Running head: SMOKING CESSATION HEALTH POLICY 1

Smoking Cessation: the Implementation of an Effective Health Policy in Escambia County,

Florida

Haley Higgins

University of South Florida

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Smoking Cessation: the Implementation of an Effective Health Policy in Escambia County,

Florida

In the United States, 15.1% of all adults aged 18 years or older are current cigarette

smokers (Centers for Disease Control and Prevention [CDC], 2017). Despite efforts to reduce

the number of persons smoking, tobacco use remains the leading cause of preventable disease

and death. Smoking tobacco has serious health consequences and is associated with higher rates

of cancer, heart disease, lung disease and diabetes. Exposure to secondhand smoke is associated

with increased rates of stroke, coronary artery disease and lung cancer in persons who have never

smoked cigarettes and an increased risk of sudden infant death syndrome, respiratory infections

and ear infections in children. In the U.S., approximately 16 million people are living with

chronic illnesses related to tobacco use with an annual cost of more than $170 billion in medical

care (CDC, 2017).

Escambia County, Florida has a high rate of tobacco use with approximately 22.5% of

adults aged 18 years of age or older reporting that they are current smokers (FL Department of

Health, 2015). The negative effect smoking has on ones health makes the development of a

health policy that promotes smoking cessation a necessity in this community. The community

health nurse will play a role in implementing primary, secondary, and tertiary levels of

prevention.

Overview of Escambia County

Escambia County is located in the northwest corner of the state of Florida. With a

population of 309,966 persons, Escambia County is Floridas 19th largest county containing

roughly 1.6% of the states population (FL Department of Health, 2013). Similar to the state of

Florida as a whole, approximately half (51.1%) of Escambia Countys population falls within the
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25 to 64 age range. The 65 and older age group makes up the smallest percentage of the

countys population consisting of just 14.9% of the population. The 15 to 24 years old age group

makes up 16% of the countys population and 18% of the population is 14 years of age or

younger (FL Department of Health, 2013).

The major healthcare systems present in Escambia County are Baptist Health Care

Corporation, West Florida Healthcare and Sacred Heart Health System (FL West Economic

Development Alliance, 2017). Healthcare is the top industry present in Escambia County

employing more than 20,000 persons (U.S. Census Bureau, 2016). Retail trade is the second

largest industry, employing more than 14,600 persons. Accommodations/food service is the

third largest industry in the county, employing more than 11,500 persons (U.S. Census Bureau,

2016).

Comparison of Local versus State Populations

In Escambia County, 12.1% of families are living below the poverty level (FL

Department of Health, 2015). This is in line with the overall population of families living below

the poverty level in the state. Between 2010 and 2014, estimates indicated that approximately

12.2% of families in Florida were living below the poverty line (FL Department of Health,

2015).

In the state of Florida, 29.5% of adults 25 years of age and older have obtained a high

school diploma (FL Department of Health, 2015). Escambia County falls just below the state

level with 28.9% of adults 25 years of age or older having obtained a high school diploma (FL

Department of Health, 2015). Approximately 40% of Escambia Countys 25 years of age and

older population has obtained an associate, bachelor or graduate level degree. The state of

Florida has a slightly lower rate with approximately 34.7% of persons 25 years of age and older
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having obtained an associate, bachelor or graduate level degree (FL Department of Health,

2013).

In Escambia County, 2.8% of individuals 5 years of age and older do not speak English

proficiently. The state of Florida has a higher percentage with approximately 11.7% of

individuals 5 years of age and older not able to speak English proficiently (FL Department of

Health, 2015).

Escambia County has 799 licensed physicians which equates to roughly 260 licensed

physicians available per 100,000 persons (FL Department of Health, 2015). This is higher than

the state average which is 249 licensed physicians per 100,000 persons. Additionally, Escambia

County has more hospital beds and nursing home beds available to the community when

compared to the state average. The Escambia County public health department spends an

estimated $16,400,000 per year which equates to $53.68 per person in the community. This is

considerably more than the state average of expending $36.52 per person (FL Department of

Health, 2015).

