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Protection from secondhand smoke in countries belonging to the WHO European Region: an assessment of legislation
  1. Cristina Martínez1,2,
  2. Jose María Martínez-Sánchez1,
  3. Gillian Robinson3,
  4. Christina Bethke4,
  5. Esteve Fernández1,5
  1. 1Tobacco Control Unit, Cancer Prevention and Control Department, Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
  2. 2Medicine and Health Sciences School, Universitat Internacional de Catalunya, Barcelona, Spain
  3. 3City and Hackney Public Health Directorate, NHS North East London and the City, London, UK
  4. 4Independent Lawyer, specialized in tobacco legislation, Berlin, Germany
  5. 5Department of Clinical Sciences, School of Medicine, Campus of Bellvitge, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
  1. Correspondence to Cristina Martínez, Tobacco Control Unit, Cancer Prevention and Control Department, Institut Català d'Oncologia, Av. Gran Via de L'Hospitalet, 199-203, L'Hospitalet de Llobregat, Barcelona E-08908, Spain; cmartinez2{at}gmail.com, cmartinez{at}iconcologia.net

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Introduction

Exposure to secondhand smoke (SHS) causes death, disease and disability.1 The evidence further demonstrates that there is no safe level of exposure.2 In 2003, the World Health Assembly unanimously adopted the WHO Framework Convention on Tobacco Control (WHO FCTC). Article 8 of the treaty addresses SHS exposure as a health risk and identifies interventions, such as smokefree bans, to protect citizens from its hazardous exposure. Fundamentally, the treaty requires parties to implement clear indoor air laws.3 Smokefree legislation can be implemented in a variety of sectors and facilities to protect the population from the harmful effects of SHS.4 ,5

To date (October 2011) the WHO FCTC has been ratified by 174 countries, including 47 out of 53 countries, in the WHO European Region.6 Several countries have updated their smokefree legislation prohibiting smoking in public places.7 However, the characteristics, disposition and level of protection offered by these laws are different, with some offering comprehensive protection (eg, prohibiting smoking without exceptions) and others allowing smoking under specific conditions or circumstances. For example, Ireland (2004), UK (2007) and Spain (2010) applied comprehensive smokefree legislation in many public sectors including bars and restaurants. However, Malta (2004), Italy (2005) and Sweden (2005), despite updating and strengthening their legislation recently, still allow smoking in designated areas.8

Several studies have evaluated the impact of smokefree legislation in enclosed public places in European countries either by using surveys among the population or by objective measurements such as cotinine airborne nicotine or PM2.5.4 ,9–12 These studies conclude that legislation which does not enforce comprehensive smokefree environments are ineffective.13–15 Therefore, comprehensive smokefree legislation is the most effective tool to protect the population from SHS and assure healthy smokefree environments.1

Although, there have been some efforts in developing mechanisms to empirically evaluate tobacco control policies, they do not assess the level of protection provided by legislation. Rigotti and Pashos16 evaluated the smoking restrictions among US cities and states. Klonoff et al17 in the USA and Joossens et al in Europe18 developed scales of what a comprehensive tobacco control law should include, such as, environmental tobacco smoke, advertising and promotion, youth access and taxes. However, up to now, there is no mechanism for evaluating the theoretical level of protection provided by the smokefree legislation following the WHO guidelines for the correct implementation of Article 8 of the FCTC, taking into consideration the terms that smokefree ordinances may apply (eg, 100% smokefree without exceptions, or providing separate areas, ventilation or other conditions).19 Therefore, the aim of this study is to assess the level of protection from SHS in the national and regional laws of countries belonging to the WHO European Region, and according to the principles provided by the WHO guidelines. To do this we developed a new methodology to evaluate smokefree legislation by assessing and rating the features of the laws.

