Chapter 3 - chronic disease prevention
Globally, 60% of all deaths in 2005 were due to chronic diseases (heart disease, stroke, cancer, chronic
respiratory diseases, and diabetes), with 80% of these deaths occurring in low- and middle-income countries.
Although it is likely the result of a complex interaction of genetic, behavioral, and environmental influences, the
rate at which chronic diseases have risen may suggest that behavioral and environmental influences have played
a larger role than biological changes.
Disease prevention involves three levels:
- Primary: directly addresses the mediating causes of diseases and is carried out before the onset of
disease, thereby preventing its occurrence.
- Secondary: early detection and treatment of a disease before a full-blown illness develops (screening).
- Tertiary: attempts to prevent recurrence or progression of a disease that has already occurred.
While chronic diseases have both genetic and modifiable risk factors, this chapter focuses on modifiable risk
factors. Modifiable risk factors become even more important when genetic risk factors are already present (i.e.,
family history). Each modifiable risk factor individually increases the risk of disease. Multiple risk factors for
the same condition, when in combination, increase risk dramatically. It is very common for people to have these
multiple risk factors simultaneously.
There are four primary prevention interventions that significantly impact the diseases presented. These are
tobacco cessation, weight loss, healthy diet, and regular exercise, which are referred to here as the Four Pillars
of Primary Prevention (4Ps), because they form the basis of primary prevention, are also useful in secondary
and tertiary prevention, and support an overall healthy lifestyle.
This figure displays the direct and indirect effects of the 4Ps on chronic disease prevention.
It is important to note that adoption of the 4Ps does not completely preclude the onset of chronic disease. Even
those who live a healthy lifestyle can still develop chronic disease, because genetic factors also play a
significant role. Therefore it is more accurate to consider the 4Ps as a strategy to reduce the probability of
developing chronic disease.
Cigarette smoking causes several types of cancer (lung, oral, bladder, larynx, esophagus, and pharynx), heart
disease, and COPD, and significantly contributes to stroke and other cancers (cervical, pancreatic, and kidney).
Smoking is responsible for 80 to 90% of COPD deaths and approximately 90% of lung cancer deaths. The
benefits of smoking cessation are almost immediate. After only 20 minutes of cessation blood pressure and heart
rate drop to normal, after 3 months lung function improves by up to 30%, after 9 months respiratory symptoms
decrease, after 1 year risk of coronary heart disease decreases by 50%, after 10 years precancerous cells are
,replaced by normal cells, thereby decreasing cancer risk, and after 15 years death rates are nearly the same for
ex-smokers as they are for those who never smoked.
Approximately 300,000 deaths per year are attributable to obesity, making it a leading cause of death in the
country.
Obesity increases the risk of type 2 diabetes, heart disease, stroke, hypertension, osteoarthritis, colon and breast
cancer, sleep apnea, and depression. Approximately 20 to 30% of coronary heart disease mortality can be
attributed to excess body weight. Further, obese women are nearly six times more likely to develop
hypertension, and obese persons have almost 10 times the risk of diabetes as compared to non-obese peers.
Research supports that losing as little as 5 to 10% of body weight can significantly reduce obesity-related
conditions.
It is recommended that patients gradually build up to 30 to 45 minutes of moderate exercise three to five times
per week. Exercise need not be strenuous and may include walking, weight lifting (anaerobic), and other aerobic
activities (swimming, running, bicycling, etc.). The benefits of regular exercise are far reaching and include
weight loss (by expending calories), improved mood (by releasing endorphins), lowered blood pressure (by
dilating blood vessels), improved cholesterol levels (by removing low-density lipoprotein [LDL] from artery
walls), lowered risk of CVD, lowered risk of type 2 diabetes (by improving physical response to insulin),
lowered risk of osteoporosis (by promoting bone development), and decreased risk of certain cancers. Those
who are physically inactive are twice as likely to develop CHD as those who exercise regularly. Regular
exercise is associated with fewer outpatient and inpatient services and needing less medication.
