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This chapter summarizes the conclusions and recommendations from the Task Force on interventions to reduce the initiation of tobacco use, to increase tobacco use cessation, and to reduce the exposure to environmental tobacco smoke (ETS). To reduce tobacco use initiation, the Task Force recommends increasing the unit price for tobacco products, mass media education campaigns, and community mobilization. To increase the cessation of tobacco use, the Task Force recommends increasing the unit price of tobacco products, mass media campaigns, healthcare provider reminder systems, and reducing out-of-pocket client costs for effective cessation therapies. To reduce exposure to ETS, the Task Force recommends smoking bans and restrictions.

Tobacco dependence is a chronic condition that often requires repeated assessment, intervention, and multiple attempts to quit. This chapter describes principles underlying treatments for tobacco dependence that have been elucidated in the guidelines for smoking cessation. A common thread in the guidelines is the use of the 5As consisting of asking about smoking, advising on quitting, assessing nicotine dependence, and stage of readiness to change, assisting with smoking cessation using a range of components of interventions, and follow up to monitor progress. There are many effective components of treatments for smokers that produce long-term permanent abstinence. Cognitive behavioural counselling and pharmacotherapy increase the likelihood of cessation and clinicians should recommend these treatments to smokers. A multipronged approach is important to assist smokers to quit including reinforcement of non-smoking from several clinicians using a variety of evidence-based smoking cessation techniques.

This chapter aims to describe all the main interventions that are believed to promote smoking cessation, show why statements about effectiveness will always require semi-quantitative judgements that go beyond the current ‘hard’ evidence, and give estimates of effectiveness based on that evidence. It includes population level interventions such as tax increases, and clinical interventions such as use of nicotine replacement therapy. The chapter also presents a model describing how smoking cessation interventions work. It begins with examination of why developing and implementing smoking cessation interventions is such a major public health priority.

North Lawndale in the city of Chicago is a community that is predominantly Black, poor, and dilapidated. Smoking is a pervasive public health issue for North Lawndale compounded by the deeply rooted issues of race and class. This chapter begins with an introduction to the data on smoking prevalence for North Lawndale gathered from a comprehensive community survey. It then discusses a community-based intervention illustrating all of the features of its multi-faceted design. The intervention features a collaboration that started with a few community partners and the state public health department and grew into substantial partnerships with local community groups, schools, churches, and outreach organizations — all focused on eliminating tobacco use in North Lawndale. Finally, the chapter discusses some key outcomes and lessons learned from the intervention.

This chapter reviews research on the effectiveness of incentives in general health promotion, and in interventions for smoking and other drug addictions in particular. Consistent with basic principles of learning and reinforcement, and from a behavioral economic perspective, it finds that (1) incentives are effective in encouraging smoking cessation and other health behaviors; (2) incentives are effective while in place but not after they are terminated; and (3) nonsmoking may be encouraged by increasing the availability of reinforcing activities that substitute for the reinforcement from nicotine. Incentives may be especially effective when smoking cessation is a priority for a specific period of time, such as during pregnancy. Incentive programs appear to influence otherwise “hard-to-reach” groups. The impact of incentives is enhanced when implemented in the context of broader programs promoting smoking cessation, and incentives applied to populations may be cost efficient by achieving modest effects for large numbers of individuals. Basic principles of reinforcement and the use of incentives understood within a behavioral economic framework should continue to inform public-health interventions and may lead to new insights into effective approaches for influencing health behavior.

While tobacco-control experts in many developed countries announce remarkable reductions in tobacco consumption, nutrition and physical activity experts in these same countries bemoan the growing epidemic of obesity. Food and physical activity differ substantially from tobacco in that they are essential to life. Whereas the goal with tobacco control is to eliminate all use, obesity control focuses on reducing some behaviours (excessive and unhealthy food intake) and increasing others (physical activity). On the other hand, both tobacco control and obesity control involve influencing complex behaviours. For example, many overweight people struggle with tendencies similar to smokers by compulsively ingesting food for gratification even though they have surpassed their nutritional requirements. Such similarities suggest that there may be some overlap between obesity control and tobacco control. This chapter builds on and updates previously published work in seeking to draw lessons from the successes of the tobacco-control experience that can be applied to efforts to reduce and prevent obesity.

This chapter discusses the effects of smoking cessation on lung cancer mortality and on all-cause mortality in Europe and North America, under-estimation of eventual hazards of smoking and benefits of stopping in many studies of other populations, contrasting national trends in tobacco-attributed mortality at ages 35-69, and worldwide trends in smoking.

This chapter focuses on the health behaviours outlined in the previous chapter from research evidence which suggested the key targets for intervention to be: smoking cessation, nutrition and parenting education. It outlines the range of effective interventions at our disposal and considers the local delivery of two important structural targets: early-years education and childcare. It concludes that the most effective interventions tend to be multifaceted, ranging from education and health through to social inclusion and community development.

This chapter focuses on three aspects of health behaviour vital to the reduction of coronary heart disease (CHD): smoking cessation, increased physical activity, and improved diet. The successes achieved at the population level in reducing tobacco use are not yet evident for unhealthy eating and exercise practices.

HELP is the first attempt to build a pan European public health brand. This chapter analyzes its progress in terms of three key branding constructs: recognition, promise, and delivery. A mixture of qualitative and quantitative research suggests that it is making progress in all three areas. HELP suggests that international public health brands can be successfully built and deployed. However, it also suggests that building these brands presents unique challenges. In particular, it is difficult to pull together like minded but nonetheless independent Government and NGO tobacco control stakeholders behind a cohesive brand strategy; a corporation, such as Philip Morris or BAT, with its more hierarchical and clearly defined structures does not face these problems.

