We agree with the authors of this letter that closing the gap between
the smoking prevalence in Indigenous and other Australians is possible,
but we do not agree how this is most likely to be achieved.
Many health clinics in remote Indigenous communities in Australia are
better at providing brief advice than is implied by the authors. An audit
of records in 56 health clinics found that 43% of diabetics and 25% th...
We agree with the authors of this letter that closing the gap between
the smoking prevalence in Indigenous and other Australians is possible,
but we do not agree how this is most likely to be achieved.
Many health clinics in remote Indigenous communities in Australia are
better at providing brief advice than is implied by the authors. An audit
of records in 56 health clinics found that 43% of diabetics and 25% those
with no chronic disease had had smoking brief advice in the last six
months (Bailie, R. 2009, pers.comm. 4 August) Nevertheless, more
intensive counseling is only very poorly available, but is only slightly
more effective than brief advice.[1] We agree that it is daft that
nicotine replacement therapy and other cessation pharmacotherapies have
been less available than other medicines regularly dispensed by these
clinics, when they have been shown to be more cost-effective.[2]
However, concentrating on improving cessation services, as they
suggest, will not make much impact on the high prevalence of Indigenous
smoking. The finding that 76% of their sample had quit or attempted to
quit without any interaction with medical cessation services, is not an
indictment of the poor availability of cessation services, but evidence of
Indigenous smokers quitting in ways similar to all other populations: by
themselves, without medical assistance.[3] This figure is unlikely to
change greatly, even with improved access to cessation services.
The absence of cues to quit and the omnipresence of cues to smoke in
these Indigenous communities is not just an impediment to the success of
cessation services. Instead, this is where most of our attention should
now be focused: by improving Indigenous exposure to well-researched
graphic media campaigns, to smokefree public and private spaces, and to
advocacy about the harms of smoking. Increased levels of these
population health activities, and increased taxation (and cigarette
prices), have been associated with the steepest declines in the prevalence
of smoking in the total Australian population,[4] and have the most
potential to quickly reduce Indigenous smoking.
No conflict of interest
References
1. Stead LF, Bergson G, Lancaster T. Physician advice for smoking
cessation. Cochrane Database of Systematic Reviews 2008;Issue 2:Art. No.:
CD000165. DOI: 10.1002/14651858.CD000165.pub3.
2. Bertram MY, Lim SS, Wallace AL, Vos T. Costs and benefits of
smoking cessatioin aids: making a case for public reimbursement of
nicotine replacement therapy in Australia. Tob Control 2007;16:255-260.
3. Chapman S. The inverse impact law of smokign cessation. Lancet
2009;373:702-3.
4. Winstanley M, White V. Trends in the prevalence of smoking. In:
Scollo MM, Winstanley MH, editors. Tobacco in Australia: Facts and issues.
Third Edition. Melbourne: Cancer Council Victoria, 2008. Available at
www.tobaccoinaustralia.org.au (accessed 4 August 2009).
In our study in remote Indigenous communities in Arnhem Land we have
now interviewed 305 smokers. Of these, 181 had quit intentions and 37
were trying to quit at the time of interview. The effectiveness of more
intensive support compared with brief advice has not been evaluated in
these populations. However, the need for more intensive support is
highlighted in smokers’ own words, for example:
In our study in remote Indigenous communities in Arnhem Land we have
now interviewed 305 smokers. Of these, 181 had quit intentions and 37
were trying to quit at the time of interview. The effectiveness of more
intensive support compared with brief advice has not been evaluated in
these populations. However, the need for more intensive support is
highlighted in smokers’ own words, for example:
“I’m trying to find a way.”
and
“I can’t do it on my own.”
In our survey, smokers and non-smokers alike called for more
intensive community-based support for smokers to quit, for example:
“… form support groups ….. away from the clinic because they are too
busy doing other djama [work].”
and
“… we need house to house education, every house, clan by clan …”
Our research is trialing interventions that are not limited to quit
support. We agree with Thomas and Johnston that population-level
interventions have been associated with the steepest declines in smoking
prevalence in Australia generally. For Indigenous Australians, especially
those living in remote communities, it is not yet known if such smoking
reduction initiatives can work. High smoking rates that have not changed
in 20 years is evidence that impacts of wider initiatives have not been
felt in remote communities.
The authors’ response to my comments fails to disqualify my
criticism. A large part of their response consists of a misinterpretation
of some of my points. This appears to be due to confusion about
terminology. Unfortunately, terminology practices are not as perfectly
unequivocal as would be desirable. If the authors had been well enough
familiar with the international scientific literature in this field, they
should ha...