Poor dietary choices have been implicated in hyperlipidemia, hypertension, CVD, certain cancers, and type 2
diabetes. Saturated fats are implicated in heart disease because they increase LDL (“bad cholesterol”) levels.
Saturated fats come from natural sources, such as red meat, whereas trans fats (i.e., partially hydrogenated
vegetable oil) are vegetable fats that have hydrogen added to them to improve taste and lengthen storage
capacity. Trans fats are heavily implicated in heart disease and are widely used in commercial baking and frying.
Fruits and vegetables have been found to have a protective effect against CVD and certain cancers. Of
Americans age 2 and older, only 28% consumed at least two daily servings of fruit, and only 3% met daily
intake requirements for vegetables. Healthy foods are usually less calorie dense and may therefore lead to
weight loss, further reducing health risk.
Leading causes of death in the United States, in order from higher to lower mortality rates, are:
- Cardiovascular disease (CVD) (both heart disease and stroke): Major modifiable risk factors for CVD
include the 4Ps, hyperlipidemia, hypertension, and diabetes. For instance, smoking has been linked to
CHD because tobacco smoke can cause buildup of cholesterol on artery walls and can promote the
formation of blood clots. As weight increases, so does CVD risk. Regarding hyperlipidemia, high total
cholesterol, high LDL cholesterol, or low high-density lipoprotein (HDL; “good”) cholesterol doubled
the risk of heart disease among middle-aged women. Hypertension increases the risk of CHD and
stroke by putting increased pressure on the artery walls, and those with hypertension have about three
times the risk of CHD as compared to their nonhypertensive counterparts. Diabetes increases the risk of
CVD because it contributes to the development of atherosclerosis (hardening of the arteries) and
increases blood pressure and cholesterol levels. Stroke: caused by disrupted blood flow to the brain,
usually from a blocked or ruptured vessel. The good news is that an estimated 80% of heart attacks can
be prevented or delayed through lifestyle changes. After 1 year of quitting smoking, the risk of CHD
decreases by 50%, and physical activity has also been found to reduce the risk of CHD by up to 50%
by lowering associated risk factors, such as being overweight.
- Cancer: more than 50% of cancers can be prevented through tobacco cessation and healthier diet. In
addition, exercise and weight control also contribute to cancer prevention, especially for breast cancer.
Greater use of screenings could prevent at least half of the deaths from cancer.
, - Chronic respiratory diseases - Chronic Obstructive Pulmonary Disease (COPD) deaths can be
attributed to smoking in 80-90% of the cases.
- Diabetes: type 1 (insulin-dependent) and type 2 (non-insulin-dependent) diabetes affect approximately
7% of the population, with type 2 diabetes accounting for 90 to 95% of all diabetes diagnosed. Diabetes
causes high blood glucose levels from insufficient insulin production or action, which can lead to
additional serious health problems. For instance, over 70% of diabetics have blood pressure in the
prehypertensive range, and adults with diabetes have up to four times the rate of death from heart
disease and up to four times the risk of stroke as compared to those without diabetes. Modifiable risk
factors for T2DM include the 4Ps and control of blood pressure and cholesterol levels. Of these, weight
is considered the greatest modifiable risk factor for diabetes onset, given that approximately 80% of
those diagnosed with T2DM are obese. Further, smokers are at increased risk of developing diabetes
because smoking lowers insulin levels while increasing blood glucose levels. Primary prevention of
T2DM must include lifestyle changes that address the 4Ps, and is especially crucial for those with
pre-diabetes, or impaired glucose tolerance that has not reached diabetic levels Exercise, diet, and
weight loss are not only essential in preventing diabetes, but are also important in managing blood
glucose for those who already have the disease, because glucose control can prevent progression and
later complications. Effective glucose control requires daily monitoring of blood glucose levels, and
only 60% of adult diabetics do so. Control of blood pressure and cholesterol levels are also important
secondary prevention strategies. By controlling blood pressure or cholesterol, diabetics can reduce their
risk of CVD by up to 50%.