Analysis and Interpretation of Data

Identified Strengths

In Escambia County, the percentage of adults with high cholesterol is lower than the state

average; 29.6% of adults in Escambia County report having high cholesterol whereas 33.4% of

adults in the state of Florida report having high cholesterol (FL Department of Health, 2015).

The percentage of women aged 40-74 years who received a mammogram in the last year

in Escambia County is above the state average (58.6% in Escambia County versus 57.5% in the

state) (FL Department of Health, 2015). This is a positive sign that reflects education on the
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importance of health screenings is being passed on to the individuals in the community and they

are receptive to this health information.

Another strength identified within the Escambia County community is that the percentage

of adults with diabetes who have had a foot exam in the last year is higher than the state average

(77.5% in Escambia County versus 67.6% in the state) (FL Department of Health, 2015). This

signifies that those with a chronic health condition, such as diabetes, are being informed of the

ways in which they can prevent complications and are taking action to protect their health.

Identified Weaknesses

Thirty-six percent of adults within Escambia County report that they have, at some point

in their lifetime, been diagnosed with hypertension (FL Department of Health, 2015). Within the

state of Florida, 34.6% of adults have been diagnosed with hypertension. Between 2002 and

2007, Escambia County showed signs of progress with a decrease in the number of adults

diagnosed with hypertension. However, between 2007 and 2013 the percentage of adults

diagnosed with hypertension began to rise, increasing from 27.8% to 36.7% over the six year

period (FL Department of Health, 2015).

In Escambia County, 184.7 per 100,000 deaths within the county are due to some form of

heart disease. Within the state of Florida, an average of 153.6 per 100,000 deaths are due to

heart disease (FL Department of Health, 2015). This difference in the number of heart disease

related deaths at the local and state level signifies an area in need of improvement.

Another area in need of improvement within Escambia County is the number of smokers

within the community. Within Escambia County, approximately 22.5% of adults are smokers

whereas approximately 16.8% of adults within the state of Florida are smokers (FL Department

of Health, 2015). Smoking is a major risk factor for cardiovascular disease and hypertension.
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Reducing the number of smokers within the community could reduce the number of adults living

with hypertension and the number of heart disease related deaths in the county.

Identification of a Priority Health Issue

Approximately 1 out of every 5 adults in the Escambia County community are smokers.

Healthy People 2020 is the United States national initiative to promote health and prevent

disease. This is accomplished by setting health goals for the country that target the most

prevalent preventable diseases and formulating a plan to reduce the number of persons living

with these diseases. In regards to smoking, one of the main objectives of Healthy People 2020 is

to reduce tobacco use by adults aged 18 years and over. The goal is that by the year 2020, 12%

or less of the U.S. population will be smokers (Office of Disease Prevention and Health

Promotion, 2014).

Tobacco use is detrimental to the health of those who partake in the activity and impacts

the health of innocent bystanders in the community who are exposed to tobacco smoke.

Implementing an effective smoking cessation health policy is imperative to the overall health of

a community.

Discussion and Application of Community Health Models

Social determinants of health are all of the social and environmental factors that impact

ones health status. The social determinants of health model is utilized to assess all of the social

and economic conditions in a community and determine the effect these conditions will have on

the overall health of that community (Savage, Kub, & Groves, 2016). Health is impacted by

many factors, some of which include socioeconomic status, access to healthcare services,

genetics and the physical environment in which one lives. All of these factors and more combine

to have a powerful impact on the health of individuals and communities alike.

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When discussing the health of a community, it is also important to assess the healthcare

resources available within the community. Individuals who do not have access to healthcare

services due to lack of availability, lack of financial resources and/or lack of insurance are more

likely to forgo routine medical care which increases their risk of developing serious health

conditions.

Research by Yang et al. (2015) assessed the social and environmental factors that

influenced smoking initiation and cessation. Results of the study revealed that frequent alcohol

consumption and frequent exposure to secondhand smoke increased the likelihood of smoking

initiation and decreased the likelihood of cessation among participants in the study. The results

also revealed that smoking initiation was strongly correlated with educational attainment; higher

educational attainment was associated with a lower rate of smoking initiation (Yang et al., 2015).

Population Diagnosis

Adults 18 years of age and older in Escambia County are at increased risk for the

development of cardiovascular disease due to inadequate smoking cessation programs in the

community.