The authors’ response to my comments fails to disqualify my
criticism. A large part of their response consists of a misinterpretation
of some of my points. This appears to be due to confusion about
terminology. Unfortunately, terminology practices are not as perfectly
unequivocal as would be desirable. If the authors had been well enough
familiar with the international scientific literature in this field, they
should have noticed that the phrase “quit rate” is used with different
meaning in different settings. An instructive note on the terminology
situation is found in the pertinent WHO guidelines [1]. After defining
“prevalence of cessation”, the guidelines say (I quote from page 80):
<<Other terms, such as the “quit rate”, the “quit index”, or the
“quit ratio”, have also been used to describe this or a similar
measure.>>
I had questioned the validity of the authors’ indication of rate of
quitting during one year in their study, since the possibility of
remaining relapses was not considered. This can have inflated the
registered rate of quitting, and the likelihood of such a risk appears to
be strengthened by my observation that in the same period the nationwide
decrease in smoking prevalence (mainly due to cessation of smoking) was
quite a bit lower.
I had also questioned an entirely different part of the original
article, the comparison between cessation practices in the US and in
Sweden. While the authors had no real basis at all for such a comparison,
I just presented easily understandable evidence in terms of figures for
“prevalence of cessation” in these two countries. When I thereby used the
denominator phrase “quit rate” (cf above), I started with a perfectly
clear, explicit definition of the meaning that I attached to that phrase
(ratio between ex-smokers and ever-smokers), so there is no justification
for the kind of misinterpretation brought forward in the authors’
response.
In their response the authors say: “The way that Ramstrom placed all
his confidence in a single factor explanation without making an effort to
rule out other strong alternative explanations strikes us as rather
unscientific.” But there is no ground whatsoever for this statement,
neither in my comments, nor in any other publication of mine. I have
always been very careful to point out that the effect snus use in Sweden
is just one of several factors contributing to the Swedish success in
reducing smoking and smoking-related diseases. The authors’ procedure to
groundlessly attribute a blameworthy opinion/behaviour to a counterpart in
a scientific discussion, that is indeed ‘unscientific’.
As I said in the introduction to my original comments, the Zhu et al
article did raise a number of interesting questions. And, beside the
weaknesses that I have looked at, it did contain good points as well. But,
I still find the final conclusion too pessimistic as far as the possibly
positive role of low-toxicity smokeless tobacco is concerned.
Reference:
World Health Organization. Guidelines for controlling and monitoring
the tobacco epidemic. World Health Organization. Geneva, 1998. ISBN 92 4
154508 9.
In "Tobacco-related disease mortality among men who switched from
cigarettes to spit tobacco" Tob Control 2007; 16: 22-28, Henley, et al
compared mortality rates for smokers who switched to spit tobacco to the
rates for those who quit all forms of tobacco. This is useful
information. However, the fact that the number of smokers in the US has
remained relatively unchanged for the past 20 years tells us that there
are t...
In "Tobacco-related disease mortality among men who switched from
cigarettes to spit tobacco" Tob Control 2007; 16: 22-28, Henley, et al
compared mortality rates for smokers who switched to spit tobacco to the
rates for those who quit all forms of tobacco. This is useful
information. However, the fact that the number of smokers in the US has
remained relatively unchanged for the past 20 years tells us that there
are tens of millions of smokers who cannot or will not overcome their
dependence on nicotine. Thus, it is vital for tobacco policy makers to
establish viable harm-reduction plans. Was there mortality data collected
on the group who continued smoking? If so, it would be very useful for
the authors to publish a follow-up article that compares the mortality
rates for switchers to the rates of those who continued smoking.
Innovative opportunities and strategies should be considered for
reducing the harm of tobacco in the 21st century. Since the mid 20th
century, governmental approaches have evolved from a laissez-faire
attitude to active NIH funding for tobacco research, aggressive promotion
of nonsmoking environments and, now, congressionally mandated regulation
of the tobacco industry. The tobacco industry itself has also evolved
fro...
Innovative opportunities and strategies should be considered for
reducing the harm of tobacco in the 21st century. Since the mid 20th
century, governmental approaches have evolved from a laissez-faire
attitude to active NIH funding for tobacco research, aggressive promotion
of nonsmoking environments and, now, congressionally mandated regulation
of the tobacco industry. The tobacco industry itself has also evolved
from the mid 20th century position denying tobacco-induced harm, to the
current disclosure of health risks and a remarkable amount of support from
some segments of the industry for both smoking prevention and cessation
efforts.
