Leisure Education as a Tobacco Control tool

21/8/09

By: Shaun Cavanagh

For: Associate Professor Bob Rinehart

Paper: Directed Study SPLS 590-09C

Waikato University

“After studying in-depth the health hazards of smoking, I was dumbfounded – and furious. How could the tobacco industry trivialize extraordinarily important public health information: the connection between smoking and heart disease, lung and other cancers, and a dozen or more debilitating and expensive diseases? The answer was – it just did. The tobacco industry is accountable to no one”

- C Everett Koop, Memoirs (Rongey, 2001).

Introduction

This excerpt from former U.S. Surgeon-General C. Everett Koop carries several themes

in relation to health promotion from the perspective of Recreation Therapy. These

themes include: Human responsibility and freedom of choice, Locus of control,

Independence and dependence, Interaction between a person and their environment, and

operation of commercial motives through regulatory frameworks. The existing

conditions for sale and consumption of tobacco mean that New Zealanders aged 18 and

over are able to purchase products identified as causing death and disability. The

challenge for health promoters and medical professionals is addressing the smoking-

related effects, occurring after the individual has developed a dependency on the product.

Attention needs to be directed to consumer perceptions of the potential harm at the point

of sale, despite the legal status of tobacco. On a community-wide basis, smoking is the

health status factor most readily changed to decrease morbidity and mortality (McLean,

Richmond, Lopatko, Saunders, and Young, 2002, p. 111). Tobacco has been described

by the World Health Organisation (WHO) as ‘the only legally available product that

when used as the manufacturer intends, kills half its users’ (Anderson and Mathews,

2005, p. 9). A 1995 American College of Chest Physicians (ACCP) position statement

stated: ‘tobacco use is the single most important preventable risk to human health in

developed countries and an important cause of premature death worldwide’ (Anderson,

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Jorenby, Scott and Fiore, 2002, p. 932). From a global perspective according to the

United Nations Secretary General (2004), it has an adverse impact on health, poverty,

malnutrition, education and the environment, and consequently, tobacco control has to be

recognized as a key component of efforts to reduce poverty, improve development, and

progress toward the Millennium Development Goals which seek to eradicate extreme

poverty and hunger (WHO, 2002, 2). By 2030, 10 million people will die each year, with

70% of those in developing countries. If current trends continue, about 650 million

people alive today will be killed by tobacco, half of them in middle age, each losing 20-

25 years of life. A predominant focus for WHO is how tobacco control policies in a range

of countries can take into account the specific characteristics and needs of women and

girls, men and boys (WHO, 2002, 2). This is because marketing efforts for tobacco

products target particular groups, especially in developing nations.

Globally, an estimated 4.9 million people die each year from tobacco-related illness,

compared with 3.1 million from AIDS, 2.1 million from diarrhoeal diseases, 1.6 million

from violence, nearly 2 million from tuberculosis, 1.2 million from road injuries and 1

million from malaria (Chapman, 2007, p. 3). Fifty percent of all deaths from lung disease

are linked to tobacco; Eighty percent of smokers live in low and middle income

countries; and 520 million people will die from tobacco use in the next 50 years

(www.tobaccofreeunion.org). In New Zealand, around 23 percent of the population

smoke tobacco, and prevalence is much higher among Maori (46 percent) and Pacific

peoples (36 percent). It causes significant morbidity and contributes to socioeconomic

and ethnic inequalities in health in New Zealand (Ministry of Health, 2007, p. 1).

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Broughton (1996, p. 35) notes that the use of tobacco by Maori was widespread in New

Zealand by the end of the 1840’s, just 70 years after it’s introduction by Captain Cook,

and a decade of the signing of the Treaty of Waitangi, and this caused a dramatic change

in the population dynamics of this country. This was despite that in pre-European times

tobacco cultivation and preparation was completely alien to Maori (Broughton, 1996, p.

12). He states that there was no doubt that tobacco use was implicated in the increased

death rates of Maori over the latter half of the nineteenth century by exacerbating chronic

illness, respiratory disease and poverty (Broughton, 1996, p. 93). An estimated 18,000

pregnancies and 9,000 preschool children annually are exposed to smoking in families. It

is well understood as the biggest single factor undermining the health, development, well-

being and survival of this group (Cowan, 2007, p. 4).

By reference to a legally available product that kills, what is implied is a person-

environment interaction where the resulting health outcomes depend on lifestyle choices

made in the context of that interaction. This bears relevance to the concept of leisure, and

to leisure education on the basis of lifestyle, which requires humans to seek variety and to

explore their surroundings. Examples of the interaction between leisure and tobacco

include leisure-related themes on packaging, debate over retail tobacco displays, debate

over second-hand smoke in public places and parks, the presence of smoking in movies,

sponsorship of leisure related events and programmes, the relationship of tobacco and

other substances such as alcohol, and the effects of illness on personal ability to engage in

a leisure lifestyle. Learning and familiarization with personal surroundings is part of the

concept of internalization, defined by a developmentalist (Vygotsky, 1978) as ‘a set of

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social relationships, transposed inside, and having become functions of personality and

the forms of its structure’ (Linzey, 1991, p. 242). It is during the young adult stage of life

that leisure routines and lifestyle appear to become more stable and set for most people. If

conscious awareness of leisure and a valuing of the phenomenon occurs, it most likely

takes place at this stage of life (Peterson and Stumbo, 2001, p. 37). Drewery and Bird,

(2004, p. 4) note that ‘Human beings are dynamic, interacting with others and their

environment at every moment’. Leisure helps shape who we are as human beings. It is

expressed through our lives and is revealed in our histories, life goals, growth and

development, and behaviors (Russell, 2002, p. 1). Social behaviour is the reciprocal

exchange of responses between two or more individuals (Peterson and Stumbo, 2000, p.

5, emphasis added). ‘Culture is paideia, something you absorb as a child’ (de Grazia,

1962, p. 355). A sociological perspective known as symbolic interaction theory holds

that people actively interpret each others actions and behave in accordance with the

interpretation (Thio, 2000, p. 96). The taking in of the culture which surrounds by a

developing person may be considered as a ‘natural dependency’, since the flow of

resources (such as information) is from outside, independent of the person, inwards.

