Smoking

Smoking

Cause Mapping Example:

Smoking is estimated to cause 440,000 premature deaths per year and results in an annual cost of nearly $200 billion. Progress is being made in lowering the number of smokers nationwide, but more work is still needed. We can look at smoking in a proactive Cause Map to determine some of the causes of smoking, and what can be done.

Step 1. Define the Problem

The first step of the Cause Mapping approach is to define the problem by asking the four questions: What is the problem? When did it happen? Where did it happen? And how did it impact the goals? One person may say that the problem is increased death. Another person might say that the problem is disease, and a third person could say that the problem is medical costs. We can write down these three “problems” on the first line. In the Cause Mapping methodology the facilitator anticipates that the group may disagree so all three responses are written down. There is no need to spend time debating the problem. The magnitude of this incident is defined by the impact to the goals.

The second question is the "When?" which, in this case, is ongoing. We also capture differences here - in this case, smoking is the single most preventable cause of death.

In an investigation there can be several pieces of information that need to be captured when specifying the location. At a minimum the physical/geographic location and the process should be captured. Here we are limiting our analysis to cigarette smoking in the United States.

The next section is the impact to the overall goals. A country's safety goal is to have a healthy population. Smoking causes 440,000 premature deaths per year, and 8.6 million people currently suffer from smoking-related illnesses. Additionally, there are more than 900 infant deaths resulting from smoking during pregnancy. These are all impacts to the safety goal. The environmental goal is impacted because smoking results in the release of over 250 toxic chemicals. Annual productivity losses (an impact to the production goal) are estimated to be $97.6 billion. I have included a "financial" goal to capture the health care costs of smoking, which are $96.7 billion caused directly by smoking, and $4.98 billion caused by secondhand smoke exposure.

Step 2. Identify the Causes (The Analysis)

The analysis step is where the incident is broken down into causes which are captured on the Cause Map. The Cause Map starts by writing down the goals that were affected as defined in problem outline. These are the first cause-and-effect relationships in the analysis.

The analysis can continue by asking Why questions and moving to the right of either of the cause-and-effect relationships above. In this example we’ll start with the health care bills and productivity losses, which were caused by the the premature deaths each year, and the smoking-related illnesses. The premature deaths and illnesses were caused by an increased risk of death and disease. The next question is “What caused the increased risk of death and disease?”

The increased risk of death and disease is caused by an increased risk of cancer, an increased risk of cardiovascular disease, and an increased risk of respiratory disease. We'll look at each of these in turn.

An increased risk of cancer is caused by genetic changes (or mutations) in cells. These mutations are caused by an increased host susceptibilty (caused by genetic factors), and carcinogens that bind to DNA. This occurs due to exposure to carcinogens, which occurs from regular exposure to tobacco smoke.

An increased risk of cardiovascular disease is caused by a reduced supply of oxygen through the body. This occurs in two ways,which we will discuss in more detail. First, there are reduced levels of oxygen in the blood. Oxygen supply is also reduced due to reduced circulation.

Oxygen levels in the blood are reduced because the ability to carry oxygen is diminshed as carbon monoxide displaces oxygen in the blood. This occurs from exposure to carbon monoxide which is found in - you guessed it - tobacco smoke.

Reduced oxygen supply is due to reduced circulation from artherosclerosis (hardening of the arteries), which is caused by endothelial dysfunction. This occurs when oxygen molecules mutate DNA (known as oxidative stress). This is caused by increased exposure to oxidations, due to inhalation of cigarette smoke, and by a decreased antioxidant capacity, also caused by inhalation of cigarette smoke.

An increased risk of respiratory disease is caused by chronic obstructive pulmonary disease (COPD), and increased respiratory infections. The COPD is caused by chronic lung injury and increased scarring of the airways. The chronic injury is caused by an increased inflammation response due to oxidative stress (as discussed above), and increased host susceptibility (also discussed above).

The scarring is caused by an increased inflammatory response, which, along with a decreased protective response causes the respiratory infections. This is due to suppression of the immune response due to exposure to nicotine, which occurs from inhalation of cigarette smoke.