- Hyperlipidemia: High blood cholesterol can increase risk of hypertension, CHD, and stroke because it
causes atherosclerosis. Optimal LDL cholesterol is below 100 mg/dL, optimal HDL cholesterol is
above 60 mg/dL, and total cholesterol should be below 200 mg/dL. HDL cholesterol helps protect
against heart disease by removing LDL cholesterol from the blood. Three of the 4Ps (weight loss,
regular exercise, and dietary changes) are modifiable risk factors for hyperlipidemia.
- Hypertension (high blood pressure): can cause atherosclerosis, forcing the heart to work harder to
pump blood through the arteries, thereby increasing the risk of CVD. In fact, hypertension is the
leading cause of congestive heart failure, hemorrhagic stroke, ischemic coronary disease, and
cerebrovascular disease. Hypertension is known as the “silent killer” because there are usually no
symptoms and nearly one-third of those who have hypertension do not know it. Primary hypertension
is caused by a combination of genetic and environmental factors and secondary hypertension is the
result of another medical condition or medications. There are numerous antihypertensive medications
available to lower blood pressure (i.e., beta-blockers, calcium channel blockers), but adherence to
prescription regimens is often a barrier to reducing blood pressure. However, even a slight decrease in
blood pressure can reduce the risk of CVD. While the exact cause of hypertension is unknown,
modifiable risk factors include three of the 4Ps: weight loss, exercise, and diet with limited salt intake.
Although tobacco use does not directly contribute to the development of hypertension, it can
exacerbate its effects. Furthermore, negative interpretations of stressful events and personality
characteristics, such as hostility, can increase the level of stress experienced. Stress activates the
sympathetic nervous system, thereby causing physiological arousal, such as increased heart rate,
peripheral vasoconstriction, and blood pressure. Prolonged and chronic stress may therefore negatively
impact the heart and blood vessels.
Minority groups and those with lower socioeconomic circumstances are at greater disadvantage for chronic
disease risk factors and are overrepresented in chronic disease populations. These disparities are in part
attributed to lack of insurance, poverty, language barriers, and racial discrimination.
Smoking is also three times more likely among adults with less than a high school education as compared to
those with education at the bachelor’s level or higher.
African American and Mexican American are overall more susceptible to get one of the above mentioned
chronic diseases. They are also most often uninsured. It is difficult to reach the uninsured population for primary
prevention, which increases the likelihood of disease onset and inadequate treatment to manage or slow disease
, progression. Consequently, the uninsured are more likely to be diagnosed at later stages of disease, with
subsequently higher death rates
Increased focus on chronic disease prevention stems, in large part, from the associated financial burden. A major
reason for continuously increasing U.S. health care expenditures is that chronic diseases account for more than
60% of those expenditures, with some estimates as high as 76%.
Total costs are composed of both direct costs, which are health care expenditures, and indirect costs, which are
those related to lost productivity from disability, unemployment, and premature death. When these chronic
disease figures are separated into direct and indirect costs, direct costs accounted for 60% of CVD, 35% of
cancer, 70% of diabetes, and 50% of COPD expenditures. Therefore, CVD and diabetes are the most costly
diseases for the health care system, while cancer leads to the greatest costs in lost productivity. Health care
expenditures have also been reported in terms of lifestyle behaviors.
Cost-effectiveness analysis is a measure of economic outcome that is suitable for application in health care
programs and interventions because it is not purely a financial calculation. Contrary to a measure such as
cost-benefit analysis (CBA), where all aspects of the calculation are converted to dollar units, CEA evaluates the
relationship between the financial investment of a program and its clinical outcomes. Those clinical outcomes
are not measured in financial units, as in CBA, but rather in quality adjusted life years (QALYs). Cost-benefit
analysis outcomes are therefore reported as dollars per QALYs gained, and both direct and indirect costs are
factored into the calculation. For this reason, tobacco cessation is considered to be the gold standard of
cost-effective interventions. For instance, smoking cessation programs ranging from $1,100 to $4,500 in cost
have saved one QALY. Even when the results are presented in purely financial CBA terms, the outcomes are
still impressive, where tobacco cessation programs have demonstrated a benefit-to-cost ratio of 3:1 (i.e., for
every dollar invested in the program, three dollars is saved).
