Running head: TOBACCO CONSUMPTION 1

Tobacco Consumption:

The Fight to Prevent Unnecessary Death

Rebecca Netjes

University of South Florida

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Tobacco Consumption: The Fight to Prevent Unnecessary Death

The discipline of nursing seeks to address health concerns regarding the emotional,

physical, and mental health of each individual patient. In order to do so effectively, nurses must

further consider the environment in which the individuals live. This way of thinking allows

health care professionals to address health practices that occur on a larger scale that affects

unique patients. This paper seeks to analyze the specific health practices and beliefs in Pasco

County, Florida that contribute to the health and wellness of the inhabitants, with specific

attention to the high level of tobacco consumption among adults.

Overview of Pasco County

Pasco County was established in 1887 from what was a part of Hernando County (Pasco

County Florida, n.d.). It is positioned to the north of Tampa, Florida, on the west coast of the

state. Pasco County is unique in that within its 742 square miles, there are recreational facilities

and synthetic ocean reefs, but there has been significant urban growth along the coast and in the

divisions just north of Tampa (Pasco County Florida, n.d.).

According to the 2010 Census, Pasco County is considered to be a largely urbanized

county, with growth occurring at a rapid rate in the areas near Tampa (United States Census

Bureau, n.d.). The census indicates that the majority of the population identifies their race as

white, with African American and Hispanic/Latino being the second and third most identified,

respectively (United States Census Bureau, n.d.). Within Pasco County, the three major

employers include occupations in trade/transportation/utilities (23.7%), education/health services

(20.2%), and government (15.4%) (Office of Economic & Demographic Research, n.d.). Racial

identification and occupation begin to lay a foundation for which overall health can be

understood, but it is critical to assess for other contributing factors within the population.
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Comparison of Local vs. State Populations

Socioeconomic factors, such as income, often play a large role in whether persons have

the financial means to access health care. Despite physical availability, if individuals do not have

the ability to compensate financially, they may not use health care services. In Pasco County,

14.6% of households are considered to be below the poverty line; while in Florida, 15.8% of

households identified in this manner (Office of Economic & Demographic Research, n.d.).

Health literacy is another factor contributing to the likelihood of a person to utilize health

care services. Often times, a patient will report that they do not utilize health care services stating

they will not understand the instruction provided. In Pasco County, 88% of persons 25 years of

age or older have obtained a high school diploma; at the state level, 86.9% of persons identify

this to be true (Office of Economic & Demographic Research, n.d.). Furthermore, 14.4% of

individuals in Pasco County, age five or older, report speaking a language other than English

(United States Census Bureau, n.d.). In the state of Florida, 21% of persons identified with this

category (United States Census Bureau, n.d.). It is critical that providers provide education at the

level of education the patient has obtained and in the language they are most comfortable with.

Additionally, the physical availability of health care providers plays a role in the

likelihood of utilization of health care. If there are not ample providers, there may be an increase

in delay of treatment. In Pasco County, there are 53.8 primary care providers per every 100,000

individuals, the average in the United States being 48 providers per 100,000 (Community Health

Status Indicators, n.d.). While Pasco County has more providers per 100,000 individuals than the

national average, it would be beneficial for the community to continue to increase this number. If

the community members to not believe that their provider has enough resources and time to treat

them effectively, they may delay seeking treatment.

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Analysis and Interpretation of Data

Identified Strengths

Cancer screening test are pivotal in that they allow for early diagnosis and rapid

treatment. In 2013, in Pasco County, the percentage of adults that are 50 years of age and above

who received a sigmoidoscopy and/or colonoscopy, in the last five years, was 59.4% (Florida

Health Charts, n.d.). With regards to the state of Florida, 55.3% of the eligible adults received a

sigmoidoscopy and/or colonoscopy in the last five years (Florida Health Charts, n.d.). This may

indicate that adults in Pasco County are more willing to undergo cancer screening tests.

From 2014 to 2016, the percent of children entering kindergarten fully immunized (in

accordance with standards set by the Florida Department of Health) was 95.4% (Florida Health

Charts, n.d.). In comparison, in the state of Florida, 93.4% of all students were fully immunized

(Florida Health Charts, n.d.). The percentage of immunization rate for students entering

kindergarten has been consistently higher in Pasco than in Florida since 2009. This corresponds

with less children contracting preventable disease. For example, there was only one reported case

of a child less than five years of age, per every 100,000 people, contracting Haemophilus

influenzae (Florida Health Charts, n.d.).