As the environment is a central part of leisure experience, these examples demonstrate

that the presence of tobacco in that interaction has the potential to undermine the quality

of that experience. For example, regulations about retail tobacco displays (and the

function of cigarette packets) have recently been debated in New Zealand. Cigarette pack

design is an important communication device for cigarette brands and acts as an

advertising medium. Many smokers are misled by pack design into thinking that

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cigarettes may be ‘safer’ (Wakefield, Morley, Horan, and Cummings, 2002). A key

tobacco control strategy is to develop an environment that prompts people to quit and that

is fully supportive of people who are trying to stop smoking (Paynter, Freeman and

Hughes, 2006, p. 7). Trends suggest that substantial and sustained efforts will be

required to further reduce the prevalence of tobacco use and thereby reduce tobacco-

related morbidity and mortality (American Legacy Foundation, 2007, p. 5).

Following on from initial discussion of the relationship between Tobacco Control

measures and the allied health profession of Recreation Therapy, this literature review

investigates further examples of where the tool of leisure education can be of benefit to

attempts to prevent smoking initiation, and aid quit smoking attempts. Attention to both

aspects is essential due to the preventable nature of smoking-related illness. Tobacco use

was described by C. Everett Koop in his tenure as U.S. Surgeon General (1982-1989) as

‘the chief, single avoidable cause of death in our society, and the most important public

health issue of our time’ (Taylor, 1984, xvii). This position on the effects of tobacco is

supported by international evidence, and endorsed by major organizations such as the

World Health Organisation, Centers for Disease Control, Department of Health and

Human Services, National Cancer Institute, and the Royal College of Physicians. These

major groups all make their own authoritative statements on the harmful effects of

tobacco use that guide policy internationally. The potential relevance of leisure education

is increased by the description that avoidable deaths result from tobacco use, as this

suggests that there are lifestyle determinants that can be changed to reduce this scenario,

and leisure education places a primary emphasis on the nature of lifestyle.

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Thesis Statement

People making quit smoking attempts experience many challenges despite the outcomes

of their attempt, and frequently experience a vacuum where they are required to find

alternative activities to avoid relapse. These challenges can occur irrespective of the use

or non-use of Nicotine Replacement Therapy (NRT) to aid the quit attempt.

Research questions:

• How can existing strategies for prevention and for compliance with quit smoking

attempts be effectively supported with the tool of Leisure Education?

• What support can the allied health profession of Recreation Therapy provide

Tobacco Control efforts that no other discipline can?

The methods used to answer these questions include taking Recreation Therapy and

leisure education core principles and looking for examples of crossover situations where

they apply to Tobacco Control measures. It is anticipated that these examples will not just

exist in intervention contexts, but will exist in areas such as regulatory frameworks,

cultural influences and social activities, education, and also in the comparison of existing

models that are shared by both disciplines. Accounting for these aspects could benefit the

clients served in treatment contexts, and serve to reduce smoking prevalence. These core

principles are what guide practitioner activity, and most likely exist in other disciplines in

some form. Core principles as they currently apply in Recreation Therapy, and have

application to Tobacco Control are:

- Learned helplessness vs Mastery or Self-Determination

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- Intrinsic Motivation, Internal Locus of Control, and Causal Attribution

- Personal Choice

- Flow

(Peterson and Stumbo, 2000, pp 9-12).

In New Zealand, there are three key objectives of tobacco control activities: 1) to reduce

smoking initiation, 2) to increase quitting, and 3) to reduce exposure to second-hand

smoke (www.moh.govt.nz). According to Aguilar and Munson (1992) many adolescents

may consume their first drink or drug in the context of leisure activities, and ongoing

drug and alcohol use may occur during social activities including parties, other social

gatherings, or concerts (Nation, Benshoff, Malkin, 1996, p 15). Contained within this

statement are the themes of youth (with all their healthy potential) and use of leisure

(often filled by choice of activities that harm, rather than enhance heath). The expression

of the Therapeutic Recreation principles above (with the exception of learned

helplessness) in the leisure lifestyles of people are inconsistent with the behavior and

effects of smoking, as indicated by the symptoms that result. This is because the very

nature of the substance works to undermine health, and the extent to which these

principles are expressed in a person’s leisure lifestyle, defined as ‘the day to day

behavioral expression of one’s leisure-related attitudes, awareness, and activities revealed

within the context and composite of the total life experience’ (Peterson and Stumbo,

2000. p. 7). This concept relates to the determinants of health, due to the cumulative

effects of given behaviors over a lifespan. The essence of leisure is freedom (Mundy and

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Odum, 1979, p. 4). This is a central point in considering the relationship between

smoking and leisure, and accounting for the effects on a sustainable basis.

The role leisure education can play is preventive as well as rehabilitative. Many people

who make the initial decision to smoke seek something immediate, as indicated by

Burkeen and Alston (2001, p. 81) who endorse the use of recreation in the lives of youth

who might otherwise choose to fill their time with ‘negative leisure activities’, thereby

undermining their potential for growth and personal development. Smoking is also

linked to socioeconomic status, lower income and poorer education being strongly linked

with current smoking (Bittoun, 2007, p. 17). With emphasis on lifestyle choices and

leisure awareness, leisure education can teach people to stay away from, or to quit

smoking. Programs that tend to be effective in reducing substance use and abuse

problems address a number of relevant individual, social, and cultural factors (Durrant

and Thakker, 2003, p. 219). The acquisition of favorable attitudes toward leisure during

formative years lays the foundations for satisfactory socialization in later stages of the

lifespan (Iso-Ahola, 1980, p. 163). The intention of leisure education is to instill a leisure

ethic within people, so that they may freely and willingly take part in activities that can

bring them satisfaction and enjoyment, with the ultimate goal of enriching and enhancing

their lives (Dattilo and Murphy, 1991, p. 8).

This report takes the stance that the harm done by tobacco occurs by stealth, and that it is

usually not detected by the smoker until well after an addiction has formed, making it

extremely difficult for the person to quit. The association of smoking with leisure has

been acknowledged as a non-traditional example of adult leisure involvement (Peterson

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and Stumbo, 2000, p. 47), indicating that many people will trade off the long term

maintenance of health for the immediate effects of cigarettes.

Carter, Van Andel and Robb (1995, p. 395) state that a smoker may forgo social and

recreational activities because the activities occur in smoke-free settings.

