Introduction

Cancer has been infamously named the leading cause of death -worldwide- by the World Health Organization (WHO, 2019). According to the World Health Organization, the global rates of cancer incidence



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and cancer mortality

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are not improving either, but are rather continuing to increase (WHO, 2019). Currently, cancer is said to be responsible for one in every six deaths worldwide (WHO, 2019). Lung cancer, in specific, is the most commonly diagnosed cancer and is said to be the leading cause of cancer death worldwide (WHO, 2019).

Australia is drastically affected by lung cancer. According to the World Health Organization’s International Agency for Research on Cancer, Australia is known to have both the highest rates of cancer incidence and mortality compared to any other country (International Agency for Research on Cancer, 2018). While currently in Australia, more men are diagnosed with lung cancer than women, it is estimated that women’s incidence rate of lung cancer will surpass men’s incidence rate within the next decade (Yu, X., Kahn, C., Luo, Q., Sitas, F., & O’connell, D., 2015). Furtehr on, there has been a significant increase in disparity across socioeconomic areas for lung cancer (Yu, X., Luo, Q., Kahn, C., Cahill, C., Weber, M., Grogan, P., … O’Connell, D., 2017) in Australia.

In addition to Australia, lung cancer in the United States of America is said to be the number one killer cancer for both men and women (American Lung Association Scientific and Medical Editorial Review Panel, 2019). Although currently in America, men are more likely to be diagnosed with lung cancer than women, the already small incidence gap between the two sexes is decreasing (Donington, J., & Colson, Y, 2011). In America, a low socioeconomic status has also been associated with an increased risk for Lung Cancer (Hovanec, J., Siemiatycki, J., Conway, D., Olsson, A., Stucker, I., Guida, F., … Behrens, T. 2018).

The high rates of lung cancer incidence and mortality for both countries may be contributed to smoking tobacco, second-hand smoke, genetic susceptibility, poor diet, occupational exposures, and air pollution (Malhotra, J., Malvezzi, M., Negri, E., La Vecchia, C., Boffetta, P., & Malhotra, J, 2016). Further on, cultural views and stigma may be an important cause of lung cancer mortality (Crane, M., Scott, N., O’Hara, B., Aranda, S., Lafontaine, M., Stacey, I., … Currow, D, 2016). Some of lung cancer’s effects include high mortality rates, high healthcare expenditures, tobacco control initiatives, and other governmental interventions.

The following paper will consist of a body which will further explain the role that gender plays in lung cancer, the causes of lung cancer, the role that socioeconomic status plays in lung cancer, and the effects of lung cancer in Australia. Additionally, the paper will consist of an analysis that will critically examine and analyze the literatures mentioned in the body and compare the lung cancer’s causes, effects, gender roles, and socioeconomic roles in Australia to America. Lastly, the paper will include a conclusion to wrap up the paper’s main points and explain what research should be further examines for lung cancer in Australia.

Role of Gender in Lung Cancer in Australia

In Australia there is an estimated 10,000 lung cancers diagnosis per year -in which 5,950 are in men and 3,755 are in females (Australian Institute of Health and Welfare, 2019). Further on, there is an estimated lung cancer mortality of 4,715 males and 2,910 females (Australian Institute of Health and Welfare, 2019). This makes lung cancer the second cause of death for all males and the fourth cause of death for females in Australia (Australian Institute of Health and Welfare, 2019). However, over the past several years, the mortality rate from lung cancer for males has decreased by 41%, while the mortality rate for females has increased by 56% (Australian Institute of Health and Welfare, 2019). This is a huge disparity gap between both genders. This different pattern of incidence and mortality rates in males and females is said to reflect recent changed in attitude and smoking behavior. Currently men smoke more tobacco than women, but women have started smoking tobacco much more than before, whereas men have stopped smoking tobacco as much as before. This can be due to changing cultural views, in which smoking tobacco is no longer perceived a “male” activity- making women more inclined to smoke. At the same time, there has been many tobacco control initiatives targeted to the male population, which may be the cause of why the male population has decreased their smoking rates (Australian Institute of Health and Welfare, 2019).

Causes of Lung Cancer in Australia

As a chronic disease, lung cancer has many risk factors that may accumulate over time to initiate the disease. Such risk factors include smoking tobacco, inhaling second-hand smoke, genetic susceptibility, poor diet, occupational exposures, and air pollution (Malhotra, J., Malvezzi, M., Negri, E., La Vecchia, C., Boffetta, P., & Malhotra, J, 2016).

Smoking tobacco is the biggest risk factor for lung cancer as it accounts for 87 percent of all lung cancer deaths (Ball, W.,1957). In Australia, smoking tobacco became common as it exponentially increased after World War Two (Adair, T., Hoy, D., Dettrick, Z., & Lopez, A., 2011). Beneficially, within the past decades’ discovery of how harmful smoking tobacco is, the proportion of adults in Australia who were daily smokers decreased from 22.3% to 13.8% (Adair, T., Hoy, D., Dettrick, Z., & Lopez, A., 2011). During the more recent years, however, the daily smoking rate has remained relatively stable at 13.8% (Adair, T., Hoy, D., Dettrick, Z., & Lopez, A., 2011).