This chapter addresses the demand for nicotine gum in Japan. It explores the smoking cessation assistance policy with nicotine replacement therapy (NRT) using original survey data gathered in late 2001. A high price is preventing the diffusion of nicotine gum. The price of nicotine gum had a negative effect on nicotine gum purchasing, the price of cigarettes had a positive effect, and access to the gum had positive effects on nicotine gum purchasing. The benefits associated with the subsidy for nicotine gum are a decrease in smoking-related illnesses through successful smoking cessation. This would make annual medical insurance payment fall by 67.6 billion yen. When the change in the lifetime medical insurance payments and health capital accumulation are taken into account, 3,300 billion yen should be added to the benefits in the long run.

This chapter considers research evidence that links early life factors to adverse health outcomes and discusses the significance of early life experiences to health inequalities. It suggests that it is theoretically possible to identify the kinds of policy interventions that could improve the healthy development of young children from disadvantaged backgrounds by linking epidemiological evidence that highlights key risk factors to evidence of the social context of risk. It identifies key areas for intervention which include smoking cessation, nutrition and parenting education.

Perceived satisfaction with health behavior change is defined as the overall assessment of the various positive and negative experiences and outcomes that result from engaging in the target behavior. Perceived satisfaction is theorized to be a critical predictor of health behavior change maintenance. It is therefore important to understand both (1) determinants of satisfaction and (2) the effect of satisfaction on health behavior change maintenance. This chapter reviews evidence across several different behavioral domains suggesting that perceived satisfaction is an important predictor of health behavior change maintenance. However, evidence to date is not yet clear on why people are satisfied with the changes they make or how best to intervene on this construct.

This chapter reports pilot data from a neuroimaging study that recorded changes in functional magnetic resonance (fMRI) signal while overnight abstinent cigarette smokers were given opportunities to smoke, but were asked to try to resist the temptation to do so, and shows the link between performance on inhibitory tasks and activation of the frontal lobes. It also suggests that inhibitory control tasks tap functions that are relevant to voluntary control of drug taking. The reported study presents an initial step toward understanding the dynamics of control of attention, and looks at how future research efforts in this area can profit from looking at the connection between brain function and actual behavior during attempts at smoking cessation.

Health promotion seeks to improve the level of health in a population by preventing diseases, controlling hazards, improving fitness and well being and enhancing the capacity or workers to work and to function in society. Health promotion activities are generally divided into education, health protection (protecting the worker from hazards and ensuring prompt intervention if something goes wrong) and prevention of disease. Prevention, in turn, is often divided into primary prevention (the prevention of disease in the first place, for example through clean water or immunization against infectious disease), secondary prevention (the early detection of disease at a stage when it can be treated or limited, through periodic health surveillance) and tertiary prevention (prevention of disability, for example by providing rehabilitation services after an injury). The workplace is an excellent place to promote health, to the benefit of all society. For this reason, the World Health Organization has developed many sophisticated approaches to health promotion based on education, disease prevention and enhancing fitness in the workplace, based on recognition of the determinants of health and interventions based on a model of how they work together known as the health field concept. The Ottawa Charter (1986) is a key document that brought together WHO’s approach and links it with empowerment of the worker, who is encouraged to take responsibility for his or her own health. Health promotion activities take many forms but generally target exercise and activity, diet, cancer prevention, smoking cessation, and management of chronic diseases through wellness programs.

This concluding chapter sums up the key findings of this study on the impact of the Acheson Report on New Labour's policy on reducing health inequalities in Great Britain. It draws together the main unifying themes and highlights further research, policy and practice challenges if health inequalities are to be significantly reduced. It also discusses the accomplishments of the New Labour government in the areas of child poverty, smoking cessation, user involvement and community development.

The care of persons with HIV and AIDS presents clinicians, caregivers, families, and loved ones with special biopsychosocial challenges posed by the infectious nature of HIV, the specific modes of HIV transmission, the particular way HIV affects the brain, the age of onset, and the complex stigma of HIV. These challenges differentiate AIDS from other severe and complex illnesses, causes, have significant clinical and public health implications, and necessitate early recognition and treatment. The multifactorial nature of these challenges is summarized in Table 11.1, and some unique aspects of AIDS are briefly summarized in Table 11.2. AIDS psychiatrists, psychosomatic medicine psychiatrists, physicians trained in both medicine and psychiatry, and other mental health clinicians can play a vital role the care of persons with HIV and AIDS, in the prevention of HIV transmission, and in training of other clinicians to alleviate distress, reduce ongoing high-risk behavior and nonadherence, provide support for patients and families, and improve patients’ quality of life. In this chapter, we will review the biopsychosocial aspects of AIDS and suggest strategies to address the unique challenges of this devastating and complex illness. Although the AIDS epidemic was first described in the medical literature in 1981, it was not until 1983 that the first articles were published about the psychosocial or psychiatric aspects of AIDS. The first article was not written by a psychiatrist. This article, written by Holtz and colleagues (1983), was essentially a plea for attention to the psychosocial aspects of AIDS. They stated that “noticeably absent in the flurry of publications about the current epidemic of acquired immune deficiency syndrome (AIDS) is reference to the psychosocial impact of this devastating new syndrome.” The authors deplored ostracism of persons with AIDS by both their families and their medical systems of care. These authors were the first to describe the profound withdrawal from human contact as the “sheet sign” observed when a person with AIDS drew a bed sheet over his or her face and head, essentially withdrawing and hiding from visitors.

Asthma

Diagnosis

Features: wheeze, breathlessness, chest tightness and cough, typically worse at night, exacerbated by allergen exposure, extremes of temperature and exercise.

If history and examination suggest either a high probability of asthma or an intermediate probability of asthma with FEV₁:FVC <0.7,...