This expresses the important role that interventions can play in ensuring that healthy

leisure choices are made early on, using some of the strategies identified by Faulkner

(1991), O’Dea-Evans (1990), Kunstler (2002), Caldwell (2008), and Aquadro (2008)

along with others who have experience applying leisure content in this area. Given that

tobacco is a legal substance that provides immediate effects without the perception of

harm, it is likely that there will be an ongoing need for techniques such as leisure

education to address the needs of people who eventually develop smoking-related

illnesses. It may also have a potential function in endorsing regulations surrounding

tobacco, and aiding compliance. With the passing of the Smokefree Environments

(Enhanced Protection) Act which came into effect in December 2004, the environment

from the perspective of the New Zealand smoker has changed dramatically including

greater restrictions on smoking in public places and places of employment, calls for tax

increases, graphic warning images on packets, and reductions in smoking prevalence.

There have been moves to make parks and playgrounds smokefree over concerns about

the effects of second-hand smoke on children and pets (www.smokefreecouncils.org.nz).

The reasons behind greater restrictions are due to evidence-based associations of tobacco

that need to be addressed instead of left to chance. For example, tobacco causes the

greatest range of health-related harm of all drugs used in New Zealand (including lung

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cancer, chronic obstructive respiratory disease, sudden infant death syndrome and heart

disease), and there is strong evidence of the negative health effects of second-hand smoke

(Ministry of Health, 2005, p. 31). There are special features with regard to tobacco-

related harm that arguably justify special attention from a research perspective. These

include the scale and magnitude of harm caused by tobacco, the long-standing (and

culturally entrenched) nature of smoking, and the addictiveness of tobacco (Tobacco

Control Research Steering Group, 2003, p. 18)

The ‘Stages of change’ model is perhaps the most common form of assessment, and

acknowledges that personal motivation (readiness) to quit is a key factor in success.

According to the authors of this model, individuals move through five stages of

precontemplation, contemplation, preparation, action and maintenance (Durrant and

Thakker, 2003, Shank and Coyle 2002). Durrant and Thakker (2003, p. 233) state the

Stages model is ‘influential’, and provides one way of understanding the process by

which people overcome their substance use problems. Revised New Zealand guidelines

(2007) state that all reference to the Stages model has been removed because new

research challenges its utility in smoking cessation. Rather, a key message is that all

people who smoke, regardless of whether they express a desire to want to stop or not,

should be advised to stop smoking (Ministry of Health, 2007, p. 1). This is because

cessation is a leading national health goal, and a concept to describe a summary of

intervention evidence of ‘a little, and often, by many over time’ (www.efc.co.nz) is

regarded as a vital principle for health professionals to give smokers to reduce

prevalence. What makes tobacco consumption unique is that smokers can continue to

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consume without realizing they are becoming addicted, and believe they maintain the

same level of choice as when they commenced. In stating that all smokers should be

advised to stop irrespective of their stage of readiness, the guidelines are endorsing that

health professionals take the initiative with encouragement and advice so that smokers

respond and prevalence is reduced. What it is not advising is coercion for people to quit

smoking, or for health professionals to ‘stand off’ smokers without providing any support

in the hope that smokers become ready to change. Csikszentmihalyi (1986, p. 4) outlines

a scenario that resembles nicotine dependency by stating that the more a person complies

with extrinsically rewarded roles, the less he enjoys himself, and the more extrinsic

rewards he needs.

The guidelines for practitioners and the rationale behind the Stages model are consistent

with the principle of autonomy and the need to respect personal choice on the part of

health practitioners. (Peterson and Stumbo, 2000, p. 12) state that choice is inherent to,

and parallel with the concepts of intrinsic motivation, internal locus of control, and

personal causality. What is to be observed is that these concepts are inconsistent with the

nature of addiction and dependency, and the need for the practitioner to be aware of the

particular individual’s motivation is still expressed. In being aware, the practitioner can

still comply with the new cessation guidelines. Sylvester (1987, p. 84) states: ‘because

leisure resides in the self and the self’s relation to freedom, the absence of genuine choice

binds me to someone else’s design, estranging my “self” and dehumanizing me’. This

statement bears resemblance to the nature of addiction, and demonstrates that the concept

of choice is not to be confined to a given context (such as at point of sale), but given the

same value over the lifespan. This implies respect for the principle of self-determination.

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Full liberty is not simply removal of barriers, but giving persons the powers to carry them

beyond these barriers (Hemingway, 1987, p. 5). Clinical judgment and psychological tact

are important in helping smokers quit. Patients who are persistent smokers can be helped

towards better health using the strategies of combining therapies or reducing harm

(Bittoun, 2007, p. 17). Therapeutic Recreation represents the very antithesis of

controlling environment often imposed on the individual who has health problems

(Austin, 2001, p. 3). Good leisure experiences enrich and improve the participant, and

while the use of drugs and alcohol may provide momentary sociability and relaxation,

their abuse prevents any real leisure benefit taking place (Russell, 2002, p. 205). This

statement is particularly relevant to tobacco, as the person may continue smoking without

accounting for the potential harm this causes. In such a case, they are less likely to seek

remedies for quitting, and will require encouragement. For example, McArdle, Katch

and Katch (2000, p. 260) state that teenage and young adult smokers rarely exhibit

chronic lung function deterioration of a magnitude to significantly impair exercise

performance. Because of increased fitness, the young, fit smoker often believes he or she

is immune from smoking’s crippling effects (McArdle et al, 2000, p. 260). This is

endorsed by Allen and Clarke (2004) who document an information failure about the

health risks of smoking and research evidence suggesting that consumers do not

appreciate the scale of these risks nor have the ability to apply these risks to themselves.

Central to this is the concept of leisure lifestyle, and individual understanding of it.

According to scholars in the Recreation Therapy profession, aspects of an appropriate

leisure lifestyle to be encouraged are:

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- functional capabilities that allow for enjoyment in leisure and recreation

- social skills, decision-making abilities, knowledge of leisure resources, and positive

values and attitudes towards leisure.