Furthermore, those who have improved quality of life with increased life expectancy will likely contribute to
society in more productive ways, thereby decreasing indirect costs such as from disability and unemployment.
Even though prevention interventions have demonstrated solid economic outcomes, barriers to reimbursement
from insurance companies still exist.
Given the clinical evidence, it begs the question of why so few people engage in preventive care. Assuming
adequate insurance coverage, the reasons are numerous, including lack of awareness, high co-payments for
services, fear of positive screening results, prior experiences with false positive test results, time constraints, and
lack of motivation. Even those who can find the time and are aware may not value a healthy lifestyle or the
prevention of disease. It can be difficult to help someone who has yet to experience any negatively related health
consequences to give up such pleasurable indulgences (such as eating unhealthy, smoking).
According to Beck’s cognitive triad, a person suffering from depression will experience negative thoughts about
the self, the world, and the future.
Transtheoretical Model: five common processes of change:
1. Consciousness raising - helping the patient gather information about oneself and the problem, such as
through verbal clinician feedback or printed informational materials.
2. Choosing - increased awareness that there are healthy alternatives to unhealthy behaviour.
3. Catharsis - emotional expression of the problem behaviour and the process of change.
4. Conditional stimuli - includes both stimulus control (avoidance of stimuli associated with the problem
behavior and the operant extinction of that stimulus’ effect to cue the problem behavior) and
counterconditioning (is training an alternative, healthier response to those stimuli).
5. Contingency control - the use of positive reinforcement from oneself and others and reevaluation of
how the problem behavior has impacted one’s self-image and the environment.
From these five processes of change, they identified six stages of change (SOC):
1. Precontemplation - at which the person is not even considering changing his or her behavior, does not
see the behavior as a problem, minimizes associated risks, and avoids information to the contrary.
Globally, 60% of all deaths in 2005 were due to chronic diseases (heart disease, stroke, cancer, chronic
respiratory diseases, and diabetes), with 80% of these deaths occurring in low- and middle-income countries.
Although it is likely the result of a complex interaction of genetic, behavioral, and environmental influences, the
rate at which chronic diseases have risen may suggest that behavioral and environmental influences have played
a larger role than biological changes.
Disease prevention involves three levels:
- Primary: directly addresses the mediating causes of diseases and is carried out before the onset of
disease, thereby preventing its occurrence.
- Secondary: early detection and treatment of a disease before a full-blown illness develops (screening).
- Tertiary: attempts to prevent recurrence or progression of a disease that has already occurred.
While chronic diseases have both genetic and modifiable risk factors, this chapter focuses on modifiable risk
factors. Modifiable risk factors become even more important when genetic risk factors are already present (i.e.,
family history). Each modifiable risk factor individually increases the risk of disease. Multiple risk factors for
the same condition, when in combination, increase risk dramatically. It is very common for people to have these
multiple risk factors simultaneously.
There are four primary prevention interventions that significantly impact the diseases presented. These are
tobacco cessation, weight loss, healthy diet, and regular exercise, which are referred to here as the Four Pillars
of Primary Prevention (4Ps), because they form the basis of primary prevention, are also useful in secondary
and tertiary prevention, and support an overall healthy lifestyle.
This figure displays the direct and indirect effects of the 4Ps on chronic disease prevention.
It is important to note that adoption of the 4Ps does not completely preclude the onset of chronic disease. Even
those who live a healthy lifestyle can still develop chronic disease, because genetic factors also play a
significant role. Therefore it is more accurate to consider the 4Ps as a strategy to reduce the probability of
developing chronic disease.
Cigarette smoking causes several types of cancer (lung, oral, bladder, larynx, esophagus, and pharynx), heart
disease, and COPD, and significantly contributes to stroke and other cancers (cervical, pancreatic, and kidney).