In Pasco County, 83.3% of eligible women received early prenatal care (care that begins

in the first trimester) from 2013 to 2015; in the state of Florida, 79.5% of women received early

prenatal care (Florida Health Charts, n.d.). Currently, Pasco County is surpassing the overall

state of Florida’s success and the US Healthy People 2020 goal of 77.9% (Florida Health Charts,

n.d.). This may be a factor that then contributes to the lower level of low birth weights in Pasco

County (8.4%) when compared to the state level (8.6%) (Florida Health Charts, n.d.). Overall,

this may be related to greater antenatal education, access to resources, or other variables.
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Identified Weaknesses

In 2013, the age adjusted death rate per 100,000 persons, related to colorectal cancer, was

15.6 in Pasco County (Florida Health Charts, n.d.). In the state of Florida, the death rate was

13.6; while the US Healthy People 2020 initiative outlines a goal of less than 14.5 (Florida

Health Charts, n.d.). This draws attention to the need for an upstream approach to this issue.

There should be further investigation into predisposing conditions for the population,

lifestyle/environmental variables contributing to stage of cancer, and treatment options/access.

The percentage of women 18 years of age and older that received a Papanicolaou test in

the past year in Pasco County during 2013 was 41.5%; while in the state of Florida during 2013,

51.4% received the test (Florida Health Charts, n.d.). The US Healthy People 2020 goal outlines

93% of eligible women as the standard to strive towards. This likely contributes to Pasco County

having a higher age-adjusted death from cervical cancer (3.3) when compared to Florida (2.7)

and the Healthy People 2020 goal (2.2) (Florida Health Charts, n.d.).

The current US Healthy People 2020 goal for adults who report that they are current

smokers is 12% (Florida Health Charts, n.d.). In Pasco County, during 2013, 24% of adults fit in

this category. In the state of Florida, 16.8% adults identified with this group (Florida Health

Charts, n.d.). This large difference in Pasco County when compared to the state of Florida and

the national goal warrants investigation. Interventions such as early education on the importance

of abstaining from tobacco use, resources to aid in quitting, and treatment for associated health

outcomes should be implemented.

Identification of a Priority Health Issue

In the United States, the largest influence in preventable disease processes and death is
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the use of tobacco and tobacco products (Jamal et al., 2016). Unfortunately, the use of tobacco

products leads to approximately 443,000 deaths each year in the United States (Chaney &

Sheriff, 2012). With this data in mind, it is evident that the use of tobacco products in Pasco

County should be considered a priority health issue for legislators and health professionals.

Currently, there is 12% more adults identifying as currently using tobacco products than the

Health People 2020 goal (Florida Health Chart, n.d.).

Furthermore, the use of tobacco products is a priority health issue as it leads to

detrimental health consequences later in life. For example, the age-adjusted death rate was 52.8

lung cancer - while in Florida it was 42.1 (Florida Health Charts, n.d.). The Healthy People 2020

goal suggests 45.5 to be the benchmark to which health care providers strive for (Florida Health

Charts, n.d.). Physicians who come into contact with those using tobacco products must continue

to be vigilant in clinical exams and diagnostic tests, when indicated. This priority should be

addressed by implementing means of prevention and treatment for associated outcomes.

Discussion and Application of Community Health Models

Community health models are pivotal in the understanding of public health nursing in

that they provide a framework with which the nurse can assess individuals and populations in

unison. The Determinants of Health Model is a model that suggests that healthcare professionals

should assess for biological, social, environmental, and economic influences on health care

(Savage, Kub, & Groves, 2016). This model specifically suggests that the gross behaviors of the

populations set a precedent for the behavior of the individuals (Savage et al., 2016). Nurses and

other healthcare professionals should also be vigilant in that many of these factors can lead to

disparities at an individual level. After identifying the health determinants of a population, the

healthcare providers can begin to formulate unique interventions.

