文章基本信息

标题：The Tobacco Use Management System: Analyzing Tobacco Control From a Systems Perspective
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作者：Ron Borland ; David Young ; Ken Coghill 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2010
卷号：100
期号：7
页码：1229-1236
DOI：10.2105/AJPH.2009.165910
语种：English
出版社：American Public Health Association
摘要：We use systems thinking to develop a strategic framework for analyzing the tobacco problem and we suggest solutions. Humans are vulnerable to nicotine addiction, and the most marketable form of nicotine delivery is the most harmful. A tobacco use management system has evolved out of governments’ attempts to regulate tobacco marketing and use and to support services that provide information about tobacco's harms and discourage its use. Our analysis identified 5 systemic problems that constrain progress toward the elimination of tobacco-related harm. We argue that this goal would be more readily achieved if the regulatory subsystem had dynamic power to regulate tobacco products and the tobacco industry as well as a responsive process for resourcing tobacco use control activities. There have been numerous recent calls for a more systematic application of systems thinking to public health issues.^{1 , 2} Work to date has focused on the utility of systems modeling in general³ and of specific subclasses of systems approaches (e.g., organizational network analysis^{4 , 5}). We use a social–ecology, or open systems, framework⁶ to analyze both the dynamics and the outcomes of tobacco control initiatives and to identify problems and possible solutions. Aggregate tobacco use is the outcome of complex interactions between forces aimed at increasing use and those aimed at decreasing use, the balance of which can be influenced by governments’ policy frameworks. The primary relationship is between the industry and the smoker. This relationship has changed from one in which smokers were driving demand and the industry was essentially meeting that demand ( Figure 1 , path 1) to one in which modern marketing influences smokers and potential smokers to increase demand ( Figure 1 , path 2). Open in a separate window FIGURE 1 Forces involved in the dynamics of tobacco use management. As the problems caused by tobacco use mounted, governments came under pressure to intervene. Initial interventions were inadequate—tobacco use was too prevalent, and the industry was too powerful for strong action to be contemplated—thus, elimination of tobacco use became a long-term goal rather than an immediate policy. Governments gradually implemented rules to govern the industry ( Figure 1 , path 3), such as restrictions on advertising and other forms of promotion. They also established or supported the establishment of programs ( Figure 1 , path 4) to provide public information about cessation assistance and the harms of tobacco use ( Figure 1 , path 5). They have also acted more directly on smokers via taxes and laws to restrict where they can smoke ( Figure 1 , path 6). To date, these actions of governments have been largely imposed on the system, with changes negotiated between multiple government departments and ministries (e.g., economic, health, environment, and trade). The existence of dedicated tobacco control legislation and the establishment of programs to constrain tobacco use make it useful to extend the open systems perspective and characterize tobacco control as a tobacco use management system. A management system has a set of dynamically interrelated elements and a framework of processes and structures to constrain its activities toward a goal—in this case, changing the level of tobacco use or the level of harm caused by its use. We position central government outside the tobacco use management system, because it acts only intermittently on it. Figure 2 offers a more comprehensive description of how the tobacco use management system operates. The goal is not to build a complete model but to identify the smallest set of elements that need to be considered to understand how the system operates (each subsystem can be further elaborated as the need arises). The outputs (actions or behavior) of each subsystem are driven or motivated by 3 kinds of processes: (1) influences from the broader environment, (2) influences from the outputs of the other subsystems, and (3) influences from processes intrinsic to the nature of each subsystem, which can both motivate action independently and moderate the effects of inputs. These intrinsic capacities are currently determined largely from outside the tobacco use management system. Open in a separate window FIGURE 2 Framework for investigating the social ecology of tobacco use. We use an analysis of the structure of the tobacco use management system to identify problems that currently make the management of tobacco problematic. Two of the problems are fundamental, being associated with factors that are not amenable to change and, therefore, have to be managed continuously. The remaining 5 are systemic and are, at least in principle, amenable to resolution, although some of these 5 may need to be accepted as ongoing and thus managed instead of resolved.