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Smoking is not an individual disease; it is a collective health epidemic

Should smoking be considered an individual disease or is it a behaviour that is shaped by social conditions?

If smoking is a disease it requires medical treatment. If lighting up is a social behaviour it is shaped by norms, attitudes and environmental influences. So, is smoking an illness or a collective activity?

Medical definitions have reinforced the idea that smoking is indeed a disease. For instance, tobacco dependence was included as a psychiatric condition by the American Psychiatric Association (APA) in 1980. Eight years later, the US Surgeon General's Report declared smoking to be an addiction. Since then, the majority of doctors have treated smoking as a disease requiring medical attention.

Once smoking was labelled a disease, research into its causes and effects increased and advanced our understanding of tobacco addiction. Scientists consequently developed medical treatments such as nicotine replacement patches, gums, sprays and even vaccines. Each treatment is based on the premise that smoking is addictive and leads to compulsive drug seeking.

But to treat smoking uniquely as a disease is not the best option since in doing so we can only help people quit – prevention is left out of the equation. To see smoking as a disease alone is to miss the collective and social nature of this health epidemic.

Since the 1980s, the social nature of such health-related behaviours was exposed by Geoffrey Rose. The British physician and public health leader claimed that health behaviours are shaped by our environment and affect us as a group. A case in point? Some cities are more tolerant and open to smoking than others – think Montreal versus Vancouver. Montrealers are known for their love of lighting up, with Quebeckers being among the biggest smokers in Canada, according to Statistics Canada. Vancouverites, on the other had, scorn even the thought of smoking. It is environmental factors, such as public permissiveness, that have shaped these differences – not medical treatment.

To decreases smoking rates across the nation, health experts have targeted the environmental conditions that shape smoking. In 1986, the Canadian government adopted a comprehensive tobacco control policy that included policy development, legislation and regulations, enforcement, mass media campaigns, community action, public education and taxation. This strategy involved programs and policies to alter how society relates to cigarettes.

The focus of these policies was to make smoking abnormal, less acceptable, less desirable and less common as a social behaviour. By depicting smoking as a social anomaly the goal was to increase the number of people who would attempt to quit while decreasing the number of folks who take up the habit.

Empirical research has demonstrated that these campaigns have been effective in reducing Canadians' smoking. And general attitudes towards smoking have changed too. While it's impossible to claim that these anti-smoking programs alone helped in the dramatic drop in smokers, according to Health Canada only 19 percent of people aged 15 years and older smoke today. Compare that lowered rate to a high of 33 percent in 1986.

Yet Canada's tobacco control strategy has stalled. Smoking rates have stagnated and the habit remains high mostly in certain segments of our society. Canadians with less income, for instance, are experiencing slower rates of decline and higher rates of uptake in smoking than their wealthier counterparts.

Clearly we need to consider new approaches to ensure anti-smoking initiatives continue to be successful. To cut smoking rates further, scientists and policy makers need to examine why tobacco use remains so pervasive among the groups still smoking: homeless persons, aboriginal populations, lower income groups, adolescents and people with mental illness.

Geoffrey Rose provided the original answer: shared conditions affect shared behaviours. In this case, Canadians who still smoke may be affected by social conditions different from their fellow citizens but common in their communities.

We need to investigate why some groups are at a greater risk to begin and continue this life-threatening habit. As we begin 2009, novel interventions and increased research are needed to inhibit the social triggers that keep smoking a health concern.

Katherine Frohlich is a professor at the Université de Montréal's Department of Social and Preventive Medicine and a CIHR New Investigator.

(Source: Université de Montréal: March 2009)

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