Community/Population-based Interventions

Primary Level of Prevention

Primary levels of prevention focus on the promotion of health and the prevention of

disease before it even has a chance to occur (Savage, Kub, & Groves, 2016). According to the

2012 U.S. Surgeon Generals report, 9 out of 10 smokers began smoking cigarettes before they

were 18 years old (U.S. Department of Health and Human Services, 2017). It is imperative that

a health policy regarding tobacco use include substance use prevention education in the public
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school setting in order promote health in the community and reduce the rate of smoking initiation

among this age group.

The recipients of this level of prevention would be all children in Escambia County who

attend a public school. Stakeholders affected by this intervention are the children who attend

public school in Escambia County and their parents/families. The Escambia County School

District, local teachers and school nurses are also stakeholders as their time and resources will be

spent making sure children under their care receive substance use prevention courses during the

school year.

The school nurses in Escambia County would play a major role in this intervention. The

school nurse would be involved in the development of a lesson plan and would organize

presentations to all children in their respective schools. This could be a challenge as school

nurses have several other responsibilities and this could place stress on their time and resources.

The public school system may have to hire more school nurses in order to achieve this level of

intervention which may not be financially possible.

Secondary Level of Prevention

Secondary prevention interventions are formed to detect disease early and assist the

individual in modifying their lifestyle in order to prevent further damage to ones health (Savage,

Kub, & Groves, 2016). According to data from Healthy People 2020, tobacco screens are

performed on only 62.4% of adults in the outpatient care setting and only 60.2% of adults in the

hospital care setting (Office of Disease Prevention and Health Promotion, 2014). Implementing

a health policy that would increase tobacco screening in all healthcare settings would ensure that

a larger number of persons in the community are being screened and offered resources to quit

before serious health consequences have developed.

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The recipients of this intervention would be all individuals who visit a healthcare facility

within Escambia County. Stakeholders on this level of intervention are the nurses and

physicians who would be performing the tobacco screenings. The community health nurse

would play a role in carrying out the intervention and following up with individuals after the

intervention has been implemented. The community health nurse would be responsible for

asking each patient they come in contact with if they are current smokers. If patients reply that

they are current smokers, the nurse would then assess how frequently the patient smokes and if

they are interested in quitting. This would provide the community health nurse with an

opportunity to supply the patient with smoking cessation resources. The community health nurse

could make follow up phone calls to patients who have committed themselves to stop smoking in

an effort to encourage cessation and offer additional guidance if the patient has questions or

concerns.

Tertiary Level of Prevention

The goal of tertiary interventions is to prevent further disability and subsequent death

from a disease that has already developed in the individual (Savage, Kub, & Groves, 2016).

Research has shown that nicotine replacement therapy (NRT) in the form of either nicotine

patch, nicotine gum or nicotine inhaler is strongly associated with successful smoking cessation

(Voci, Zawertailo, Hussain, & Selby, 2016). Individuals who stop smoking tobacco, no matter

how many years they were smokers, have a lower risk of lung cancer, heart disease, stroke and

other respiratory disorders when compared to current tobacco users (CDC, 2017). Incorporating

free NRT to smokers who have complications related to smoking as part of the health policy will

ensure that all who wish to stop smoking tobacco products have access to resources that will aide

their cessation before further damage has been done to their health.
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The recipients of this intervention will be all individuals in the Escambia County

community who are current smokers who have developed a smoking-related illness or disease.

The community health nurse will provide education to NRT recipients regarding proper usage

and potential side effects of the medication. Stakeholders include smokers receiving NRT as

well as the healthcare providers providing education on NRT use. The pharmaceutical industry

would also be a stakeholder in this intervention as they may need to increase the supply of NRT

available in this community. Funding for the nicotine replacement therapy would come from the

Escambia County department of health.

Development of Health Policy

The smoking cessation health policy developed for Escambia County will focus on

secondary prevention measures that involve increasing tobacco screening in the healthcare

setting. The objective will be to reduce the percent of adults age 18 years or older who smoke

from 22.5% to 12% within the next 5 years. The proposed health policy will have a positive

impact on the health of both smokers and non-smokers in the community. Over time, the county

will experience decreased rates of heart disease, cancer and other smoking-related illnesses as the

percentage of smokers in this community is reduced.