Materials and methods

This study reviews and assesses smokefree laws from countries belonging to the WHO European Region that were in force from July 2011 to October 2011. The WHO European Region comprises 53 countries from Europe, the Caucasus region and Western Asia (see list at http://www.who.int/about/regions/euro/en/index.html). To evaluate the level of protection provided by the laws we used a conceptual framework from the WHO guideline on ‘Protection from exposure to second-hand tobacco smoke’ published in 2007.19

The criteria for the inclusion of laws in the study were the following: national/regional smokefree laws from countries belonging to the WHO European Region, in force between July and October 2011, available in English, German, Portuguese or Spanish (originally or translated). The laws were retrieved from three sources. The main source was the legal database of the Tobacco Free Initiative (TFI) at WHO. The second source was the database of the European Network for Smokefree Prevention (ENSP). Finally, as the third source, we used personal contact through email with ENSP national representatives and/or tobacco control experts. We mainly used this third search strategy among countries from Eastern and Central Europe (Serbia, Azerbaijan, Tajikistan and Turkmenistan) whose latest laws could not be found through either of the previous two sources.

To assess the features of the laws we defined the country/region name, publication year and jurisdiction level (national or regional). Evaluation of the laws was performed in two steps: first, we assessed how the laws prohibited or allowed smoking, and second, we determined the level of protection provided according to the elements described in the first part of the evaluation.

An assessment protocol was created for indoor areas to evaluate the level of protection provided by the laws. This protocol described conditions under which the laws prohibited or allowed smoking by each sector and type of facility assessed. The instrument was based on the SHS WHO guideline.19 This tool was created and tested during the summer of 2009 for a previous study.20 The guideline and evaluation protocol were developed by three members of the team. Two were research law evaluators (CM and GR) and the third was a senior tobacco control expert from TFI at WHO. The protocol included a series of questions (Q) used to establish whether each law addressed the regulations:

  • Q1: Does the law prohibit smoking in this sector without any exception?

To answer question Q1 three responses codes were established: 0—No, smoking is allowed; if this was the case the reviewer must continue answering the questions Q2, Q3, Q4 of the subsector. 1—Yes, smoking is forbidden in this sector under any exception. Following the WHO policy recommendations for SHS protection to exposure, this possibility was defined as a law that provided ‘comprehensive smokefree or 100% smokefree area’. Therefore, the law did not include designated smoking rooms, ventilation, and/or any kind of condition/circumstance under which smoking could be permitted. If this was the case the reviewer must move to the next sector and answer question Q1. 9—No information was provided by the law or absence of regulation.

  • Q2: Does the law permit smoking in a designated area? (with four options: enclosed areas, non-passage ways, mechanical separations, sliding doors with close position by default) and/or

  • Q3: Does the law permit smoking in a ventilated area? (with four options: independent input, independent exhaust, replacement rate air, negative air pressure) and/or

  • Q4: Does the law prescribe other condition/s under which smoking is allowed aside from designated and ventilated stipulations? (with 17 different circumstances) (see figure 1).

Figure 1

Algorithm flow process for arriving at each secondhand smoke level of protection.

Three response codes were established to answer questions Q2, Q3, Q4: 0—if this type of condition was mentioned as not prescribed/allowed by the law; 1—if this type of condition was mentioned as prescribed/allowed by the law; 9—if no information was provided by the law or absence of regulation.

After the characteristics of the laws were defined, we selected the areas, sectors and facilities to include in the evaluation. We included evaluation from six main sectors: health and social care facilities; education; public places; workplaces; hospitality; and public transportation (detailed in box 1). Each main sector was composed of several facilities, with a total of 28 facilities. (For instance, ‘Education’ included the four following facilities: primary school, secondary school, university, and other kind of education premises. See detailed list per sector in box 1.)

Box 1

Sectors and subsectors included in the evaluation of the laws

  • Health and social care facilities:

    • General healthcare facilities, which include hospitals and primary care buildings

    • Mental health facilities, which are divided into three categories according to the service provided:

      • long stay

      • short stay/acute attention

      • ambulatory

    • Nursing health facilities, which are divided into three categories according to the service provided:

      • long stay

      • short stay/acute attention

      • ambulatory

    • Health vehicles services, if not regulated under the general transportation regulations

  • Education

    • Primary school

    • Secondary school

    • University

    • Other kind of education premises

  • Public places

    • Cultural facilities, such as cinemas, theatres

    • Recreational facilities, such as arcades, playing grounds

    • Commercial/shopping facilities, such as shopping malls

    • Sports facilities, such as stadia

    • Other public places (including streets, beaches, parks, ATMs, phone booths, and so on)