Smoking is responsible for 80 to 90% of COPD deaths and approximately 90% of lung cancer deaths. The
benefits of smoking cessation are almost immediate. After only 20 minutes of cessation blood pressure and heart
rate drop to normal, after 3 months lung function improves by up to 30%, after 9 months respiratory symptoms
decrease, after 1 year risk of coronary heart disease decreases by 50%, after 10 years precancerous cells are
,replaced by normal cells, thereby decreasing cancer risk, and after 15 years death rates are nearly the same for
ex-smokers as they are for those who never smoked.
Approximately 300,000 deaths per year are attributable to obesity, making it a leading cause of death in the
country.
Obesity increases the risk of type 2 diabetes, heart disease, stroke, hypertension, osteoarthritis, colon and breast
cancer, sleep apnea, and depression. Approximately 20 to 30% of coronary heart disease mortality can be
attributed to excess body weight. Further, obese women are nearly six times more likely to develop
hypertension, and obese persons have almost 10 times the risk of diabetes as compared to non-obese peers.
Research supports that losing as little as 5 to 10% of body weight can significantly reduce obesity-related
conditions.
It is recommended that patients gradually build up to 30 to 45 minutes of moderate exercise three to five times
per week. Exercise need not be strenuous and may include walking, weight lifting (anaerobic), and other aerobic
activities (swimming, running, bicycling, etc.). The benefits of regular exercise are far reaching and include
weight loss (by expending calories), improved mood (by releasing endorphins), lowered blood pressure (by
dilating blood vessels), improved cholesterol levels (by removing low-density lipoprotein [LDL] from artery
walls), lowered risk of CVD, lowered risk of type 2 diabetes (by improving physical response to insulin),
lowered risk of osteoporosis (by promoting bone development), and decreased risk of certain cancers. Those
who are physically inactive are twice as likely to develop CHD as those who exercise regularly. Regular
exercise is associated with fewer outpatient and inpatient services and needing less medication.
Poor dietary choices have been implicated in hyperlipidemia, hypertension, CVD, certain cancers, and type 2
diabetes. Saturated fats are implicated in heart disease because they increase LDL (“bad cholesterol”) levels.
Saturated fats come from natural sources, such as red meat, whereas trans fats (i.e., partially hydrogenated
vegetable oil) are vegetable fats that have hydrogen added to them to improve taste and lengthen storage
capacity. Trans fats are heavily implicated in heart disease and are widely used in commercial baking and frying.
Fruits and vegetables have been found to have a protective effect against CVD and certain cancers. Of
Americans age 2 and older, only 28% consumed at least two daily servings of fruit, and only 3% met daily
intake requirements for vegetables. Healthy foods are usually less calorie dense and may therefore lead to
weight loss, further reducing health risk.
Leading causes of death in the United States, in order from higher to lower mortality rates, are:
- Cardiovascular disease (CVD) (both heart disease and stroke): Major modifiable risk factors for CVD
include the 4Ps, hyperlipidemia, hypertension, and diabetes. For instance, smoking has been linked to
CHD because tobacco smoke can cause buildup of cholesterol on artery walls and can promote the
formation of blood clots. As weight increases, so does CVD risk. Regarding hyperlipidemia, high total
cholesterol, high LDL cholesterol, or low high-density lipoprotein (HDL; “good”) cholesterol doubled
the risk of heart disease among middle-aged women. Hypertension increases the risk of CHD and
stroke by putting increased pressure on the artery walls, and those with hypertension have about three
times the risk of CHD as compared to their nonhypertensive counterparts. Diabetes increases the risk of
CVD because it contributes to the development of atherosclerosis (hardening of the arteries) and
increases blood pressure and cholesterol levels. Stroke: caused by disrupted blood flow to the brain,
usually from a blocked or ruptured vessel. The good news is that an estimated 80% of heart attacks can
be prevented or delayed through lifestyle changes. After 1 year of quitting smoking, the risk of CHD
decreases by 50%, and physical activity has also been found to reduce the risk of CHD by up to 50%
by lowering associated risk factors, such as being overweight.
