Smoking Cessation Intervention for Costa Rican Adults

Introduction: Tobacco Use as a Public Health Concern

Tobacco use is one of the most deeply ingrained and consistently troubling public health concerns facing the world today. A substance with inextricable ties to commerce, culture, and lifestyle, tobacco continues to invoke mixed emotions among those engaged in the discourse over the hazards it represents to health, environment, and productivity. Within this complex web of responses lies the opportunity to better understand a negative behavior pattern that has been so intricately woven into our collective instinct — and to influence withdrawal from tobacco use or addiction by way of cessation programs.

The fields of medicine and public health are mutually dependent upon one another, but they tend to differ in one central capacity. With medicine being an admirable but largely reactionary science, it falls to those in the field of public health to encourage preventative health behavior. Tobacco use presents a great concern within this context. Nicotine addiction — itself a disease with extremely oppressive power over those it afflicts — is also a leading cause of high blood pressure, heart disease, lung cancer, and emphysema. Each of these conditions is a point of concern for people of every race, class, and ethnicity. Tobacco use thus stands as one of the most dominant factors in determining the prevalence of said conditions. This justifies an experimental program that attempts to establish the effectiveness of smoking cessation intervention through public health avenues in a developing-world context.

One of the greatest challenges in stemming the tide of cigarette use and tobacco addiction is addressing the methods used to induce tobacco dependency in the developing world. The study presented here focuses on Costa Rica, which is emblematic of the obstacles facing public health agencies in less developed nations where smoking is concerned. The reason for selecting Costa Rica is the apparent correlation between the comparably low cost of cigarettes there and the problem of addiction among Costa Rican adults. According to John (2008), "tobacco products in Costa Rica are much cheaper than in the United States and European nations. In developed countries, high taxation has been added to tobacco products to cover the increasing health costs incurred by national health systems. This practice has not yet been implemented in Costa Rica or other developing countries, so they become prime markets for tobacco companies" (John, p. 1).

Program Description: Setting and Service

This represents a significant public health problem for the population of Costa Rica and imposes significant costs upon the country's universal health system. According to John, "although the Caja Costarricense de Seguro Social (CCSS) has no specific data on the costs of treating lung cancer, in 2006, this organization spent about $61 million (¢30.489 million) to treat people with illnesses related to tobacco use (allergies, asthma, and cancer among others)" (John, p. 1). These realities create a clear rationale for the study conducted here, which is intended to mitigate these conditions through intervention and smoking cessation programs.

Costa Rica is also an opportune place to conduct this intervention based on the resources readily available through its public health system. Government funding of an array of primary care facilities dedicated to health threat intervention helps to make this program both feasible and desirable.

The intended services of the proposed study are the cessation of smoking and continued abstinence from smoking among its subjects. These two distinct phases of the project indicate the need for two distinct measures: one relating to the cessation of smoking and one relating to continued abstinence from smoking. The first service will incorporate myriad therapeutic approaches during a 12-week program. The second service will focus on providing strategies for independent abstinence and preventing relapse. Both of these service goals are supported by evidence that smoking cessation can have meaningfully positive health outcomes even for those who have maintained a smoking habit for a lengthy period.

To this end, all indications are that for those who are already smokers, there is a significant opportunity to improve life expectancy and health upon quitting and remaining tobacco free. According to the American Heart Association (AHA, 2009), "male smokers who quit between ages 35 to 39 add an average of 5 years to their lives. Female quitters in this age group add 3 years. Men and women who quit at ages 65 to 69 increase their life expectancy by 1 year" (AHA, p. 1). This is the core rationale for the intended intervention and the focus of the services applied.

The mode for executing this project would be through the various public health clinics in Costa Rica. Their service to their respective regions provides an outlet through which to access adult populations that fairly represent smoking patterns in those regions. In addition to providing demographic parameters for understanding participant backgrounds, this approach may allow for an evaluation of differentiated responses based on regional and demographic characteristics.

Target Population and Intended Outcomes

Evidence suggests that adult tobacco users in Costa Rica have shown receptiveness to anti-tobacco intervention campaigns. Euromonitor International reports that "government organisations, such as the Ministerio de Salud (Health Ministry) and Instituto Sobre Alcoholismo y Farmacodependencia (IAFA — Institute of Alcoholism and Drug Dependency), engaged in anti-tobacco campaigns to increase awareness of the negative effects of tobacco. These had a damaging effect on the industry's performance" (EI, p. 1). This provides promise with respect to the target population and the intention of using public avenues to reach appropriate individuals.

The focus here will be on adults, though smoking is a real health problem for individuals of all ages. According to the year 2000 National Census on Drug Use, there are approximately 600,000 active smokers between the ages of 12 and 70 in Costa Rica (John, 2008). However, because adult smokers between the ages of 18 and 65 represent the best cross-section of individuals with tobacco addiction problems and are simultaneously most likely to benefit from intervention programs, the program devised here focuses on adults only.

With respect to gender, an intervention would be best suited to meeting the interests of both men and women, as both face unique health risks in the area of tobacco use. Men make up approximately 74% of smokers in Costa Rica (John, 2008). However, evidence also suggests that women are increasingly reflecting the problems of smoking addiction in Costa Rica — and particularly the costs imposed upon the healthcare system by related health threats. The John (2008) article reports that "the number of women with lung cancer doubled from 1993 to 2003. In a time span of 10 years, the percentage of female lung cancer patients went from 2.76 to 4.4 per 100,000" (John, p. 1). These two patterns together construct a target population of adult smokers of both sexes.

The intervention program is intended to promote smoking cessation, to be confirmed both six months and one year after the conclusion of the 12-week program. This outcome is supported by published findings from the Centers for Disease Control and Prevention, which promotes a smoking cessation agenda based on the recognition of its role in creating a widespread and costly public health crisis. The relationship between public cessation programs and individual success in quitting is demonstrated by the research reported here and justifies viewing intervention as the primary area of need in addressing smoking addiction and its related health threats.

According to Fiore et al. (1990), this need is further underscored by evidence of cessation education's importance in the fight against cigarette use. Fiore et al. indicate that "among smokers who had attempted cessation within the previous 10 years, 47.5% of persons who tried to quit on their own were successful whereas only 23.6% of persons who used cessation programs succeeded. We conclude that cessation programs serve a small, but important, population of smokers that includes heavier smokers, those most at risk for tobacco-related morbidity and mortality" (Fiore et al., p. 2760).