  • Workplaces

    • Governmental offices and facilities

    • Ministry of Health, if not included under governmental facilities regulations

    • Non-governmental offices

    • Non-governmental manufacturing facilities

    • Prisons and correctional facilities

  • Hospitality sector

    • Mainly food-catering/serving businesses, such as restaurants and cafeterias

    • Mainly beverage-serving businesses, such as pubs, bars and nightclubs

    • Mainly non-institutionalized temporary residential facilities, such as hotels, motels and inns

    • Mainly gaming facilities, such as casinos and bingos

  • Public transportation

    • Vehicles for collective or individual public transportation (such as, buses, taxis, aircraft)

    • Trains

    • Ships

    • Transportation terminals and transportation-related facilities, such as stations, stops and railways (bus stations, bus stops and airports)

After this evaluation process, the research team created an algorithm to allocate the theoretical level of protection provided by each law after following the ruling characteristics of the laws.

The algorithm allocated seven indoor levels of protection (0=absence of protection; 1=allow smoking under certain conditions without designated and/or ventilated areas prescribed; 2=allow smoking under certain conditions with designated and/or ventilation areas prescribed; 3=allow smoking if designated and ventilated areas are both prescribed; 4=allow smoking if ventilated area is prescribed; 5=allow smoking if designated area is prescribed; 6=100% smokefree without exceptions). The algorithm flow process for arriving at each level of protection is detailed in figure 1.

The process of evaluating the laws was carried out by three trained research members (CM, GR and CB) to ensure the correct usage of the evaluation instrument. The three experts were from Spain, the UK and Germany. The evaluation process was conducted from July 2011 to October 2011. The laws were assessed independently by two researchers. Any inconsistencies found were reviewed by the third expert. In some cases due to the complexity of the laws and because they were translated into English, it was necessary to contact the key tobacco control lead of each of the countries to make the final consensus decision. First, the evaluation provided information on the level of protection offered in each sector by the law, and after gathering these data algorithm implementation was applied separately by two members of the evaluation team to avoid mutual influences. After this stage, the data were compared. The level of protection by using the algorithm was conducted between January and March 2012.

To analyse the data we calculated percentages and 95% CIs for each of the four group characteristics of the smokefree legislation—comprehensively smokefree (or smokefree without any exception); smoking allowed in enclosed areas; ventilated; or other conditions specified in the law—for each of the six main sectors and 28 facilities preselected for the study. In addition, we calculated medians and IQRs for the results obtained by each sector, and the percentages and 95% CIs for each level of protection provided after running the algorithm evaluation for each sector.

Results

Description of the sample

Using study inclusion criteria, relevant laws were identified for 48 of the 53 WHO European Region countries. Of those 48 countries, 44 had signed the WHO FCTC and 42 had passed new smokefree legislation from 2005 to October 2011 (when the study finished). From the 48 countries, we assessed 68 laws, as Germany has 16 federal laws which cover all the sectors except for workplaces, public transport and national facilities (ruled by a national law). Additionally, the UK has separate legislation for each of its countries (England, Northern Ireland, Scotland and Wales). This means that the overall number of laws evaluated was different for each sector. The numbers of laws assessed were 66 for the health and social care sector; 66 laws for the education sector; for the public places sector, 67 laws for governmental facilities, 66 for recreational facilities, commercial/shopping facilities, and sports facilities, 51 for workplaces including offices and manufacturing facilities, and 65 for prisons; 66 laws for the hospitality sector; and 51 laws for the public transportation sector (see table 1).

Table 1

Percentage of laws that rule 100% smokefree without any exception (Q1)

Overall results: level of protection among the 28 sectors by country

Across all 48 countries, there were 1758 sectors studied through the assessment of 68 laws (as mentioned above, the numbers of sectors assessed were different than expected (28 sectors×68 laws=1904) because not all countries had the same number of laws; for example, Germany had 16 regional and 2 national laws). Of these, 706 sectors (40.8%) comprehensively protected people from indoor smoking and 769 (44.9%) regulated the sector but included the possibility of smoking in designated closed and/or ventilated rooms with or without other circumstances (see online supplementary table S1).