- Cancer: more than 50% of cancers can be prevented through tobacco cessation and healthier diet. In
addition, exercise and weight control also contribute to cancer prevention, especially for breast cancer.
Greater use of screenings could prevent at least half of the deaths from cancer.
, - Chronic respiratory diseases - Chronic Obstructive Pulmonary Disease (COPD) deaths can be
attributed to smoking in 80-90% of the cases.
- Diabetes: type 1 (insulin-dependent) and type 2 (non-insulin-dependent) diabetes affect approximately
7% of the population, with type 2 diabetes accounting for 90 to 95% of all diabetes diagnosed. Diabetes
causes high blood glucose levels from insufficient insulin production or action, which can lead to
additional serious health problems. For instance, over 70% of diabetics have blood pressure in the
prehypertensive range, and adults with diabetes have up to four times the rate of death from heart
disease and up to four times the risk of stroke as compared to those without diabetes. Modifiable risk
factors for T2DM include the 4Ps and control of blood pressure and cholesterol levels. Of these, weight
is considered the greatest modifiable risk factor for diabetes onset, given that approximately 80% of
those diagnosed with T2DM are obese. Further, smokers are at increased risk of developing diabetes
because smoking lowers insulin levels while increasing blood glucose levels. Primary prevention of
T2DM must include lifestyle changes that address the 4Ps, and is especially crucial for those with
pre-diabetes, or impaired glucose tolerance that has not reached diabetic levels Exercise, diet, and
weight loss are not only essential in preventing diabetes, but are also important in managing blood
glucose for those who already have the disease, because glucose control can prevent progression and
later complications. Effective glucose control requires daily monitoring of blood glucose levels, and
only 60% of adult diabetics do so. Control of blood pressure and cholesterol levels are also important
secondary prevention strategies. By controlling blood pressure or cholesterol, diabetics can reduce their
risk of CVD by up to 50%.
- Hyperlipidemia: High blood cholesterol can increase risk of hypertension, CHD, and stroke because it
causes atherosclerosis. Optimal LDL cholesterol is below 100 mg/dL, optimal HDL cholesterol is
above 60 mg/dL, and total cholesterol should be below 200 mg/dL. HDL cholesterol helps protect
against heart disease by removing LDL cholesterol from the blood. Three of the 4Ps (weight loss,
regular exercise, and dietary changes) are modifiable risk factors for hyperlipidemia.
- Hypertension (high blood pressure): can cause atherosclerosis, forcing the heart to work harder to
pump blood through the arteries, thereby increasing the risk of CVD. In fact, hypertension is the
leading cause of congestive heart failure, hemorrhagic stroke, ischemic coronary disease, and
cerebrovascular disease. Hypertension is known as the “silent killer” because there are usually no
symptoms and nearly one-third of those who have hypertension do not know it. Primary hypertension
is caused by a combination of genetic and environmental factors and secondary hypertension is the
result of another medical condition or medications. There are numerous antihypertensive medications
available to lower blood pressure (i.e., beta-blockers, calcium channel blockers), but adherence to
prescription regimens is often a barrier to reducing blood pressure. However, even a slight decrease in
blood pressure can reduce the risk of CVD. While the exact cause of hypertension is unknown,
modifiable risk factors include three of the 4Ps: weight loss, exercise, and diet with limited salt intake.
Although tobacco use does not directly contribute to the development of hypertension, it can
exacerbate its effects. Furthermore, negative interpretations of stressful events and personality
characteristics, such as hostility, can increase the level of stress experienced. Stress activates the
sympathetic nervous system, thereby causing physiological arousal, such as increased heart rate,
peripheral vasoconstriction, and blood pressure. Prolonged and chronic stress may therefore negatively
impact the heart and blood vessels.
Minority groups and those with lower socioeconomic circumstances are at greater disadvantage for chronic
disease risk factors and are overrepresented in chronic disease populations. These disparities are in part
attributed to lack of insurance, poverty, language barriers, and racial discrimination.