Poor diet is also one of the major risk factors for lung cancer. A diet high in red meat and low in vegetables is shown to have a strong correlation to lung cancer (Xue, X., Gao, Q., Qiao, J., Zhang, J., Xu, C., Liu, J., & Xue, X., 2014). Australians consume approximately 100kg of red meat per year- ranking Australia as the number one country with the highest red and processed meat intake per person (“FED: Snapshot of Australia’s health”, 2018). In addition to red and processed meat, only 68% of children and five percent of adults have a sufficient intake of vegetables (“FED: Snapshot of Australia’s health”, 2018). This shows that Australia’s diet is extremely poor and could be why so many Australians are affected with lung cancer.

Stigma and other cultural views may also be an important cause of lung cancer mortality. When it comes to lung cancer screenings in Australia, there is a common belief in that a person should only go to the doctor if the symptoms are severe enough— since they “know their body, and would know if something was wrong” (Crane, M., Scott, N., O’Hara, B., Aranda, S., Lafontaine, M., Stacey, I., … Currow, D, 2016). Another widely held view is to not mention “mild” symptoms to the doctor since it will “go away” (Crane, M., Scott, N., O’Hara, B., Aranda, S., Lafontaine, M., Stacey, I., … Currow, D, 2016). Lastly, many smokers admitted that they would not tell their doctor if they experience symptoms of smoking because of the stigma associated with smoking (Crane, M., Scott, N., O’Hara, B., Aranda, S., Lafontaine, M., Stacey, I., … Currow, D, 2016). This is an obstacle to secondary prevention for lung cancer, which is critical for early treatments and stopping further spread of the cancer.

Roles of Socioeconomic Status in Lung Cancer in Australia

Currently in Australia, there has been a significant increase in disparity across socioeconomic areas for lung cancer (Yu, X., Luo, Q., Kahn, C., Cahill, C., Weber, M., Grogan, P., … O’Connell, D., 2017). Many studies show a strong negative correlation with one’s smoking rate and one’s socioeconomic status; people in the lowest socioeconomic status group are almost twice that of the highest socioeconomic class to smoke tobacco (AIHW, AIHW & AACR, 2008). As a result, people with lower socioeconomic statuses have higher lung cancer incidence and mortality rates than people from higher socioeconomic statuses (AIHW, 2010a). More specifically, the Aboriginal and Torres Strait Islander population of Australia show a relative socioeconomic disadvantage to other Australians. As a result, the age-standardized incidence rate of lung cancer are significantly higher for Indigenous than non-Indigenous Australians (AIHW, 2010a). In specific, Indigenous (Aboriginal and Torres Strait Islander) males were 1.7 times as likely to be diagnosed with lung cancer as non-Indigenous males and Indigenous females were 1.6 times as likely to be diagnosed with lung cancer as non-Indigenous females. This difference may be explained, at least in part, by the fact that Indigenous adults have a relatively low socioeconomic status (AIHW, 2010a). Being in a low socioeconomic status puts the Indigenous population at a more than twice as likely chance to be a current daily smoker and not be able to afford healthy and nutritious foods (AIHW, 2010a).

Effects of Lung Cancer in Australia

Premature mortality is the biggest effect of lung cancer in Australia. Other effects of lung cancer include high healthcare expenditures, tobacco control initiatives, and increased research for lung cancer. As previously mentioned, lung cancer has extremely high mortality rate in

Australia; the chance of surviving at least five years of lung cancer is only 17 percent (Torre, L., Siegel, R., Jemal, A., & Torre, L., 2016). Most people who die prematurely from lung cancer not only cause emotional damage on their families, but they become a lost value in their country as a whole; in Australia, the amount of premature deaths from lung cancer in 2003 resulted in 88,000 working years lost and was estimated to be a $4.2 billion economic cost for the country (Carter, H., Schofield, D., & Shrestha, R., 2016).

Lung cancer in Australia also creates high healthcare expenditures. Just in 2004 alone, Australia’s healthcare expenditure for lung cancer was approximated to cost $166 million (AIHW, 2010b). 79% of the health expenditure on lung cancer was for hospital admitted patient services -costing around $131 million (AIHW, 2010b). Another 18% was spent on out-ofhospital medical services -costing around $30 million, and the last 3% was spent on prescription pharmaceuticals -costing nearly $5 million (AIHW, 2010b). This is an extremely high spending as in 2004 it was found that the proportion of health-care expenditure for lung cancer was more than the healthcare expenditure for all other cancers and all diseases (AIHW, 2010b).

Additionally, the future cost for lung cancer healthcare expenditures is estimated to have a sharp increase (AIHW, 2010b).

There have also been tobacco control initiatives as a result of the high lung cancer rates in Australia. In Australia, such initiatives such as putting health warnings on tobacco packaging, making smoke-free zones, tobacco price increases, and increased anti-tobacco marketing campaigns have already been shown to avert a great number of deaths in the country, preventing roughly 400 thousand deaths from lung cancer from 1956-2015 (Dela Cruz, C., Tanoue, L., & Matthay, R., 2011).