None of the 48 countries prohibited smoking in the 28 sectors assessed. However, seven countries (Cyprus, Greece, Malta, Slovakia, Spain, Tajikistan and Former Yugoslavia) presented laws that completely protected ≥80% of their sectors from SHS. In addition, six other countries (Albania, Lithuania, Luxemburg, Slovenia, Turkey, UK (England, North Ireland, Scotland and Wales)) presented laws that protected 65–80% of the 28 sectors.

Smoking restrictions by sectors

Table 1 summarises the percentage of laws in the WHO European Region which provide 100% smokefree environment without any exception (Q1). Table 2 provides information about the circumstances under which these laws prescribe smoking: provision of restricted areas (Q2), and/or ventilation conditions (Q3), and/or other circumstances or conditions (Q4).

Table 2

Percentage of laws that allow smoking in restricted areas (Q2), allow smoking under ventilated conditions (Q3) and allow smoking under other circumstances or conditions (Q4)

From the 66 laws evaluated in the healthcare sector, 50% of laws gave complete protection in general health facilities (Q1, table 1). WHO European Regions’ laws were less protective in providing SHS environments in other types of health services, such as mental health, nursing and social health facilities. Among these facilities, 62.1–63.6% of the laws allowed smoking. Of these, about 87.8–95.1% were under restricted area conditions (Q2), 36.6–39.0% under ventilation conditions (Q3) and 68.8–70.8% under other circumstances (Q4) (table 2). In this case, 18 laws permitted smoking in general health, mental health and nursing home facilities to patients and/or personnel under medical approval and/or under individual use of the premise (data not shown).

In the education sector, 86.4% (55/66) of the laws provided comprehensive smokefree legislation (table 1) in primary schools, 83.3% in secondary schools, 65.2% in universities and 77.3% in other school facilities. About 32.0% of the laws allowed smoking in universities in restricted areas (Q2), 55.5% with ventilation (Q3) and 52.3% under other conditions (Q4), such as at the discretion of an authority or at certain times (data not shown).

In the public places sector, 41.8% (28/67) of the laws completely prohibit smoking in governmental facilities (Q1). Of the 39 laws in which smoking was allowed, 87.2% included restricted areas (Q2), 35.9% ventilated areas (Q3) and 71.8% other conditions (Q4). The facilities with the weakest protection were prisons: about 40.0% (25/65) of the laws did not provide any kind of regulation in this sector and 55.4% (36/65) allowed smoking as follows: enclosed (88.9% or 33/36), ventilation (22.2% or 8/36) or other conditions (72.2% or 26/36). Some of the most frequent conditions under which smoking was allowed in prisons were providing collective areas for smoking (15/26 laws ruled this condition), allowing areas for individual use (15/26 laws), and at the discretion of an authority (6/26 laws) (data not shown).

In the hospitality sector, 25.8% (17/66) of the laws completely prohibit smoking (Q1) in restaurants and cafeterias. Thus, 71.2% (47/66) of the laws allowed smoking in restaurants and cafeterias and 3% did not have any regulations (Q1). Of the laws that permitted smoking, 76.6% (36/47) allocated a specific area (Q2), 27.6% (13/47) asked for ventilation requirements (Q3) and/or 72.3% (34/47) included other conditions (Q4). The most frequent conditions (Q4) were to reserve a minimum/maximum area or a proportion of the venue for smoking (23/34 laws had this condition), allow smoking according to the size of the venue (17/34 laws), allow smoking as long as minors are not present (10/34 laws), prohibit smoking in venues where food is served (6/34 laws), and allow smoking during performances (3/34 laws) (data not shown).

About 24.2% (16/66) of the laws completely prohibit smoking (Q1) in pubs, bars and nightclubs, and only 6.1% in hotels (4/66). About 36.4% (24/66) of the laws did not cover any kind of smoking in hotels. The laws that permitted smoking under certain conditions ruled that a minimum area of the hotel should be reserved for smokers (10/38 laws).

Overall, 72.5% of laws prohibited smoking in public vehicles (Q1); however, a lower percentage of laws did so in trains (60.8%), ships (51.0%) and stations (54.9%). In these facilities, smoking was allowed mainly under other conditions (80.0% of laws for ships and 64.7% of laws for stations). For example, smoking was permitted in some of the structures of the vehicle or in a specific area of the vehicle (data not shown).

