This document discusses how leisure education can be used as a tobacco control tool. It notes that tobacco causes significant death and disease globally. While legal, tobacco undermines health when used as intended. The document explores how leisure interacts with tobacco use through themes on product packaging, sponsorship of events, and debates around smoking in public places. It argues that leisure education during formative years can promote healthy attitudes and activities to prevent smoking initiation or help with quit attempts. Interventions addressing individual, social and cultural factors can reduce substance abuse. The document examines how recreation therapy principles like intrinsic motivation and mastery can support tobacco control efforts through leisure-based education and alternatives to smoking.

1. 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

2. “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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3. 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).
3

4. 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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5. 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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6. 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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7. 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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8. - 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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9. 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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10. 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
10

11. 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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12. 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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13. 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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14. - 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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15. 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
15

16. (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
16

17. 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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18. 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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19. 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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20. 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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21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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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