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With regards to the consumption of tobacco, biological determinants of health such as

gender, race, and family history play a role in the likelihood of an individual to consume tobacco

products. For example, it was found in 2015 that males of American Indian/Alaska Native

heritage were more likely to report a history of cigarette smoking (Jamal et al., 2016). This

indicates that interventions for screening and treatment regarding the consumption of tobacco

products should be emphasized in these patient populations. The biologic health determinant is

one that health providers should be assessing for at each patient encounter.

The current health system within a population can also be considered a health

determinant. If the providers within the community are not educated on appropriate treatment for

tobacco consumption and methods of therapeutic communication, rapport may not be established

and patients will not engage in treatment. When providers are not assessing for the use of

tobacco products at each visit, they may not be accurately identifying patients consuming

tobacco products. It is recommended that providers employ a nationally approved screening

technique at each visit – such as the “five A’s” (Chaney & Sheriff, 2012). The available health

care providers make up the overall health system, which is a determinant of the community’s

health. Therefore, providers must practice screening, education, and treatment for health issues,

such as tobacco use, at each patient encounter.

The environmental and social determinants of health are often closely related, in that

one’s environment is populated by those they are in relationship with. It has been noted that

factors such as living conditions and education can contribute to the health of individuals. This is

exhibited in that those who possess a General Education Development certificate (GED) and are

below the poverty line are more likely consume tobacco products (Jamal et al., 2016).

Demographics such as the place of residence and highest level of education are helpful in that
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providers can identify populations who may be at an increased risk for disease processes or

health outcomes. The environmental and social determinants of health should be considered by

providers as they screen patients for new health conditions. In doing so, patients will receive

targeted education to prevent illness and interventions to promote overall health and wellness.

Population Diagnosis

Adults in Pasco County engage in a higher rate of tobacco consumption because of

inconsistent or ineffective screening and treatment in the primary care setting.

Community/Population-based Interventions

Primary Level of Prevention

Primary prevention are those efforts aimed at preventing or delaying the onset of a

disease process (Savage et al., 2016). With regards to prevention surrounding tobacco

consumption, one effort that is often implemented is education in schools. Students are often

provided information on the harmful effects of smoking on the body, such as dependence on

nicotine and an increase in risk for cardiovascular and respiratory complications, to deter them

from consuming tobacco products. (Chaney & Sheriff, 2012). This intervention is largely

supported by community members or healthcare providers that volunteer their time to provide

this education. As a result of this dedication of time and resources, these two groups make up a

large portion of the targeted stakeholders.

Furthermore, a community nurse would be invaluable in this role, as this position has a

large focus on education. The nurse is in a unique position in that they are able to establish

rapport, provide instruction, and evaluate the results. Education by the community nurse also

facilitates risk factor modification. The education provided will decrease the consumption of

tobacco, which in turn decreases the patient’s risk of developing chronic diseases processes and
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associated health outcomes. Evaluation would be key in a primary level intervention in the form

of education, as there may not be a visible change with which could inspected.

Secondary Level of Prevention

Interventions that fall under the category of secondary level are carried out with the aim

of identifying disease processes early so treatment may be initiated immediately (Savage et al.,

2016). A community wide intervention that should be implemented is the use of standardized

screening questions among health care professionals in the primary care setting. Chaney and

Sheriff (2012) provide the “Five A’s” as an excellent example, as it segues into treatment once

the patient’s risk is identified. To engage in the “Five A’s”, practitioners should “ask” the patient

in a straightforward manner at each visit about their use of tobacco, and if necessary, “provide

advice” on how to engage in smoking cessation. They should “assess” to see if the patient is

ready mentally, physically and emotionally to engage in cessation and “assist” them in creating a

unique plan. Finally, follow up visits should be “arranged” (Chaney & Sherrif, 2012). The major

stakeholder in this scenario is the healthcare provider as they are the team member implementing

the intervention. Typically, this is something that could be covered in a physical or office visit,

so the provider would be compensated financially. The community nurse could assist the

provider in collecting this information and identify trends in the patient’s report. This would

allow the healthcare team to collaborate with the patient in making adjustments as needed.