Before we talk about why people smoke, let's look at a goal we haen't covered yet: infant deaths. Annually, 900 infant deaths are caused by smoking because birth weight is decreased (the key predictor of infant mortality) and the risk of stillborn birth is increased. These are both due to an increased risk of premature birth.

The risk of premature birth increases because pregnancy complications increase due to constricted blood vessels in the uterus and umbilical cord caused by smoking while pregnant.

Decreased birth weight is also caused by fetal growth restriction, which occurs because nicotine reduces the amount of blood in the fetus as it transfers to the fetus, and the constricted blood vessels cause decreased oxygen.

Regular exposure to tobacco smoke can be caused by actually smoking a cigarette (we'll talk about this more later). However, regular exposure to tobacco smoke can also be caused by being exposed to secondhand smoke. This can happen at home, if a family member smokes in the house or the car, or at work, if there is not a smoke-free policy. Smoke-free policies are not in place in some locations because of concerns that bans would decrease business, and successful lobbying (to Congress and by donations to candidates, political parties, and action groups.)

So, the big question is: why do people smoke cigarettes? People smoke because they start smoking, and it is extremely difficult to quit. Obviously, there's a lot of discussion on why this is.

There is a ton of research about why people start smoking. Although different studies place a different emphasis on which of the causes is most to blame about people beginning to smoke, most agree that the main causes are these (we’ll go into more detail about each): lack of increase in the cost of cigarettes, positive imagery of smoking, beginning smoking as a child, and believing benefits outweigh the risks.

One of the reasons people start smoking is the lack of increase in the cost of cigarettes. Or, conversely, less people would start smoking if cigarettes cost more. This is because the cost of cigarettes (national average of $4.26 a pack) does not reflect the true cost (estimated at $10.28 a pack for health costs and productivity losses). Additionally, small increases in taxes have been offset by promotions, and coupons by the cigarette companies. The tax increases have not increased proportionally with price. This is because the federal excise tax is not keeping up with inflation (due to successful lobbying, see above), and because of worries that increasing taxes will increase the black market, and interstate smuggling, because state taxes vary (and tend to be lower in tobacco producing states, again due to lobbying).

The positive imagery of smoking is caused by heavy advertising and promotion of cigarettes, including promotional items. This is particular poignant because children are more susceptible to advertising than adults, and most smokers begin as children (which we'll discuss next). There is a lack of counter-advertising due to a lack of funding. (The guaranteed federal funds provided from the cigarette company settlement ran out in 2003. Additionally state budget shortfalls have caused a decrease in state funding.) There is also a lot of smoking in popular culture. Cigarette companies sponsor sports teams, and athletes, and there is also the effect of smoking in movies. There is increased smoking in movies, especially in PG-13 movies (or movies that are marketed to adolescents), and kids tend to want to be like smoking characters: either tough rebels or heroes, who smoke at a higher rate than the general population.

We've alluded to it before, but most smokers start smoking as kids. 90% of smokers began smoking before the age of 18 (despite the fact that purchasing cigarettes before 18 is illegal). This is because children are more susceptible to addiction than adults, and because cigarettes entice children, with their heavy advertising, and promotion (see above), the use of cartoon mascots, and designs and flavors, including candy-flavored cigarettes, that appeal particularly to children. Children are also prone to experimentation and rebellion. Additionally, most children don't get counseling against using cigarettes, from physicians, or parents, possibly because their parents smoke. Last but not least, peer pressure plays a role. People find it difficult not to smoke when others around them are. This includes parents and peers.

Some people believe the benefits of smoking outweigh the risks. Cigarettes can relieve stress and help people concentrate because they result in an improved, calmer mood. It may help people lose weight, both because nicotine is an appetite suppressant and because it is a distraction from eating. People may not fully realize the risks, because risks were not widely known prior to the 1960s, due to a lack of information from physicians, and because children (remember that most people start smoking as children) tend to underestimate their personal risk and believe they will be able to stop smoking easily. And, the risks seem too far off to be a concern.

We've discussed why people start smoking. Now let's look at why it is so hard for them to quit. Research has shown that people have trouble quitting because: they switch to modified brands instead, cigarettes are extremely addictive, former smokers relapse, they have a lack of asisstance in quitting, they are afraid of weight gain, and the lack of increase in the cost of cigarettes (which we discussed above - here an increase in the cost of cigarettes would help encourage some people to stop smoking as well).