- as a result of these skills, attitudes and behaviors, the individual perceives choice,

motivation, freedom, responsibility, causality, and independence with regard to his or her

leisure (Sylvester, Voelkl and Ellis, 2001, p. 82)

New UK guidelines are a variation on the ‘Stages’ model. The basis of these guidelines

are that for people not ready to quit, nicotine replacement therapy can still be used by

them to cut down (by at least 50%) and therefore reduce the harm done. This is one key

message of the guidelines, that the authors want health professionals to integrate (Raw,

McNeill, West, Armstrong, and Arnott, 2005, p. 1). The regimen, called NARS (Nicotine

Assisted Reduction to Stop), has shown good unintentional long-term quitting rates

(Bittoun, 2007, p. 21). A focus of this report is on smoking cessation, and whether it

should be treated as an absolute goal, or whether health professionals should be treating it

also as a stage in the process of quitting smoking, and health maintenance. In implying

that quitting smokers are left in a vacuum that needs filling with alternative activities, the

quit attempt should be viewed as one stage in a process over a period of time.

Durrant and Thakker (2003, p.224) state that it is important to establish just why someone

is using a specific substance, what benefits they obtain from that use, and in what context

use occurs. This means there is a need to establish what the role and function of drug use

is in that individuals’ life. Faulkner (1991, p. 88) states ‘When a process or substance is

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used to avoid dealing with the world outside of the self, then trouble will soon be

knocking on the door’. An ergogenic (‘work producing’) aid is defined as ‘any

substance, process, or procedure which may, or is perceived to, enhance performance

through improved strength, speed, response time, or endurance of the athlete’ (Fox,

Bowers and Foss, 1989, p. 632). This helps to explain the reasons why people smoke,

because nicotine is a substance frequently consumed for these reasons, even if it not

consumed by athletes. Even accounting for nicotine’s addictiveness, if there were no

perceived benefit in commencement, there would be no initial consumption.

The primary purpose of Therapeutic Recreation is to assist clients in developing

substance-free leisure that is meaningful and healthy. Many turn to substances such as

tobacco early on in the life span (Faulkner, 1991, p. 88). Kunstler (2001, p. 99) discusses

Csikszentmihalyi’s concept of ‘flow’, noting that recreation activities are designed to

make flow (characterized by joy, creativity and total involvement) easier to achieve, and

that drugs (including tobacco) produce a shallow or false state of flow in which users are

not really in control of their minds and actions. This statement is also applied to other

drugs, but in the case of tobacco, the consumer will be regarded as maintaining mental

control, especially early in the lifespan. However, addressing smoking-related illness is

tied to mental health as a priority area, as is increasing levels of physical activity in the

New Zealand Health Strategy (Ministry of Health, 2004). Every single smoker,

irrespective of age and history of smoking, can at least improve their oxygen carrying

capacity, notwithstanding the potential improvement of respiratory and vascular functions

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(Bittoun, 2007, p. 18). The purpose of healthy activity is to restore balance and energy

which is then used to deal with the world outside of the self (Faulkner, 1991, p. 88).

The primary purpose of Therapeutic Recreation is to assist clients in developing

substance-free leisure that is meaningful and healthy. Many turn to substances such as

tobacco early on in the life span (Faulkner, 1991, p. 88). Prevention of relapse is

dependent upon developing, practicing and incorporating into the persons value systems

leisure options perceived as challenging, rewarding, and self-governing (Carter et al,

1995, p. 397). If part of the great appeal of many psychoactive drugs is in their ability to

generate positive emotional experiences and to alleviate negative ones (at least in the

short term), then one plausible tactic for intervention is to examine the strategies that

people employ to get ‘natural’ satisfaction out of life experiences (Durrant and Thakker,

2003, p. 236). Some of the needs previously met through drug taking that a recreation

therapist must address are curiosity, boredom, pleasure seeking, peer acceptance, self-

discovery, social interaction, rebelliousness, and the desire for a “quick fix” (Kunstler,

2001, p. 97). Regardless of the disabling condition and the limitations or barriers it

presents, the individual has the right to experience leisure involvement and satisfaction.

This opportunity, however, is dependent upon sufficient leisure-related attitudes,

knowledge and skills (Peterson and Stumbo, 2000, p. 53). Applied to smoking as an area

for intervention, the detrimental effects on human functioning manifest themselves over

time rather than immediately, and the leisure involvement and satisfaction referred to

may be taken for granted by the smoker who does not realize the extent of the threat

posed to their health by smoking. People do not comprehend the relevance of stopping

smoking because their definitions of health are based on current (pre-diagnosis) levels of

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functioning. In such a scenario, the brief messages provided by health professionals,

family members and co-workers that the revised Ministry of Health guidelines (2007)

advocate are intended to motivate the person to make a quit smoking attempt.

Kunstler (2001, p. 103) outlines the top 5 for Recreation Therapy interventions for

substances: Lack of positive coping strategies; Low self-esteem and feelings of

inadequacy; Lack of knowledge of how leisure can prevent relapse; Social isolation and

loneliness; and Lack of positive ‘non-using’ experiences.

The pre-2007 smoking cessation guidelines issued by the Ministry of Health were based

around a ‘5 A s’ concept described as follows:

1) Ask: identify and document smoking status; 2) Assess: assess a person’s willingness to

quit; 3) Advise: offer cessation advice on a regular basis, over an extended period, to all

smokers; 4) Assist: offer appropriate treatment and assistance to smokers or recent

quitters; offer nicotine replacement therapy; and 5) Arrange: follow-up for smokers

(Ministry of Health, 2004, pp. 5-10).

An American leisure education model for addicted persons (O’Dea-Evans, 1990) has

traditional use treating alcoholism, though contains a similar structure and process for

health practitioners to work through with this population. The model is made up of:

1) Assessment: identify leisure issues (use leisure assessment tools).

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2) Assist: problem solving structural and environmental barriers (patient is given

information on leisure as their own responsibility and how leisure issue resolution

can benefit their recovery from addiction).

3) Confront: irrational belief system (guilt, fear, lack of resources, passive leisure

pattern, social network of addicted associates, limited practice sober social

interactions, poor activity skills, embarrassment, intact defenses of past limited

leisure involvement, work addiction, undeveloped planning skills and depression.

4) Plan: leisure involvement (through disease progression, addicted people learn not

to plan, which is as dysfunctional as the disease progression itself).