Analysis

The articles used in the body of this paper contribute to the larger body of science by bringing in comprehensive snapshots of Australia’s lung cancer’s latest statistics and their collective impact. This is important since one must know the collective effects, gender roles, socioeconomic roles, and causes of lung cancer for decision-making, resource allocation and the evaluation of programs and policies regarding lung cancer in Australia. All of the literatures used in the body are appropriate, as they are credible -all are peer reviewed and the experimental research papers have even been repeated multiple times by different studies in which similar results were found-, they are also relevant as they have the most recent data, and are directly related to the topic of lung cancer in Australia such as explaining genders’ roles in lung cancer, causes of lung cancer, socioeconomic roles on lung cancer, and the effects of lung cancer.

When it comes to gender roles’ effect on lung cancer in America compared to Australia, the gap between female and male lung cancer incidence and mortality rates is much smaller than Australia’s. In America, there is an estimated 228,150 new cases of lung cancer per year -in which 116,440 are in men and 111,710 are in women (American Cancer Society, 2019). Additionally, there is an estimated 142,670 deaths from lung cancer every year -in which 76,650 are in men and 66,020 are in women (American Cancer Society, 2019). It is important to note that the number of deaths are much larger in America since the population in America is bigger than Australia’s -however, Australia still has a higher mortality rate. Overall, in America the chance that a man will develop lung cancer in his lifetime is about 1 in 15, while for a woman the risk is about 1 in 17. Just like the disparity that the Aboriginal population of Australia face when it comes to lung cancer, black men and women in America also face a disparity as they are about 15% more likely to develop lung cancer than white men and women (Desantis, C., Miller, K., Goding Sauer, A., Jemal, A., & Siegel, R., 2019). In America, both black and white women have lower rates of lung cancer incidence than men, but this gap is very close to closing (American Cancer Society, 2019).

During the past 50 years there has also been a dramatic increase in the incidence of lung cancer in women in America- just like in Australia (Donington, J., & Colson, Y., 2011). There is a gap in the literatures when it comes to causes of the increase in lung cancer for women in both Australia and America. Most of the articles contribute this rise to an increase in smoking tobacco within the female population, however, approximately 1 in 5 women with lung cancer have never smoked (Donington, J., & Colson, Y., 2011). Some small studies have tried examining the significance of gender-based differences in epidemiology, genetics, hormones, and treatments of lung cancer to find what is the cause of 20 percent of the women with lung cancer, but not many studies have found significant data (Donington, J., & Colson, Y., 2011).

When it comes to the causes of lung cancer, Australia and America both struggle with the same causes. Australia’s historical trends in smoking tobacco and lung cancer were very similar to America’s (Adair, T., Hoy, D., Dettrick, Z., & Lopez, A., 2011). In America, the tobacco smoking rate were also extremely high after World War Two, where 42.4% of U.S. adults would smoke cigarettes (Angelicalavito, 2018). America’s smoking trends recently reached a record low of 14% after a 67% decline since 1965, just like they did in Australia (Angelicalavito, 2018). Further on, when it comes to dietary trends, in America, although high rates of red meat intake persist along with low rates of vegetable intake, there has been a national decrease in red meat consumption and a national increase in vegetable consumption (Neff, R. A., Edwards, D., Palmer, A., Ramsing, R., Righter, A., & Wolfson, J., 2018). This shows that America is less likely to be affected by lung cancer because of their diet as compared to Australia. In addition, cultural views such as stigma also persists in America as many lung cancer patients fear being denied treatment and conceal their condition and their psychosocial distress (Hamann, H., Ostroff, J., Marks, E., Gerber, D., Schiller, J., & Lee, S., 2014). Not many studies are done on how to effectively reduce this stigma in both America and Australia. Such stigma and cultural views prevent many people in both Australia and America in getting primary, secondary, and tertiary prevention for lung cancer.

When it comes to socioeconomic status’ role in lung cancer, many studies also showed a negative correlation between one’s socioeconomic status and lung cancer incidence in America just as they did in Australia (Hovanec, J., Siemiatycki, J., Conway, D., Olsson, A., Stucker, I., Guida, F., … Behrens, T., 2018). This can in part be due to people in lower socioeconomic classes for both countries are less likely to be educated about the importance of their health and more likely to be targeting by tobacco ads. Further on, people in lower socioeconomic statuses for both countries are less likely to afford healthy foods and are more likely to eat processed meats from fast food store chains, which increases their chances of developing lung cancer. There is a gap in articles that talk about the disparity in lung cancer mortality rates in Australia and America due to socioeconomic class roles. Although one might assume people from lower socioeconomic classes have higher mortality rates because they might have less access to quality healthcare- since this is generally a case of higher mortality rates in least developed countries as seen in the video of Dead Mum Don’t Cry (British Broadcasting Corporation, 2005) and talked about in the book “Introduction to Global Health” by Kathryn H. Jacobsen on chapters explaining infectious disease and disparities in least developed countries (Jacobsen, K. H., 2019) -however, this is not supported by scientific evidence for lung cancer. Further on, little is known about the relation between the strength of association and the level of adjustment and level of aggregation of the socioeconomic status measure for both Australia and America. One literature found “a weak positive association between individual income and lung cancer survival” however this correlation is too weak to have any significance (Finke, I., Behrens, G., Weisser, L., Brenner, H., & Jansen, L., 2018).