People switch to modified brands (such as light or low-tar cigarettes) because they believe they have a lower risk, due to health claims by cigarettes manufacturers. Manufactureres can make such claims because of a lack of regulation by the FDA. This is due to successful lobbying (as discussed above), concern that FDA regulation would be taken as approval, lack of FDA funding, and a Supreme Court ruling that FDA lacks jurisdication over tobacco.

Cigarettes are extremely addictive because they contain nicotine, which is extremely addictive. Nicotine is addictive because you need it to feel normal because your body and mind quickly become used to it. It results in an improved, calmer mood, because it triggers the release of dopamine in the brain, which improves your mood and makes you feel calm. Additionally, it delivers a high dose very quickly, and addiction occurs extremely quickly. Research hasn't shown exactly why yet.

Many former smokers relapse because habits are difficult to break, and because severe withdrawal symptoms and stress can cause relapses. This is because smoking is associated with a pleasant experience (whereas withdrawal is a very unpleasant one).

Finally, people have trouble quitting smoking because of a lack of assistance. This is due to a lack of asisstance from physicians and a lack of use of smoking cessation aids.

A lack of asisstance from physicians is because physicians tend to have a lack of follow-through, and a lack of practical advice and strategy. Additionally, many times smokers are not identified, doctors don't bring up the subject because they are uncomfortable or don't know how, and because smokers do not ask for assistance because they believe they can quit on their own.

Additionally, there is a lack of use of smoking cessation aids. Some people are afraid to use nicotine-replacement aids because they (wrongly) believe nicotine is a cause of cancer. Some don't use aids because they are expensive, and may not be covered by insurance or because they believe aids are not necessary, either because they are not helpful or because they believe they can quit on their own.

As you've watched the cause map build, you have probably identified some solutions to the smoking epidemic facing our nation. Some of them are for the government, some are for doctors, some are for smokers, some are for parents. But, there is something all of us can do to help stop smoking. It can be as simple as talking to your kids, or as complicated as trying to quit yourself. This cause map is a compendium of the research on smoking, both effects, and causes. As more research is performed, more detail can be added to this Cause Map.

Step 3. Select the Best Solutions (Reduce the Risk)

Once the Cause Map is built to a sufficient level of detail with supporting evidence the solutions step can be started. The Cause Map is used to identify all the possible solutions for given issue so that the best solutions can be selected. It is easier to identify many possible solutions from the detailed Cause Map than the oversimplified high level analysis of "don't smoke." Because if it were that easy, it wouldn't be the problem it is today.

Solutions can be documented directly on the Cause Map.  Solutions are typically placed in a green box directly above the cause the solution controls.   At this stage, all solutions are considered and put on the Cause Map. After the analysis is complete, the best solutions are selected based on the impacts to the organization's goals. Shown below is a solution added to a cause from the Cause Map. 

There are causes to every issue. The smoking epidemic at a high level has only one cause. At a more detailed level it has 8 causes, 27 causes and more than 160 causes. All of the levels of the Cause Map are accurate - some simply have more detail that others.

Cause Mapping Improves Problem Solving Skills

The Cause Mapping method focuses on the basics of the cause-and-effect principle so that it can be applied consistently to day-to-day issues as well as catastrophic, high risk issues. The steps of Cause Mapping are the same, but the level of detail is different. Focusing on the basics of the cause-and-effect principle make the Cause Mapping approach to root cause analysis a simple and effective method for investigating safety, environmental, compliance, customer, production, equipment or service issues.

Click on "Download PDF" above to download a PDF showing the Root Cause Analysis Investigation.

Resources

The information used to make this Cause Map was obtained from Nemours Foundation, Medline (A Service of the National Library of Medicine and the National Institutes of Health, American Cancer Society, Centers for Disease Control and Prevention, National Toxicology Program, Department of Health and Human Services, Society of Actuaries, National Public Radio, Smoke-Free Movies (UCSF), National Institute on Drug Abuse, Biomed Central, and World Bank.