5) Behavior change; new involvement in leisure alternatives and/or reinvolvement in

past leisure activities

6) Recollection: identify feelings and rewards related to leisure (the addicted person

needs to develop an awareness of leisure as part of their recovery program and

assistance in developing recollection skills).

(O’Dea-Evans, 1990).

This model resembles the 5 A’s that were part of smoking cessation guidelines in New

Zealand by containing the words assess, and assist. However, it deals with substances

beyond tobacco, and encompasses a leisure emphasis as a means of addressing the

particular dependency being dealt with. In 2007, the NZ Ministry of Health announced

new guidelines that summarise the most recent national and international evidence on

best practice in smoking cessation. These were structured around a new ‘ABC’ memory

aid that incorporates and replaces the 5 A’s. This prompts health care workers to: Ask

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about smoking status; give Brief advice to all smokers to stop smoking; and provide

evidence-based Cessation support for those who wish to stop smoking (Ministry of

Health, 2007, Executive Summary, emphasis added).

According to this document, the current evidence does not show a beneficial effect of

exercise on long-term smoking quit rates, though it may alleviate some of the symptoms

of tobacco withdrawal and assist in the short term (Ministry of Health, 2007, p. 52). It

does not specify the different types of exercise regimes that could potentially be used as

interventions, and thus produce different training effects for the participant. Fox, Bowers

and Foss (1989, p. 689) state that only from the energy released by the breakdown of the

compound adenosine tri-phosphate (ATP) can the cell perform work. They also state

(1989, p. 29) that both anaerobic and aerobic systems contribute energy during exercise;

however, their relative roles are dependent upon 1) the types of exercises performed, 2)

the state of training, and 3) the diet of the athlete. For example, if exercise is

acknowledged to be a technique of stress regulation, this will affect the amount of

smoking a person does. Even as the person participates in the exercise, the ability to

systematically regulate one’s breathing, and thus control one’s symptomatic experience

of stress, gives the client a reliable tool for self management (Young, 2001, p. 147).

Recreational activity, particularly of a vigorous physical type, does much to develop

cardiopulmonary efficiency, strength, flexibility, and fitness as well as a perception of

psychological soundness (Shivers and de Lisle, 1997, p. 83).

The focus for leisure education is to restore the individual to a maximal level of

independent functioning, or if possible prevent this from being undermined by smoking.

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In either case, the intervention would likely make substantial use of exercise in one form

or another at some stage in the process as one aspect of the intervention, acknowledging

that the systems relied upon to participate produce benefits to the person that transcend

those perceived to have been gained by smoking. Leisure may contribute significantly to

improved physical, social, and emotional or psychological aspects of health

(Csikszentmihalyi, 1993, p. 5). Exercise fights the urge to smoke because in addition to

smoothly increasing dopamine it also lowers anxiety, tension, and stress levels (Ratey,

2008, p. 178). As a treatment, exercise works from the top down in the brain, forcing

addicts to adapt to a new stimulus and thereby allowing them to learn and appreciate

alternative and healthy scenarios (Ratey, 2008, p. 169). Increasing levels of physical

activity is listed as one of the associated priority health areas in the New Zealand Health

Strategy (NZHS) linked to priority smoking goals by the long-term strategy to address

smoking-related illness in New Zealand (Ministry of Health, 2004, p. 9).

As part of the strategy to reduce smoking initiation in New Zealand, key priorities are to

prevent smoking commencement are to 1) to reduce smoking initiation, 2) to increase

quitting, and 3) to reduce exposure to second-hand smoke (www.moh.govt.nz). The

Health protection/health promotion model is one of the templates for Recreation Therapy

practice. Four components make up the model: diagnosis/needs assessment,

treatment/rehabilitation, education, and prevention/health promotion. It’s suitability to

the field of tobacco control is alluded to in the name. (Austin, 2001, p. 9) states that

therapeutic recreation may be seen as a means of preventing health problems, although

the preventive function has only recently begun to develop. The intervention process is

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characterized by decreasing practitioner control and growth in client independence, based

around the concepts of the stabilizing tendency by helping individuals to restore health,

and the actualizing tendency by enabling persons to use leisure as a means to personal

growth (Austin, 2001, p. 9). This process is represented on a continuum, as the potential

for a leisure experience increases as the client becomes more and more autonomous

(Austin, 2001, p. 10). For a person seeking therapeutic intervention from a health

practitioner, what is implied is that the person approached has resources and expertise to

share that the person who initiates does not have. The health practitioner is ‘independent’

with regard to the resources and expertise sought. In the context of leisure interventions

and programming, the practitioner will have a leisure repertoire that they rely on, and in

this is a variety of leisure-related techniques specific to the profession.

Edginton, Hansen, Edginton and Hudson (1998, pp.10-11) offer non-economic benefits

of leisure that have potential to change behaviour momentarily or on a long-term basis.

Without providing the explanations given, the headings are as follows: Personal

Development; Social Bonding; Physical Development; Stimulation; Fantasy and Escape;

Nostalgia and Reflection; Independence and Freedom; Reduction of Sensory Overload;

Risk Opportunities; Sense of Achievement; Exploration; Values Clarification/Problem

Solving; Spiritual; Mental Health; Aesthetic Appreciation.

The withdrawal phase is defined as negative physical and psychological effects which

develop when the person stops taking the substance or reduces the amount (Davison,

Neale and Hindman, 2004, p. 358). These are described as the way the human body

21

reacts when it stops getting nicotine and all the other chemicals in tobacco smoke.

Quitting smokers are advised to think of them as recovery symptoms (Cancer

Society/Ministry of Health, 2007, p. 14).

The relationship between relapse and recovery is an expression of the locus of control,

which is about independence. It is defined as ‘the degree to which the individual

attributes the cause of his or her behavior to environmental factors or to his own

decisions’ (Chaplin, 1995, p. 260). Relapse is a component of the chronic nature of

nicotine dependence, not an indication of personal failure by the patient or clinician

(Fiore et al, 2006). The reference to environmental factors is concerned with the

surrounding space around the person, which includes other people and stimuli that have

the potential to threaten or support the quit smoking attempt depending on their nature.