When it comes to the effects of lung cancer, Australia is more drastically impacted than America. For instance, the chance of surviving lung cancer after five years in Australia is only 17 percent, whereas in America that number is increased to 56 percent (American Lung Association Scientific and Medical Editorial Review Panel, 2019. Additionally, when it comes to the cost of healthcare expenditures, lung cancer in America does not have the highest healthcare expenditures out of all other cancers like it does in Australia (Yabroff, K. R., Lund, J., Kepka, D., & Mariotto, A., 2011) -even though lung cancer healthcare expenditures in America are estimated to be a whopping $12.1 billon (Yabroff, K. R., Lund, J., Kepka, D., & Mariotto, A., 2011). In addition, the same tobacco control initiatives have been used in America and have resulted in an 8% short-term relative reduction in smoking and a 12% long-term relative reduction in smoking prevalence through the greater impact on youth smoking (Levy, T., Tam, T., Kuo, T., Fong, T., & Chaloupka, T., 2018), reaching more people than the initiatives in Australia. There is a gap in articles about more efficient tobacco control initiatives in Australia that will primarily affect the minority groups such as the Aboriginal population, people in lower socioeconomic statuses, and women in Australia in order to eventually close the disparity gap. The only major area in which lung cancer is more drastically affecting America than Australia is the projected 3 million years of life that will be prematurely lost due to lung cancer -leading to about $145 billion in economic loss for the country (American Cancer Society, 2019). America is estimated to lose more money from premature deaths of lung cancer than Australia since the American population is larger, and more deaths in total mean more money lost in total. In America, it was also estimated that the cost of lung cancer healthcare expenditures will increase in the following years just like they will increase in Australia (Yabroff, K. R., Lund, J., Kepka, D., & Mariotto, A., 2011).

Conclusion

In reflection, lung cancer greatly impacts the population of Australia as it has both the highest incidence rate as well as the highest mortality rate out of all other cancers. Smoking tobacco, poor diet, and stigma are some of the causes of lung cancer that can be changed. Decreasing lung cancer incidence rates through primary prevention is said to be the most efficient way in dealing with lung cancer. That being said, further research should be done to find the most efficient ways to change people’s behavioral attitudes towards smoking tobacco, diet, and stigma. Such research should be especially aimed at populations who are most effected by lung cancer -such as the Aboriginal population in Australia, people in lower socioeconomic classes, and women. More research done in these areas should be able to remove the disparity gap and overall lung cancer incidence rates by guiding with decision-making, resource allocation and the evaluation of programs and policies regarding lung cancer. In addition, further questions should be asked on how America has made increased their five-year lung cancer survivability rate to 56 percent whereas it is only still 17 percent in Australia. Australia can learn a lot from America’s approach -as both countries have had very similar trends, causes, and effects (including the high mortality rates, high healthcare expenditures, and money spent on future tobacco prevention initiatives) of lung cancer.

Bibliography

AIHW & AACR (Australasian Association of Cancer Registries). (2008.) Cancer in Australia: an overview, 2008. Cancer series no. 46. Cat. no. CAN 42. Canberra: AIHW.

AIHW. (2010). Australia’s health 2010. Cat. no. AUS 122. Canberra: AIHW.

AIHW. (2010)b. Health system expenditure on disease and injury in Australia, 2004–05. Health and welfare expenditure series no. 36. Cat. no. HSE 87. Canberra: AIHW. Adair, T., Hoy, D., Dettrick, Z., & Lopez, A. (2011). Reconstruction of long-term tobacco consumption trends in Australia and their relationship to lung cancer mortality. Cancer Causes & Control, 22(7), 1047–1053. https://doi.org/10.1007/s10552-011-9781-0 American Cancer Society. (2019). About Lung Cancer. Retrieved November 10, 2019, from https://nlcrt.org/about-lung-cancer/.

American Cancer Society. (2019). Cancer Facts & Figures 2019. Retrieved November 11, 2019, from https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts figures/cancer-facts-figures-2019.html.

American Cancer Society. (2019). Lung Cancer Statistics: How Common is Lung Cancer. Retrieved November 10, 2019, frohttps://www.cancer.org/content/cancer/en/cancer/lung cancer/about/keystatistics.html#references.

American Lung Association Scientific and Medical Editorial Review Panel. (2019). Lung Cancer Fact Sheet. Retrieved November 5, 2019, from https://www.lung.org/lung-health-and diseases/lung-disease-lookup/lung-cancer/resource-library/lung-cancer-fact-sheet.html.

Angelicalavito. (2018, November 8). CDC says smoking rates fall to record low in US . Retrieved November 10, 2019, from https://www.cnbc.com/2018/11/08/cdc-says smoking-rates-fall-to-record-low-in-us.html.

Australian Institute of Health and Welfare. (2019). Lung cancer in Australia: an overview, Summary. Retrieved November 10, 2019, from https://www.aihw.gov.au/report/lung cancer-in-australia-an-overview/contents/summary.