Support for the proposed health policy will come from healthcare workers, public health

workers, and community members who are in support of the policy. The health policy could

face opposition from members of the tobacco industry who fear the health policy could

negatively impact their business. Opposition could also come from the community of smokers

who feel that smoking is their personal choice and that healthcare workers do not have the right

to question their lifestyle choices.

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Many individuals and groups in the community will be affected by this policy change.

Smokers in the community are the most important stakeholders as they are the ones who will

benefit directly from tobacco screening. Other stakeholders of the proposed health policy are the

healthcare providers who would be responsible for screening the patients they interact with for

tobacco use. Health insurance companies will also be affected by the policy as healthcare

providers may request payment for the extra time and counseling spent with patients discussing

their smoking habits.

In order to get the health policy into practice, the health policy proposal will be presented

to the local Florida Nurses Association chapter in order to gauge their response and willingness

to support the policy. Next, the Escambia County Medical Society and Florida Panhandle Nurse

Practitioner Coalition will be consulted to determine if the policy is something the healthcare

providers in the community would be able to put in place in their healthcare settings. After

consulting these various healthcare organizations, a formal health policy proposal will be

composed and presented to the Escambia County board of county commissioners in order to gain

their support in establishing the health policy and working towards the goal of reducing the

percentage of smokers in the community.

As I go forward into my nursing career, I will take with me the importance of health

screening in the promotion of health and prevention of disease. Health screenings can lead to

early identification of risk factors for disease such as smoking. Asking patients a few simple

questions in regards to their lifestyle could bring to light these risk factors and open up the

conversation to offer ways to modify their current lifestyle in ways that would protect and

preserve their health for years to come.

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References

Centers for Disease Control and Prevention. (2017). Smoking & tobacco use. Atlanta, GA: U.S.

Department of Health and Human Services. Retrieved from

https://www.cdc.gov/tobacco/

Florida Department of Health. (2015). County health profile: Escambia County. Retrieved from

http://www.flhealthcharts.com/charts/CountyHealthProfile.aspx?county=

17&reportYear=2015&tn=23

Florida Department of Health in Escambia County. (2013). Community health assessment.

Retrieved from http://www.floridahealth.gov/provider-and-partner-resources/community-

partnerships/floridamapp/state-and-community-reports/escambia-

county/_documents/escambia-cha.pdf

Florida West Economic Development Alliance. (2017). Leading employers. Retrieved from

http://www.choosegreaterpensacola.com/Business-Location-Expansion/Leading-

Employers.aspx

Office of Disease Prevention and Health Promotion. (2014). Tobacco use. Washington, DC: U.S.

Department of Health and Human Services. Retrieved from

https://www.healthypeople.gov/2020/topics-objectives/topic/tobacco-use

Savage, C.L., Kub, J.E., & Groves, S.L. (2016). Public health science and nursing practice:

Caring for populations. Philadelphia, PA: F.A. Davis Company.

Sutfin, E.L., McNamara, R.S., Blocker, J.N., Ip, E.H., OBrien, M.C., & Wolfson, M. (2012).

Screening and brief intervention for tobacco use by student health providers on college

campuses. Journal of American College Health, 60(1), 66-73.

doi:10.1080/07448481.2011.572325
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United States Census Bureau. (2016). 2012 economic census of the United States. Retrieved

from https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.

xhtml?src=CF

U.S. Department of Health and Human Services. (2017). Preventing tobacco use among youth

and young adults. Retrieved from https://www.surgeongeneral.gov/library/reports/

preventing-youth-tobacco-use/factsheet.html

Voci, S.C., Zawertailo, L.A., Hussain, S., & Selby, P.L. (2016). Association between adherence

to free nicotine replacement therapy and successful quitting. Addictive Behaviors, 61, 25-

31. doi:10.1016/j.addbeh.2016.05.012

Yang, J.J., Song, M., Yoon, H., Lee, Y., Lee, S., & Kang, D. (2015). What are the major

determinants in the success of smoking cessation: Results from the Health Examinee

Study. Plos ONE, 10(12). doi:10.1371/journal.pone.0143303