The locus of control, or level of independence is influenced by another variable of time,

over which a smoker develops a dependency relative to the frequency and intensity of

their smoking behavior. Tolerance and withdrawal will fade once a user is on the wagon,

but nothing can reverse other, long-term changes to an addict’s brain: receptors to certain

neurotransmitters remain sensitized forever (Dudding, 2007, A9). This description is

primarily about alcohol, but is applicable to tobacco also. Repeated exposure to nicotine

results in neuronal adaptations that are reflected in nicotine tolerance, sensitization, and

withdrawal (McLean et al, 2002, p. 102). According to Ratey (2008, p. 5) neurons in the

brain connect to each other through ‘leaves’ on treelike branches, and exercise causes

those branches to grow and bloom with new buds that enhances brain function at a

fundamental level. This is a viewpoint that supports exercise as a way of strengthening

brain function, based upon neuroscientific research.

22

The rationale for leisure education as a likely tobacco control tool accounts for the

potential of leisure-related content to address the challenges experienced in the quitting

process, as well as in prevention. Reviews of leisure-related definitions and content also

express an inconsistency between the nature of leisure as a concept and the long-term

physiological response to tobacco, which is smoking-related illness. Further indication

of relevance exists in the observation that despite information readily available concerned

with smoking-related harm and regulations to address this, there is a continuing demand

for tobacco products by various segments of the population, and that despite graphic

warnings being placed on cigarette packets from February 2007, some of these carry

leisure themes in words or images as a way of stimulating purchase behavior. Examples

of these are use of the names ‘Holiday’, ‘Longbeach’ and ‘Freedom’ that imply

relaxation for the consumer. Each comes with their own distinct wording design and

colour imagery to attract attention. The National Cancer Institute (NCI) summarise

concerns over media influences that could lead to smoking commencement and also

encourage smoking maintenance, that reduces the likelihood of quitting. Media

communications play a key role in shaping attitudes toward tobacco, and current

evidence shows that tobacco-related media affects both tobacco use and prevention (NCI,

2008, p. 3). Examination of changes over the years in the frequency of on-screen

depiction of tobacco highlights some discrepancies between movie portrayals of smoking

and the social reality of smoking (NCI, 2008, p. 371). Despite the agreement in the

United States to end product placement, tobacco use is appearing in American movies at

record levels (Health Sponsorship Council, 2005, p. 31). The internet has the potential to

23

influence youth tobacco use not only because it provides possible access to tobacco

products, but also because it creates a venue that may stimulate demand through

advertising and promotional messages (Health Sponsorship Council, 2005, p. 33). To

discuss wide-screen movies, the internet and other forms of media as potential influences

is only one aspect of a leisure and tobacco comparison. Due to documented evidence of

smoking-related harm, sporting organizations have enacted Smokefree/Auahi Kore

policies, with the rationale that the change in environment will protect members,

participants, spectators, volunteers, patrons and staff from the harmful effects of second-

hand smoke (Health Sponsorship Council, 2002, p. 2). These policies are generally

complied with through ground announcements and signage that remind people attending

events of the policy, though experience reveals that a proportion disregard the policy.

This behavior is inconsistent with the Reduce Smoking Initiative goal of eliminating

second-hand smoke harm. It is possible that the proportion of people who flout the

smokefree policies despite being aware of them is proportional to the national smoking

prevalence. Despite this, they are observing athletes heavily dependent upon systems that

smoking negates, therefore there’s an association between health protection, rugby, and

leisure. The CEO of one of these organizations has commented on the reasons behind

their policy: “Sport is health-oriented, smoking is not, it’s as simple as that. As a

regional body, it is important that we lead by example and look out for the future

generations of our sport” (Health Sponsorship Council, 2002, p. 2). A related example of

health promotion with a tobacco emphasis moving in a sporting context is signage on the

Kerikeri Domain for the Northland versus Auckland rugby match on August 15th 2009,

which received national coverage on subscriber pay television, and was played in front of

24

over 8000 people. A painted sign in the centre of the ground featured the 0800 toll free

Quitline number, and may be the only one like this nationwide at a premier rugby venue.

A primary consideration is what happens to the person when they consume tobacco that

ensures they repeat the behavior again. A summary of nicotine effects inside the body

includes: it increases arousal and attentiveness, and improves reaction time and

psychomotor performance; beneficial effects are on memory and learning are less clear,

but overall it appears that nicotinic receptors have an important role in modulating higher

brain functions (for example, can improve mood by relieving anxiety); and the appetite

suppressant effects are often exploited for weight control (McLean et al, 2002, p. 101).

In discussing the addictive nature of a variety of substances, Orford (2001, p. 17) states

‘if addiction is judged by the criterion of difficulty in leaving off a behavior despite

wishing to do so, then tobacco might be judged to be, not simply addictive, but probably

the most addictive of all substances’.

The Quit group (2004, p. 3) have published a booklet for relapse situations, and remind

readers that smoking addiction has three parts: 1) Addiction to nicotine, where ongoing

feelings can last beyond a few days; 2) Habit, or contexts associated with prior smoking;

and 3) Feelings, such as hungry, angry, lonely, tired, or happy, excited, stressed, nervous,

worried or grieving. These can act as triggers for the smoker trying to quit. The booklet

continues by questioning beliefs about why smoking is perceived to help, and clarifies

why it doesn’t. Benefits of remaining smokefree are featured, such as increased time and

money, and recommendations are given to acknowledge slip-ups as mistakes and identify

25

the high-risk moments and plan for them. Advice is given to engage in positive self-talk

and personalize reasons for quitting smoking well as finding a new focus for activity and

learning new skills and routines. These final aspects are approaching a domain where

leisure education can be of most assistance in the quit attempt, because they espouse

activities which are more natural to the concept of leisure lifestyle. Consideration needs

to be given to how these suggestions can be supplemented and consolidated to enhance

the quit smoking attempt for the person concerned.