Ball, W. (1957). TOBACCO-SMOKING AND LUNG CANCER. The Lancet, 270(6984), 45 45. https://doi.org/10.1016/S0140-6736(57)90598-6

British Broadcasting Corporation (BBC). (2005).

Panorama: Dead Mums Dont Cry

.

Carter, H., Schofield, D., & Shrestha, R. (2016). The Productivity Costs of Premature Mortality

Due to Cancer in Australia: Evidence from a Microsimulation Model.(Research Article) (Report). PLoS ONE, 11(12), e0167521. https://doi.org/10.1371/journal.pone.0167521

Crane, M., Scott, N., O’Hara, B., Aranda, S., Lafontaine, M., Stacey, I., … Currow, D. (2016). Knowledge of the signs and symptoms and risk factors of lung cancer in Australia: mixed methods study.(Report). BMC Public Health, 16(1), 1–12. https://doi.org/10.1186/s12889-016-3051-8

Dela Cruz, C., Tanoue, L., & Matthay, R. (2011). Lung Cancer: Epidemiology, Etiology, and Prevention. Clinics in Chest Medicine, 32(4), 605–644. https://doi.org/10.1016/j.ccm.2011.09.001

Desantis, C., Miller, K., Goding Sauer, A., Jemal, A., & Siegel, R. (2019). Cancer statistics for African Americans, 2019. CA: A Cancer Journal for Clinicians, 69(3), 211–233. https://doi.org/10.3322/caac.21555

Donington, J., & Colson, Y. (2011). Sex and Gender Differences in Non-Small Cell Lung Cancer. Seminars in Thoracic and Cardiovascular Surgery, 23(2), 137–145. https://doi.org/10.1053/j.semtcvs.2011.07.001

FED: Snapshot of Australia’s health 2018. (2018, June 20). AAP General News Wire. Retrieved from http://search.proquest.com/docview/2056820987/

Finke, I., Behrens, G., Weisser, L., Brenner, H., & Jansen, L. (2018). Socioeconomic Differences and Lung Cancer Survival-Systematic Review and Meta-Analysis. Frontiers in oncology, 8, 536. doi:10.3389/fonc.2018.00536

Hamann, H., Ostroff, J., Marks, E., Gerber, D., Schiller, J., & Lee, S. (2014). Stigma among patients with lung cancer: a patient‐reported measurement model. Psycho‐Oncology, 23(1), 81–92. https://doi.org/10.1002/pon.3371

Hovanec, J., Siemiatycki, J., Conway, D., Olsson, A., Stucker, I., Guida, F., … Behrens, T. (2018). Lung cancer and socioeconomic status in a pooled analysis of case-control studies.(Research Article). PLoS ONE, 13(2), e0192999. https://doi.org/10.1371/journal.pone.0192999

Hovanec, J., Siemiatycki, J., Conway, D., Olsson, A., Stucker, I., Guida, F., … Behrens, T. (2018). Lung cancer and socioeconomic status in a pooled analysis of case-control tudies.(Research Article). PLoS ONE, 13(2), e0192999. https://doi.org/10.1371/journal.pone.0192999

International Agency for Research on Cancer. (2018). ALL CANCERS. Retrieved November 4, 2019, from http://gco.iarc.fr/today/data/factsheets/cancers/39-All-cancers-fact-sheet.

Jacobsen, K. H. (2019). Introduction to Global Health (3rd ed.). Burlington, MA: Jones & Bartlett Learning. doi: 10.1002/wmh3.286

Levy, T., Tam, T., Kuo, T., Fong, T., & Chaloupka, T. (2018). The Impact of Implementing Tobacco Control Policies: The 2017 Tobacco Control Policy Scorecard. Journal of Public Health Management and Practice, 24(5), 448–457. https://doi.org/10.1097/PHH.0000000000000780

Malhotra, J., Malvezzi, M., Negri, E., La Vecchia, C., Boffetta, P., & Malhotra, J. (2016). Risk factors for lung cancer worldwide. The European Respiratory Journal, 48(3), 889–902. https://doi.org/10.1183/13993003.00359-2016

Morampudi, S., Das, N., Gowda, A., & Patil, A. (2017). Estimation of lung cancer burden in Australia, the Philippines, and Singapore: an evaluation of disability adjusted life years.

Cancer biology & medicine, 14(1), 74–82. doi:10.20892/j.issn.2095-3941.2016.0030 Neff, R. A., Edwards, D., Palmer, A., Ramsing, R., Righter, A., & Wolfson, J. (2018). Reducing meat consumption in the USA: a nationally representative survey of attitudes and behaviours. Public health nutrition, 21(10), 1835–1844. doi:10.1017/S1368980017004190

Torre, L., Siegel, R., Jemal, A., & Torre, L. (2016). Lung Cancer Statistics. Advances in Experimental Medicine and Biology, 893, 1–19. https://doi.org/10.1007/978-3-31924223-1_1

WHO. (2019). Cancer. Retrieved from http://www.who.int/news-room/fact-sheets/detail/cancer. Xue, X., Gao, Q., Qiao, J., Zhang, J., Xu, C., Liu, J., & Xue, X. (2014). Red and processed meat consumption and the risk of lung cancer: a dose-response meta-analysis of 33 published studies. International Journal of Clinical and Experimental Medicine, 7(6), 1542–1553.