Level of protection according to the WHO guideline (2007)

The seven levels of protection according to the algorithm are presented in table 3 for each sector and type of facility. Median scores across the items ranged from 2 to 6. From the 28 facilities described, 10 had a median of 6 (100% smokefree without exceptions); these were general health facilities, all facilities included in the education sector, shopping and sports facilities, and public vehicles including trains, ships and stations.

Table 3

Level of protection according to the WHO guideline (2007)

Health ministries, cultural, governmental, recreational, offices and manufacturing facilities obtained a median score of 3 in the level of protection, ranging from 2 to 6. Ten sectors (covering mental health, nursing homes, social facilities, prisons and hospitality facilities) had a median of 2, ranging from 2 to 6.

Laws provided a higher level of protection in the education sector. Thus, 68.2–86.4% of the laws ruled smokefree environments without exception or level 6 (see table 3). In the same sector, 9.1–16.7% of the laws allowed smoking under certain conditions, where designated and/or ventilated areas were provided (level 2).

In the healthcare sector 50% of the laws prescribed a total ban without exception (level 6) for the general health facilities and about 39.4% of the laws allowed smoking under condition 2 (smoking is permitted under certain conditions with designated and/or ventilated areas). In mental health long stay facilities, 4.5% of laws prescribed total protection (level 6) and in short stay facilities the proportion was 6.1%. In addition, in mental health facilities, 21.2% of the laws allowed smoking in designated areas (level 5), 10.6% allowed smoking under certain conditions with designated and/or ventilated areas (level 2), and 43.9% allowed smoking under certain conditions without designated and/or ventilated areas (level 1).

In the public places sector, 40% of the laws provided a level of protection of 6, except in prisons (about 40% of the laws did not provide regulations and 36.9% provided level 2 protection). Also, 30% of the laws did not cover recreational facilities, and 24.2% did not cover shopping facilities. In offices and manufacturing facilities, about 30% of the laws provided level 2 protection.

In the transport sector, 73% of WHO European Region laws completely protected public vehicles (level 6). However, only 6.1% of the laws provided level 6 protection in restaurants and 7.6% in bars. Therefore, about 50% of the laws prescribed level 2 protection in bars and 7.6% gave no protection (level 0), permitting smoking everywhere in these facilities.

Additionally, 36.4% of the laws did not mention bans or regulations for hotels and 34.8% provided level 2 protection.

Discussion

This study provides evidence of the level of compliance of FCTC recommendations to provide comprehensive smokefree laws among countries belonging to the WHO European Region.

Although some sectors such as education and public transport theoretically provide good levels of protection from SHS, many laws fail to protect the population from the hazards of tobacco smoke, despite having ratified the FCTC.

This study demonstrates the extent to which ‘comprehensive smokefree legislation’ needs to be improved in country members of the WHO European Region. Consequently, policies to strengthen the level of protection in some sectors need to be implemented.

In this paper, we interpret ‘comprehensive smokefree legislation’ as laws that do not allow smoking rooms, do not allow ventilated areas and/or do not include any kind of conditions under which smoking is permitted, in line with WHO policy recommendations for SHS protection. Currently, 28 countries in the world have comprehensive policies in place covering 100% of all non-hospitality workplaces, bars and restaurants.21 Within the WHO European Region, 16 laws corresponding to 13 countries provide comprehensive protection, by eliminating separation and ventilation law conditions, which have been demonstrated to not eliminate the health risks posed by SHS.22 ,23 This means that in the hospitality sector more effort needs to be made. However, we note that the tobacco industry has tried to undermine legislation and insert wording under which partial bans could be introduced.24–26

WHO calls on all countries not to ratify and to fully implement the evidence-based measures included in the FCTC. Legislation is the first step and enforcement is vital to ensure effectiveness.26 ,27 This study highlights the need for the WHO European countries to adopt simpler legislation with no exceptions. The research presented here can influence policymakers to adopt comprehensive smokefree policies in the diverse sectors studied. Healthcare advocates and researchers should not overlook the tobacco industry's interest in obstructing smokefree policies and take them into consideration when fighting for new legislation.28

According to the WHO report on mortality attributable to tobacco (2011), 16% of deaths among adults aged 30 and over were attributed to tobacco in European countries and 7% in Eastern Mediterranean countries.20 This difference in mortality is due to Northern and Western European countries using tobacco for a longer period of time. Smokefree legislation is one of the most effective measures to tackle the tobacco epidemic; these laws are different from other policies because their main action is to protect non-smokers and denormalise tobacco among the overall population.