Health promotion best practices for tobacco control have been described by Slama (2005)

with the overall aim of enabling people to understand and take actions to change the

determinants of their health. This is application of the concept of health literacy: ‘the

ability of an individual to access, understand, and use heath-related information and

services to make appropriate health decisions’ (www.surgeongeneral.gov). The best

practices delineated are: 1) Building healthy public policy; taxes, ad bans, clean air,

health information, facilitation of cessation, limits on tobacco industry behaviors; 2)

Supportive environments for prevention and cessation; 3) Community enforcement of

smoke-free activities; 4) Strengthened personal skills, motivation, and self-efficacy for

stopping/not starting tobacco use; and 5) Cessation strategies available in all health

services (Slama, 2005)

Assessment is the process of identifying client behavioral areas where change,

improvement or enhancement of behavioral functioning is desirable (Witt, Connolly, and

Compton, 1980, p. 51). This is the initial intervention stage where the practitioner and

26

the person seeking to remain free from smoking collaborate to discover where the person

is in relation to their desired state, what needs they have to achieve this, and it especially

seeks to discover aspects about their understanding and expression of leisure. There are

examples of crossover with existing assessments that a Recreation Therapist would use,

such as the ABC method detailed in new smoking cessation guidelines (Ministry of

Health, 2007); the series of 17 questions posed in the Quit booklet about reasons for

smoking and individual challenges experienced (Quit group, 2007, p. 6), and by

maintaining an understanding of stages of readiness as they impact on motivation.

Examples of assessments more closely aligned with Recreation Therapy are the Leisure

Diagnostic Battery (LDB) which covers domains of perceived leisure competence;

perceived leisure control; leisure needs; depth of involvement in leisure experiences; and

playfulness (Witt and Ellis, 1987, p. 20). The authors recognised the inherent

shortcomings and limitations of the time and activity participation approaches to the

assessment of leisure functioning, and the development of the LDB was based on a more

holistic view of leisure, with emphasis on leisure as a state of mind as the basis for

understanding leisure functioning (Witt and Ellis, 1989, p. 3). Also, there are a range of

assessments included in Seligman (2002, p. 159) and his concept of Signature Strengths,

which he states ‘can be nurtured throughout our lives, with benefits to our health,

relationships, and careers’. These include such strengths that a quit smoking attempt

would have increased likelihood of succeeding with on a long term basis if developed

within the person. They are further broken down into different traits that are considered

to contribute to ‘authentic happiness’ and include: 1) Wisdom and Knowledge; 2)

27

Courage; 3) Humanity and Love; 4) Justice; 5) Temperance; and 6) Transcendence

(Seligman, 2002, p. 159). It is observed that if enacted, they contribute to a lifestyle

alluded to by Hemingway (1988, p. 12) in describing a leisure ideal of ‘combining

reflection and action with deeply rooted attachment to one’s community’. This is an

effect more closely aligned with leisure definitions espoused by de Grazia (1962) and

Pieper (1963), based upon the classical definition of leisure influenced by the thought of

Aristotle. The definition of leisure is expressed as a determinant in outcomes that result

from treatment interventions.

Planning follows the assessment stage. This is where potential interventions for inclusion

into the quitting process can be included. This involves synthesizing information

gathered and continuing the collaboration begun with the client in the assessment phase

(Shank and Coyle, 2002, p. 132). If the goal of the intervention is to promote change in

the person’s situation, the interventions should have beneficial outcomes for the person

that are perceived as beneficial and health promoting. There are a range of modalities

that can be used with this intention in mind. For example, green spaces may encourage

people to be more physically active, and previous studies have suggested that parks and

open space help people reduce blood pressure and stress levels, and perhaps even heal

more quickly after surgery (www.cbc.ca). The ability of music to induce such intense

pleasure and its putative stimulation of endogenous reward systems suggest that, although

music may not be imperative for the survival of the human species, it may indeed be of

significant benefit to our mental and physical well-being (Blood and Zatore, 2001). In

short, the mass media not only function as recreational experiences themselves but also

28

help shape the publics knowledge about and interest in other recreational activities

(Shivers and De Lisle, 1997, p. 158). Results of another study suggest that if people were

recurrently exposed to anti-tobacco content in movies there is potential for a more

substantial and lasting impact on attitudes toward the tobacco industry and smoking.

(Dixon, Hill, Borland and Paxton, 2001, p. 285). Active involvement in recreation has

been demonstrated to relate positively to health outcomes for people with substance

addictions, including: improvement in ability to manage stressors that threaten sobriety;

improvement in social interaction and networks; enhancement of sober lifestyle and

identity (ATRA, 1994, p. 4).

A number of psychological resources have been consistently identified as central to well-

being, including capacity for happiness, emotion regulation, self-awareness, self-

determination, competence, optimism, and sense of meaning (Carruthers and Hood, 2007,

p. 303). Leisure education/counseling, sports and community leisure activities were the

most frequently offered programs in substance abuse treatment facilities for adolescents,

with the most often cited goals of improving social skills, self-esteem/self-efficacy and

the level of trust (Nation, Benshoff, and Malkin, 1996, p. 10). Games and simulated

environments may afford superior opportunities for learning, particularly for those

accustomed to play in videogame environments (Galerneau, 2005, p. 2). Leisure may

contribute significantly to improved physical, social and emotional or psychological

aspects of health (Csikszentmihalyi, 1993, p. 5). Physical exercise in the form of aerobics

is proposed as an especially effective alternative behavior for quitting smoking (Christen

and Cooper, 1979, p. 107). When one is engrossed in some interesting recreational

29

activity, worry, tenseness, confusion, and much fatigue will vanish (Nash, 1953, p. 50).

Going to the movies can produce an emotional idealism that may help physician viewers

achieve more positive attitudes of empathy and altruism (Shapiro and Rucker, 2004, p.

445). The fact that a variety of different [biological, psychological and social] treatments

with divergent methods and theoretical underpinnings can be, at least modestly,

efficacious points to the role of non-specific factors in recovery from drug problems

(Durrant and Thakker, 2003, p. 228). Reducing stress levels through creating better

work-life balance is a key step in putting a halt to and reversing adverse responses to

protect and recover our health and function (Geithner, Albert, and Vincent, 2007, p. 8)

Considerable evidence exists that breathing training is a clinically useful procedure and

one whose outcomes in perceived stress reduction can be readily measured (Young, 2001,

p. 141). The concept of leisure education, a broad category of services that focuses on

the development and acquisition of various leisure-related skills, attitudes, and

knowledge, (Peterson and Stumbo, 2000, p. 35) sits as the second stage in the leisure

ability model. This model has three major parts along a continuum. The first, functional

intervention, deals with improving functional ability. The responsibility for the content

of the intervention is primarily in the hands of the TR specialist. The third component,

recreation participation, has to do with structured activities that give the client the

opportunity to practice new skills while enjoying a recreation experience (Austin and

Crawford, 2001, p. 9). All three aspects are related in the continuum, and the model

expresses the importance of recreational activity as a means of maintaining compliance

with the quit attempt. Like the Health protection/health promotion model, the rationale is

for the individual receiving treatment to develop greater control and independence as the

30

intervention continues, and this is substantially reliant upon personal understanding of the

relevance of leisure to their life. This occurs as a result of the leisure education stage.