Retrieved from http://search.proquest.com/docview/1546218409/

Yabroff, K. R., Lund, J., Kepka, D., & Mariotto, A. (2011). Economic burden of cancer in the United States: estimates, projections, and future research. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology, 20(10), 2006 2014. doi:10.1158/1055-9965.EPI-11-0650

Yu, X., Kahn, C., Luo, Q., Sitas, F., & O’connell, D. (2015). Lung cancer prevalence in New South Wales (Australia): Analysis of past trends and projection of future estimates. Cancer Epidemiology, 39(4), 534–538. https://doi.org/10.1016/j.canep.2015.05.007 Yu, X., Luo, Q., Kahn, C., Cahill, C., Weber, M., Grogan, P., … O’Connell, D. (2017).

Widening socioeconomic disparity in lung cancer incidence among men in New South Wales, Australia, 1987-2011. Chinese Journal of Cancer Research = Chung-Kuo Yen Cheng Yen Chiu, 29(5), 395–401. https://doi.org/10.21147/j.issn.1000-9604.2017.05.03

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[1]
Cancer incidence refers to the number of people being diagnosed with cancer.

²

Cancer mortality refers to the number of deaths from cancer per 100,000 people in a population.

Drawing on appropriate literature, provide a critical analysis of the application of health promotion philosophies, principles and approaches underpinning public health practice in relation to a relevant topic (e.g. any public health policy in the UK)

The chosen public health topic is smoking. The student has selected this subject because it is a current issue of particular relevance because of the prohibition to premises becoming smoke- free if they are open to the public, due to be enforced in England in July 2007 (Health Act 2006). Smoking is also an important topic because it has been identified as the single most significant public health problem in the UK (Royal College of Physicians 2000); approximately 114,000 smokers in the UK die as a result of smoking (Action on Smoking and Health 2005). The treatment of smoking- related conditions costs the National Health Service (NHS) up to £1.7 billion per year with an estimated cost of £1.7 million to British industry every year as the result of lost working hours caused by smoking- related illness (Gommans 2005).

According to Tannahill (1985) health promotion is a broad concept which encompasses health education and health prevention. Health education refers to working with groups and individuals to promote healthy behaviours, whereas health prevention refers to strategies which prevent ill- health such as immunisation.

Public health is defined as:

‘The science and art of preventing disease, prolonging life and promoting health through organised efforts of society’ (Acheson 1988)

This definition implies a collective approach; however public health has been criticised as being medically dominated (McPherson 2001).

Philosophies of health promotion provide a framework for exploring our rationale and justification for wanting to change health- related behaviour. Seedhouse (2002) refers to health promotion as a ‘moral endeavour’; in other words health professionals are required to make judgments about if, how and when to intervene in relation to the health behaviours of patients, clients and service users, taking into account individual needs and priorities. In some cases health behaviours affect not only the individual but others, also; this applies to the effects of secondary smoking, for example. Taking into account the secondary effects of health behaviours may impact upon the ‘moral endeavour’ of health professionals and health policy makers. Moral judgements underpin the work of health professionals; the student recalls an incident when a lady aged 100 who had smoked all of her adult life and who clearly did not have long to live, asked to be helped to smoke a cigarette. This simple act gave her pleasure and it seemed irrational and unkind not to respond to her request. Moral judgements are not always straightforward.

Philosophical principles applicable to health promotion include logic; the development of reasoned argument (Naidoo and Wills 2000a). Our arguments for changing health-related behaviour are evidence- based involving for example, the type of statistics about smoking highlighted in para 1 of this page. There is a large body of evidence which supports the argument that smoking is damaging to health and yet, as discussed further on (para.2, p.4), it can be seen that individuals do not always respond to logical reasoned argument in relation to modifying health- behaviours.

Epistemology, another philosophical principle, is concerned with the debate about truth, in this case exploring what health really means. There are different models of health including the medical and social models. The medical model is concerned with the categorisation of illness and disease and with specific medical interventions given by the ‘expert’ (the health professional) to the patient, who has traditionally been a passive recipient of this expert advice and intervention. A social model of health involves a broader interpretation of health which is influenced by a range of determinants, such as age, gender, socioeconomic factors, education and environment. Within this model, strategies to improve health status adopt a wider perspective than the medical model, seeking to address the aforementioned determinants. In relation to health promotion, the medical model might not take into consideration, factors which affect the individual’s behaviour such as their socioeconomic status. There is evidence that smoking behaviour is more prevalent among more disadvantaged socioeconomic groups (Gulliford et al 2003). It is important therefore to take into consideration this and other, factors when developing health promotion strategies and not to reduce the issue to one of the giving and receiving of information with an assumption that behaviour will be modified as a result.

