Government’s tobacco control efforts, enforce the relevant
anti-smoking legislation and promote a smoke-free culture in Hong Kong, the
Tobacco Control Office was set up in 2001 under the Department of Health to foster inter-sectoral collaboration and community participation. Recognizing the complexity of tobacco control issues, the office has adopted a multi-pronged approach to achieve its goals. One of the priority areas is to assist managers and staff working in statutory no-smoking areas to comply with and enforce the Smoking (Public Health) Ordinance. In 2006, the Tobacco Control Office organized over 150 workshops for more than 6 500 staff responsible for management of venue involving statutory no-smoking areas, including the catering industry and other sectors. In addition, officers of the Tobacco Control Office visited over 170 restaurants and 230 shopping malls to explain the legal requirements of no smoking areas to managers of these premises. Furthermore, more than 80 smoke-free workplace workshops were conducted for over 2 000 managers and other staff members of workplaces. Since 27 October 2006, inspectors of the Tobacco Control Office have been empowered to take enforcement actions under the Smoking (Public Health) Ordinance. Up to the end of 2006, the office had issued 13 summonses to people who contravened the ban on smoking in statutory no smoking areas (Center for Health Protection 2006).
Publicity and Education
Apart from the Department of Health, an independent body, called the Hong Kong Council on Smoking and Health was established under statute to acquire and disseminate information on the hazards of using tobacco products and to advise the Government on matters related to smoking, passive smoking and health. During 2006, to coincide with the passage of the Smoking (Public Health) (Amendment) Ordinance, the council conducted publicity and community involvement campaigns with particular emphasis on nurturing a smoke-free culture in public places and workplaces. The council continued carrying out its health education programmes in schools. It gave 203 talks to primary and secondary schools and staged an interactive drama programme in 32 primary schools. In addition, the council launched a territory-wide publicity campaign called Smoke Free Hong Kong which included announcements in the public interest broadcast on TV and radio. The council has a website www.smokefree.hk as well as a hotline to receive enquiries and suggestions from the public on matters related to smoking and health (Center for Health Protection 2006).
Taxation
Taxation is widely recognized as one of the most effective tobacco control measures especially among younger smokers. The Government currently imposes a duty on tobacco products amounting to 4 for each 1 000 cigarettes, or for a pack of 20 cigarettes (Center for Health Protection 2006) .
Smoking Cessation
Recognizing the importance of smoking cessation to a comprehensive tobacco control policy, smoking counseling and cessation services are offered to smokers and their family members by trained nurses and pharmacists at 16 full-time and 14 part-time smoking counseling and cessation centers in public hospitals and general out-patient clinics. Counseling and medications are offered to quitters in treating their tobacco dependence. A ‘quit-line’ telephone hotline has been set up to provide enquiry and appointment services. During 2006, the number of enquiry and counseling cases handled at these centers amounted to 18 000 and the success quit rate as surveyed during one of the months was around 80 per cent. These centers also organized a number of support groups, health exhibitions and educational talks to further promote smoking cessation (Center for Health Protection 2006).
References
Blaxter, M. (1990). Health and Lifestyles. London: Routledge.
Buse, K., Mays, N. and Walt, G. (2005). Making Health Policy. Maidenhead, England: Open University Press.
Chen, M. and Bush, J. (1979). ‘Health Status Measures, Policy, and Biomedical Research’, In S. Mushkin and D. Dunlop (Eds.), Health: Is It Worth It? Measures of Health Benefits. New York: Pergamon Press.
Gauld, R. (Ed.) (2005). Comparative Health Policy in the Asia-Pacific. Maidenhead, England: Open University Press.
Goldsmith, S. (1972). ‘The Status of Health Indicators’, Health Service Reports, 87(3), 213.
Greer, A. (1986). ‘The Measurement of Health in Urban Communities’, Journal of Urban Affairs, 8,11.
Lalonde, M. (1974). A New Perspective on the Health of Canadians. Ottawa, Canada.
Larson, J. S. (1991). The Measurement of Health: Concepts and Indicators. New York: Greenwood Press.
Macdonald, T. H. (1998). Rethinking Health Promotion: A Global Approach. London: Routledge.
Macdonald, G. and Bunton, R. (2002). ‘Health Promotion: Disciplinary Developments’, In R. Bunton and G. Macdonald (Eds.). Health Promotion: Disciplines, Diversity, and Development. London: Routledge.
Rabin, R. L. and Sugarman, S. D. (2001). Regulating Tobacco. New York: Oxford University Press.
WHO (1986). Ottawa Charter For Health Promotion, Geneva: WHO.
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