Carruthers and Hood (2007, p. 276) note that over time, there has been a change in health

and human service emphasis on deficit reduction to an increasing awareness that the

elimination of deficits or problems alone does not result necessarily in healthy,

competent, vibrant people or communities. The concept of social capital is described as

‘a way of thinking about the broader determinants of health and about how to influence

them through community-based approaches to reduce inequalities in health and well-

being’ (Manahi, 2006, p. 1). Another definition of social capital is from Putnam (2000,

p. 19): “connections among individuals – social networks and the norms of reciprocity

and trustworthiness that arise from them”. This is another example of a concept relevant

to the classical definition of leisure already discussed in relation to Seligman (2002) and

Hemingway (1988). The relevance to issues of tobacco control are that social networks

and relationships are influential factors in smoking commencement, prevalence, and the

capacity of people to sustain quit smoking attempts. If as acknowledged, that on a

community-wide basis, smoking is the health status factor most readily changed to

decrease morbidity and mortality (McLean et al, 2002, p. 111), then consideration of

variables that contribute to smoking commencement need to be considered for their role.

Csikszentmihalyi (1993, p. 127) discusses the concepts of control and independence in

relation to tobacco when he states: “In truth, there is no way to argue that tobacco has

been a benefit to humans. It is, in fact, the other way around: humans have benefited the

spread of tobacco”. Societal context and contemplation are particularly prominent risk

31

factors in the contemplation and initiation phases of adolescent smoking (Health

Sponsorship Council, 2005, p. 60). The stages of commencement are described as:

Preparatory/trying (Stages 1 and 2); Experimental/regular (Stages 3 and 4); and

Addicted/dependent (Stage 5). Adolescents contemplating smoking were more likely than

‘never smokers’ to believe that smoking helps people relax, reduce stress, and increase

social comfort (Health Sponsorship Council, 2005, pp. 61-62).

Strengths-based practice is based on thinking about clients in terms of their capacities,

resources, goals, and lives rather than about their diagnosis or problems (Carruthers and

Hood, 2007, p. 281). Leisure Education is a developmental process designed to enhance

an individuals understanding of themselves; the relationship of leisure to his or her

lifestyle, and the relationship of leisure to society in general (Datillo, 1999, p. 4). The

anticipated function of leisure education for a youth who has yet to be exposed to

situations where they might choose to commence smoking as a result of some interaction

with their physical (such as retail displays) or social (such as peers) environment is that

leisure education will serve as a buffer that prevents them from commencement.

Peterson and Stumbo, (2000, p. 3) state that leisure very often provides important

avenues for developing a sense of self-determination, citing Coleman and Iso-Ahola

(1993) who have written that people who believe their actions are self-determined are

less likely to experience illness and disease. “As such, for many individuals leisure

involvement serves as a ‘buffer’ to stress and helps the individual cope better with daily

life demands” (Peterson and Stumbo, 2000, p. 3). Examples of therapeutic modality

interventions in the separate domains of mind-body health; physical activity; creative

32

expression; self-discovery/self-expression; social skills, nature-based; and education-

based interventions are provided by Shank and Coyle (2002, pp. 164-171).

Summary

The benefits of improved mental and physical health contributing to longer happier lives

with less illness, and the subsequent reduction in healthcare costs and employee sick days

is acknowledged by Datillo (1999, p. 11). He endorses the role of leisure education in

these outcomes: ‘Accordingly, this provides social and economic rationale for the

provision of leisure education across a variety of settings’ (1999, p. 11).

The existing nature of the tobacco control regulatory framework and treatment services

for people with nicotine addiction suggest that the aims of these are compatible with the

concept of leisure education, and that there are many overlapping concepts between the

field of Tobacco Control and the discipline of Recreation Therapy. This report and those

preceding it, have been based upon a rationale that both from a preventive and

rehabilitative perspective, leisure education has a useful contribution to make to

preventing smoking uptake and reducing it’s prevalence.

This conclusion comes from a consideration that preventable smoking-related illness and

death are associated with lifestyle factors that may be enhanced by leisure awareness and

attention to development of an improved leisure lifestyle. The initial focus for this

investigation was on the challenges experienced by people trying to quit smoking, and

how leisure education might assist them to comply with their quit attempt. This came

33

with a realization that the manner in which leisure is defined is central, and will impact

on treatment interventions. To address the prevalence of smoking-related illness, this

report endorses a definition of leisure that does not confine the meaning of leisure simply

to a ‘free-time’ notion, and instead includes a focus on an individual’s role within a

community, accounts for intrinsic motivation, freedom, intention, and development.

It appears that Recreation Therapy as a profession, while having addressed the

therapeutic needs of broader substance abuse populations, still has greater scope for

specific development in the field of tobacco control, which smoking cessation is one area

of. For progress to be made, technical aspects of Recreation Therapy practice, such as

leisure education, will need introduction into smoking cessation treatment interventions.

This statement is endorsed by the fact that despite a drop in smoking prevalence with the

introduction of new laws around public places and worksites (Smokefree Environments

Enhanced Protection Act, 2003) that tightened previous regulations, smoking is still

responsible for one quarter of all New Zealand deaths, and five thousand deaths annually

(Health Sponsorship Council, 2002, p. 2). The presence of second-hand smoke is an

environmental hazard that also contributes to various illnesses and death. Breathing

second-hand smoke causes morbidity and mortality from cancer, heart disease, as well as

acute sensory irritation (Repace, in Health Sponsorship Council, 2002, p. 2).

There are numerous sources of information for inclusion in a report on a topic such as

this, and they potentially can further demonstrate the relationships between the multi-

faceted field of Tobacco Control and the fledgling profession of Recreation Therapy. It

34

is considered that enactment of leisure and recreation principles by individuals over their

lifestyles will serve to reduce the workload on Tobacco Control workers and health

professionals, and improve the functioning of health systems in the long term.

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