The wording of smokefree legislation must be straightforward, avoiding complicated language and refraining from any kind of exception that could prevent the legislation from providing comprehensive smokefree environments.24 ,29 ,30 We consider that reviewing smokefree legislation may be an effective strategy to prevent tobacco industry tactics in obstructing legislation. If the wording is clear, the opportunity to evade legislation will decrease. The implementation and enforcement of smokefree legislation should follow the concept of ‘policy coherence’ as defined by Lanzalaco: ‘process through which governments make efforts to design policies that take account of interest of other policies communities, minimise conflicts, maximise synergies and avoid unintended incoherence’.31 The Americans for Nonsmokers’ Rights Association gives a common list of mistakes in drafting smokefree indoor legislation that have been detected in this research, such as, allowing smoking in private rooms, restricting smoking to specified places, or allowing smoking as long as minors are not present.32

Policy coherence must be continually evaluated and, in consequence, new challenges will need to be faced. First, to regulate all kinds of tobacco products through legislation, including smoked products such as waterpipes, cigars, etc, and non-smoked products such as snus, e-cigarettes etc.33 Second, to restrict smoking in some public outdoor spaces as recommended by the WHO smokefree guidelines. US hospitals34 and Spanish hospitals35 have been leaders in implementing smokefree outdoor hospital grounds. So far, we have focused on indoor smoking ban policies. It is time to broaden the scope to more restrictive outdoors policies, especially in countries where public socialisation mainly occurs in outdoor areas, such as stadiums, parks, playgrounds, etc. Third, to avoid social clubs or other new types of venues where smoking could be permitted.36

There are some limitations of this study. First, the analysis does not include all national/regional smokefree WHO European Region laws. However, we gathered information from 48 countries out of 53, which represents a total coverage of 90.5%. Second, the law assessment analysis may reflect instrumental bias. However, the instrument was tested in a previous study and a review by two researchers made it more accurate. Despite these reservations, the study also has some strengths. It presents a new methodology to describe laws and estimate levels of protection according to the 2007 WHO guideline. The algorithm permits the detection of threats to legislation that could prevent complete SHS protection. This tool might be useful in detecting legal wording clauses that should be avoided to provide 100% smokefree environments.

Nine years after the adoption of the WHO FCTC we are able to identify some barriers to and challenges for complete protection from SHS through legislation. The main barriers recognised here are legal formulas through which smoking is still allowed in public places, and the high number of laws in the WHO European Region which allow smoking in designated areas, ventilated areas, and under other conditions. Finally, we have identified some challenges for the future, such as deterring misleading clauses in laws, and broadening the scope of protection from SHS by prohibiting tobacco consumption in some outdoor public places, such as parks, beaches, etc. We firmly believe that the detailed assessment of smokefree legislation proposed here can provide an important contribution to tobacco control and public health in the future, helping to improve legislation and increase the number of countries with 100% smokefree environments.

What this paper adds

  • This is the first study to assess the theoretical level of protection provided by the laws in countries of the WHO European Region.

  • This study presents a new methodology to describe laws and estimate levels of protection according to the 2007 WHO guideline.

  • The algorithm proposed permits the detection of threats that could prevent comprehensive secondhand smoke (SHS) protection.

  • This tool is useful to detect legal clauses that should be avoided to provide 100% smokefree environments.

  • Many national/regional laws from the WHO European Region include clauses which permit smoking in designated areas, ventilated areas and under other conditions.

  • Countries belonging to the WHO European Region might not protect 100% of their citizens from SHS and, consequently, their legislation must be strengthened.

Acknowledgments

The authors would like to especially thank Armando Peruga (Chair of the TFI at WHO) for providing expert counselling during the conceptual and assessment work on this research and facilitating access to the data. In addition, the authors express their gratitude to the ENSP Chair and member representatives for their contribution in facilitating information. Finally, the authors express their gratitude to Dr Joseph Guydish for his careful revision of the manuscript.

References

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