Health promotion philosophies are also concerned with ethics. The theory of ethics is divided into two main categories: deontological and consequential. Deontology is concerned with our duty to behave according to a set of moral principles. On page 1, paragraph 5, the issues/ dilemmas involved for health professionals in making moral judgements, were referred to. Consequential ethics are based on the premise that a judgment about whether an action is right or wrong is dependent on its end result, in other words whether the ends justify the means. This has some interesting implications for health promotion. Further on (p.4) some health promotion strategies are discussed including a debate about the use of legislation, i.e. enforcement, to bring about health- related behavioural change. As stated earlier (para.1, p.1) this issue is of particular relevance to smoking. The argument for enforcement is that the end result of reducing smoking behaviours and resultant improvement in health status as well as savings made to the cost of healthcare, justifies the prohibition legislation.

Broad approaches to health promotion reflect the models of health referred to (para. 2 on this page) and are categorised by Naidoo and Wills (2000b) as medical/ preventative; behavioural change; educational; empowerment and social change. Within the medical approach there are three levels of prevention: primary, secondary and tertiary. To apply these specifically to smoking; the primary level aims to prevent smoking behaviour before it begins, the secondary level is concerned with preventing the recurrence of a smoking- related illness or disease by encouraging the patient to give up smoking and the tertiary level is about promoting quality of life within a chronic condition such as diabetes, in which case the message would be that the individual’s quality of life would be optimised if they do not smoke.

The behavioural approach focuses on lifestyle issues (Laverack 2004) Emphasis is placed upon the individual’s responsibility for health which does not take into account factors outwith the individual’s control and as such, this approach has been criticised for being ‘victim- blaming’ (Tones and Tilford 2001), shifting responsibility away from the government for example, in relation to individual health status.

The educational approach is less about placing responsibility on individuals in relation to their health- related behaviours and more about giving information and facilitating people to make informed choices about their lifestyle choices. This approach relates to the rational- empirical strategy described further on (para. 2, p.4) as it is based on the assumption that giving people information will lead to attitudinal and behavioural change. As will be seen, this does not always happen. This approach is also dependent on a level of concordance from the individual, for example a commitment to attend regular sessions as part of an educational programme.

The empowerment approach reflects the normative- re-educative strategy described further on (para. 4, p. 4) and entails giving people the means to have increased control over the determinants that affect their health status. This involves community participation, a collective approach which is embedded within the philosophy of public health. According to Laverack (2004) there can be different interpretations of what constitutes a ‘community’. We tend to think in terms of a geographical community; a locality. It might be more effective in health promotion terms to think of a community as a group with shared characteristics, such as young people. The reality of community participation is that it tends to be more evident among communities who are educated and higher up the socioeconomic scale. People who are disadvantaged are less lilkely to be motivated to participate in health- related programmes- they may feel marginalised and are preoccupied with the issues that their situation presents, such as concerns about housing and income; health promotion is not viewed as a priority, and smoking might be used as a means of helping them to cope with adversity (Hanson Hoffman 1998).

This leads onto the notion of the social change approach. This is quite a complex concept that involves health promotion initiating and driving social change in order to improve conditions that are conducive to health (Erben et al 2000). Social change would involve making the sorts of improvements that would place health issues more firmly on everybody’s agenda. There are many factors that contribute to social change such as legislation and shifts in ideas about codes of behaviour. For example, attitudes about sexual behaviour have changed over the years, contributing to health issues such as increased incidence of sexually transmitted disease and a rise in teenage pregnancies (Measor et al 2000). There is some indication that social attitudes to smoking have changed (Moonie 2005) which is arguably, a positive development; some smokers report that they feel like social pariahs! The social change approach is underpinned by an acknowledgement of the complexity of what influences health- related behaviours and can be linked to the social model of health, discussed in para. 2, p.2.

Specific health promotion methods are quite diverse including: giving information in a didactic manner, for example via talks to large groups; lobbying local health and Government authorities; making use of the mass media (for example there is currently a television information advertisement about the early signs of myocardial infarction); working with groups; teaching social or life skills that are related to health status; publicity events, e.g. health fairs; facilitating community groups; enforcing health regulation; one to one advice and education; networking and liaising with other workers; instructing on specific techniques, such as self-administration of insulin; facilitating self help groups and enabling health promotion by the provision of support services such as childcare and interpreting facilities (Naidoo and Wills 2000c). Most of these methods can be adapted for use with smoking cessation.

The change strategies framework by Bennis (1976) can be applied to health behavioural change and is of particular relevance to anti- smoking legislation. It includes three strategies for bringing about change which are based on different assumptions about human behaviour, and which, when applied to health promotion, involve three distinctly different approaches. The first strategy (rational- empirical), is based on the supposition that ‘knowledge is power’. Within this strategy it is assumed that an individual will modify their health- related behaviour in response to receiving reliable and valid information. For example, if the government or a health professional issues advice about the dangers of smoking, the individual should reduce or cease their smoking habit. It is well- known that this often does not happen; even some health professionals smoke, despite their level of knowledge about the dangers (McKenna 2001). The reasons for this are usually related to dependence. It is also possible that human beings adopt Freudian mental defence mechanisms, which are maladaptive coping strategies used (in this instance) to circumvent evidence of the negative consequences of a health- related behaviour, such as smoking. These include denial, intellectualisation (which involves citing contradictory evidence), or rationalisation, among others (Lupton 1995). Resorting to these defences can undermine the power of knowledge and evidence, however valid and reliable it is.