Tertiary Level of Prevention

Tertiary levels of protection aim to prevent the individual from experiencing an untimely

death or other negative health outcomes as a result of their diagnosis (Savage et al., 2016). In the

scenario of tobacco consumption, patients will be at an increased risk for several adverse health

situations such as cardiovascular compromise, respiratory failure, or malignancies. Therefore,

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after a patient is identified as one who consumed or consumes tobacco, they should be monitored

for the development of any complications. This could include diagnostic tests such as

electrocardiograms, spirometry, and chest radiographs (Chaney & Sheriff, 2012). The

stakeholders toward whom the intervention is geared is largely healthcare providers as they will

be ordering the diagnostic tests. However, legislators may also play a role in implementing

regulation as to which services must be covered by insurance companies. Without insurance

coverage for these tests, patients may forgo treatment and suffer undue consequences. The

community health nurse will play a key role in educating patients on the purpose of the

diagnostic tests, and lifestyle modifications they can implement to benefit their condition.

Development of Health Policy

Health policy is essential to ensuring that equal and just care be provided among the

members of a community (Savage et al., 2016). The policies implemented in a community

ideally provide healthcare professionals with a set of standard practices to implement. This

ensures that each patient has access to equal, quality care. However, as discoveries and advances

are made in health care, it is essential that policies adapt as well.

The focus of this proposed health policy is to effectively treat health consequences

associated with the high rate of tobacco consumption among adults in Pasco County, such as

lung cancer. The policy change would call for health care providers to monitor for lung cancer

based on risk factors and clinical presentation, rather than solely on the recommendation set forth

by the US Preventive Services Task Force (USPSTF) (Katki, Kovalchik, Berg, Cheung, &

Chaturvedi, 2016). This tertiary level of prevention for those consuming tobacco in Pasco

County will allow for diagnosis and treatment of any adverse health outcomes.
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Stakeholders affected by this proposal include community members, healthcare

providers, and funding sources. Community members and healthcare providers would likely be

supportive of this policy. Community members would benefit in that they would be have access

to early detection of potential complications for themselves or their loved ones. Healthcare

providers would also be satisfied in that they are able to provide the highest quality of care.

Together, these groups have immense influence, as they direct what care is provided.

Funding sources may not be immediately supportive of this policy change. This may

cause patients to incur a high portion of the bill for medical services. The influence of funding

sources is a critical component to any health policy, as many patients will forgo treatment if it is

not covered by their insurance. It would likely take a great deal of clinical data indicating this

new screening protocol has a higher rate of patient success before insurance companies would be

willing to participate. However, if implemented effectively, screenings for the health outcomes

associated with tobacco consumption will lead early diagnoses. This, in turn, will allow health

care providers to begin treatment quickly, which will improve patient health outcomes.

Furthermore, insurance companies will also likely report a decrease in overall spending as health

conditions can be treated early and effectively, with the hopes of preventing chronic disease –

such as lung cancer.

The general plan for implementation of the policy would begin with the collection of data

from clinical trials, such as the information from Katki et al. (2016), in support of the policy.

Next, the information must be presented to healthcare providers, who will then advocate for

changes with the funding source and legislators. In Pasco County, the implementation of this

policy may contribute to a decrease in adults that report a current status of tobacco use and
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associated malignancy. This policy would allow patients who did not meet recommendation for

screenings before to gain access when they and their healthcare provider feel it is indicated.

Conclusion

In its current state, Pasco County is excelling in many areas. However, it is critical that

community members do not rest until all goals have been met – especially when death could be

prevented. The proposed health policy, to adjust the requirements for monitoring for the

occurrence of lung cancer after a patient reports a history of tobacco consumption, will help the

community to do this. This policy will allow for rapid diagnosis, followed by a development of a

treatment plan, with the ultimate goal to sustain the patient’s quality of life. Tertiary prevention

is a pivotal part of health policy, as it allows health professionals to monitor for new disease

process associated with the patient’s current or past state of health.

In my clinical practice, I know that it will be inevitable that my patient will require a test

that is not covered by insurance- such as a radiograph to assess for lung cancer. I am aware that

they will be denied treatment because they do not appear profitable to a third party. This is the

moment I hope that I can collaborate with other healthcare professionals to create a strong sense

of advocacy for my patient. It is my desire that we will have the endurance to fight for our

patient and courage to create new policies that maintain the highest level of patient care. This,

the ability to fight for someone, is a great privilege I do not take lightly.
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Practitioner, 37(4), 24-31. doi:10.1097/01.NPR.0000412892.27557.e8

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10.1001/jama.2016.6255

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https://www.census.gov/quickfacts/table/POP010210/12101,00