Smoking is also three times more likely among adults with less than a high school education as compared to
those with education at the bachelor’s level or higher.
African American and Mexican American are overall more susceptible to get one of the above mentioned
chronic diseases. They are also most often uninsured. It is difficult to reach the uninsured population for primary
prevention, which increases the likelihood of disease onset and inadequate treatment to manage or slow disease
, progression. Consequently, the uninsured are more likely to be diagnosed at later stages of disease, with
subsequently higher death rates
Increased focus on chronic disease prevention stems, in large part, from the associated financial burden. A major
reason for continuously increasing U.S. health care expenditures is that chronic diseases account for more than
60% of those expenditures, with some estimates as high as 76%.
Total costs are composed of both direct costs, which are health care expenditures, and indirect costs, which are
those related to lost productivity from disability, unemployment, and premature death. When these chronic
disease figures are separated into direct and indirect costs, direct costs accounted for 60% of CVD, 35% of
cancer, 70% of diabetes, and 50% of COPD expenditures. Therefore, CVD and diabetes are the most costly
diseases for the health care system, while cancer leads to the greatest costs in lost productivity. Health care
expenditures have also been reported in terms of lifestyle behaviors.
Cost-effectiveness analysis is a measure of economic outcome that is suitable for application in health care
programs and interventions because it is not purely a financial calculation. Contrary to a measure such as
cost-benefit analysis (CBA), where all aspects of the calculation are converted to dollar units, CEA evaluates the
relationship between the financial investment of a program and its clinical outcomes. Those clinical outcomes
are not measured in financial units, as in CBA, but rather in quality adjusted life years (QALYs). Cost-benefit
analysis outcomes are therefore reported as dollars per QALYs gained, and both direct and indirect costs are
factored into the calculation. For this reason, tobacco cessation is considered to be the gold standard of
cost-effective interventions. For instance, smoking cessation programs ranging from $1,100 to $4,500 in cost
have saved one QALY. Even when the results are presented in purely financial CBA terms, the outcomes are
still impressive, where tobacco cessation programs have demonstrated a benefit-to-cost ratio of 3:1 (i.e., for
every dollar invested in the program, three dollars is saved).
Furthermore, those who have improved quality of life with increased life expectancy will likely contribute to
society in more productive ways, thereby decreasing indirect costs such as from disability and unemployment.
Even though prevention interventions have demonstrated solid economic outcomes, barriers to reimbursement
from insurance companies still exist.
Given the clinical evidence, it begs the question of why so few people engage in preventive care. Assuming
adequate insurance coverage, the reasons are numerous, including lack of awareness, high co-payments for
services, fear of positive screening results, prior experiences with false positive test results, time constraints, and
lack of motivation. Even those who can find the time and are aware may not value a healthy lifestyle or the
prevention of disease. It can be difficult to help someone who has yet to experience any negatively related health
consequences to give up such pleasurable indulgences (such as eating unhealthy, smoking).
According to Beck’s cognitive triad, a person suffering from depression will experience negative thoughts about
the self, the world, and the future.
Transtheoretical Model: five common processes of change:
1. Consciousness raising - helping the patient gather information about oneself and the problem, such as
through verbal clinician feedback or printed informational materials.
2. Choosing - increased awareness that there are healthy alternatives to unhealthy behaviour.
3. Catharsis - emotional expression of the problem behaviour and the process of change.
4. Conditional stimuli - includes both stimulus control (avoidance of stimuli associated with the problem
behavior and the operant extinction of that stimulus’ effect to cue the problem behavior) and
counterconditioning (is training an alternative, healthier response to those stimuli).
5. Contingency control - the use of positive reinforcement from oneself and others and reevaluation of
how the problem behavior has impacted one’s self-image and the environment.
From these five processes of change, they identified six stages of change (SOC):
1. Precontemplation - at which the person is not even considering changing his or her behavior, does not
see the behavior as a problem, minimizes associated risks, and avoids information to the contrary.