The second strategy (power- coercive) involves the use of legislation and policy change in order to enforce health- related change. A good example of this is the anti- smoking legislation referred to in paragraph 1, page 1. There is some evidence to demonstrate that no- smoking policies do have the effect of reducing smoking behaviour (Brigham et al 1994). There has been criticism of the legislation as it is seen by some as an infringement of the individual’s right to choose. However this view is countered by the argument that the health of non- smokers can be adversely affected by cigarette smoke, and these people have the right to be protected (HM Treasury 2004). It appears that many non- smokers feel that they should be safeguarded from the effects of passive smoking (Pilkington et al 2006).

The first two strategies adopt a ‘top- down’ approach whereas the third strategy (normative- re-educative) is based on the assumption that an individual is more likely to change their health- related behaviour if they have had involvement in bringing about the change; if they feel empowered. This approach underpins some of the health promotion strategies referred to in para. 1 of this page; for example facilitating community groups. However as discussed earlier (para. 2, p.3), it seems likely that community participation and empowerment might be of limited value within certain groups, such as people who are disadvantaged or marginalised.

In conclusion, it appears that a multi- faceted approach needs to be adopted in order to address health- behaviours which are harmful to health, in this instance smoking. The starting point is that there is incontrovertible evidence that smoking is harmful to health, and can lead to premature death, as cited in para.1, p.1. The question of whether we have the right to choose to smoke can be challenged because of the evidence- base that demonstrates that smoking can affect the health of others (para. 3, p. 4). However it is important to recognise that people who smoke need adequate support and resources in order to be able to stop. There is existing evidence that legislative and policy change can reduce smoking behaviours (para. 3, p.4) and it will be interesting to see the outcomes of the current legislation (para. 1, p. 1). However, smokers also need clear, unambiguous messages about the effects of smoking, consistent support from health professionals and accessible information about smoking cessation services (Kerr et al 2006).

References

Acheson D. Independent Inquiry into Inequalities in Health: Report. London Stationery Office 1988.

Action on Smoking and Health Factsheet No. 2. Smoking Statistics: Illness and Death. ASH 2005.

Bennis et al The Planning of Change Holt Rinehart and Winston 1976

Brigham J, Gross J, Stitzer M and Felch L Effects of a restricted work-site smoking policy on employees who smoke.

Am J Public Health

. 84(5): 1994 pp. 773–778.

Department of Health. Health Act 2006. Part 1 Chapter 1. 2006.

Erben R, Franzkowiak


P and Wenzel E. People empowerment vs. social capital: from health promotion to social marketing.



Health Promotion Journal of


Australia

. 9(3) 2000 pp. 179-182

Gommans J, Bunton J and MacDonald G. Health Promotion: 2nd Edition. Routledge. 2005. p.189.

Gulliford M, Sedgwick J and Pearce A. Cigarette smoking, health status, socio-economic status and access to health care in diabetes mellitus: a cross-sectional survey.

BMC Health Service Research

2003 pp. 3: 4.

Hanson Hoffman. Recovery from Smoking – Second Edition: Quitting with the 12 Step Process – Revised Second Edition. Hazelden. P.1

Kerr S, Watson H, Tolson D, Lough M and Brown M. Smoking after the age of 65 years: a qualitative exploration of older current and former smokers’ views on smoking, stopping smoking, and smoking cessation resources and services.

Health


and Social Care in the Community

. 14(6) 2006 pp. 572-582,

Laverack G. Health Promotion Practice: Building Empowered Communities. Sage publications. 2004. pp. 21, 22, 44.

Lupton D. The Imperative of Health: public health and the regulated body. Sage Publications. 1995. p. 111.

Mckenna H, Slater P, McCance T, Bunting B, Spiers A and McElwee G. Qualified nurses’ smoking prevalence: their reasons for smoking and desire to quit.

Journal of Advanced Nursing.

35(5). 2001. pp.769-75

McPherson K. Public health does not need to be led by doctors: for.

BMJ

. 30; 322(7302) 2001 p.3–1596.

Measor L, Tiffin C and Miller K. Young People’s Views on Sex Education: Education, Attitudes and Behaviour. Routledge 2000. p.4.

Moonie N (Ed.) GCE AS Level Health and Social Care Double Award Book. Harcourt Heinemann. 2005. p.29

Naidoo J. & Wills J. Health Promotion: foundations for practice (2nd edition). London, Baillière Tindall 2000. pp. 113

Pilkington P, Gray S. Gilmore and A. Daykin N. Attitudes towards second hand smoke amongst a highly exposed workforce: survey of London casino workers.

Journal of Public Health.

28(2) 2006 pp.104-110

Royal College of Physicians. Nicotine addiction in Britain: A report of the Tobacco Advisory Group of the Royal College of Physicians. RCP 2000.

Seedhouse D. Ethics: the heart of healthcare. Second Edition. John Wiley and Sons.. 2002. Chapter 2

Tannahill A What is Health Promotion?

Health Education Journal

44(4) 1985 pp. 167-8

Tones K and Green J Health Promotion: Planning and Strategies. Sage Publications. 2004. p. 16.

Tones K and Tilford S. Health Promotion: effectiveness, efficiency and equity. Nelson Thornes. 2001. p. 28.

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