Responding to these developments, over the last several years a
growing community of scientists has been working with progressive elements
within the tobacco industry to encourage efforts at cessation and harm
reduction. With appropriate safeguards, the use of tobacco industry
funding, like the use of tobacco taxes and tobacco settlement proceeds,
can substantially add to the magnitude of research and outreach efforts
intended to reduce tobacco-induced death and disease. However, in
accepting tobacco industry funding, some of us have been exposed to
unwarranted attacks from colleagues in tobacco control, who refuse to
accept the possibility of appropriate relationships between these
progressive elements and members of the scientific community.
While working toward a world without cigarettes, these colleagues
appear to be more comfortable if tobacco companies put all of their
resources into selling cigarettes, and do nothing positive to counteract
the adverse health effects of smoking through the funding of smoking
cessation research. In this black-or-white, good-or-evil, worldview,
staunch anti-tobacco company campaigners could see themselves as champions
of goodness. However, the real world, which allows tobacco companies to
support valid research efforts, offers more true hope of saving countless
lives lost to diseases caused by smoking.
A recent editorial by Malone and Smith (1) presents an attack on a
study that we conducted at Duke University. This study aimed to evaluate
the efficacy of the Philip Morris USA QuitAssist website, and was part of
an overall project that also included a randomized controlled trial of the
efficacy of the QuitAssist website relative to other smoking cessation
support interventions. The straightforward question being asked by this
survey of researchers in the tobacco control field was "Do you think the
approach of the QuitAssist website is useful for helping people quit
smoking or not?” A copy of the invitation to potential participants and
the study protocol are available on our website (http://www.cnscr.org).
The reader is particularly encouraged to read the invitation. Our
institutional review board approved this research study, and required the
normal confidentiality stipulation, as in all human subjects research,
that the participants’ anonymity should be assured (cf. Declaration of
Helsinki, http://www.wma.net/e/policy/pdf/17c.pdf). If we had denied our
participants confidentiality, and they were subsequently subjected to
abusive attacks in editorials such as the recent one by Malone and Smith,
we would have failed to protect the rights of these volunteers. However,
Malone and Smith take this requirement of confidentiality and twist it, to
label it as “unethical.” Further, Malone and Smith distort the disclosure
of and transparency about the funding for this project, coining the term
“deceptive transparency,” which is obviously a contradiction in terms.
We believe that many tobacco control researchers should welcome the
opportunity to provide their candid comments concerning the Philip Morris
USA QuitAssist website. These comments could run the full gamut from
positive to negative or disapproving. Indeed, any reasoned answers will
be useful in determining how best to proceed to help smokers quit. Our
field should take care not to stifle free scientific inquiry as was done
for many years by elements of the tobacco industry.
Malone and Smith assert that participation in this effort will cause
tobacco control advocates to “wonder about one another,” and question each
other’s loyalty, thus “driving a wedge into the tobacco control
community.” However, by maligning the integrity of ethical researchers,
such as by depicting legitimate participant recruitment efforts as
“phishing,” they themselves drive a wedge into the broader 21st century
tobacco control community. Although the historical origins of their
suspicions of tobacco industry sponsored research are quite
understandable, Malone and Smith should also consider the history of our
research program, and the progress it has made in tobacco addiction
treatment.
Indeed, our center has a long and accomplished track record of
progress in this area. In addition to having contributed significantly to
the inception of the nicotine patch (2), which has been an important tool
to aid smoking cessation, our research (3) has also contributed to the
development of Chantix, another potent smoking cessation treatment (4).
Our center is currently supported from a variety of sources,
including a grant from Philip Morris USA unequivocally dedicated to
advancing smoking cessation treatment. The provisions of the funding
agreement with Philip Morris USA (as with funding for the QuitAssist
evaluation) explicitly deny the company any control over the design or
execution of the research, and allow us complete publication freedom (see
http://www.cnscr.org). Recent accomplishments emerging from our research
program, aided by this support, include the following significant strides
toward improving smoking cessation treatment effectiveness:
1) Developing a new dosing regimen for NRT that doubles smoking
abstinence rates (5);
2) Inventing a novel form of NRT that promises to be more effective
than current forms (6), and proceeding through the FDA review process;
3) Conducting preclinical studies to screen and identify promising
new smoking cessation treatments (7);
4) Identifying genetic variants that predict smoking cessation
outcome (8), which may ultimately be used to tailor treatment, providing
the most effective treatment approach for a given smoker;
5) Initiating studies of adaptive treatment strategies (9), which
modify treatment if early indicators of therapeutic response indicate an
initial treatment is not likely to succeed.
In conclusion, we believe that if Malone and Smith had done their
homework more carefully, they might have learned about the actual results
of our research efforts, their implications for tobacco cessation and harm
reduction, and the careful ways in which we have tried to integrate
support from progressive aspects of tobacco companies, including assisting
cessation and harm reduction efforts of the companies themselves. We, and
like-minded 21st century thinkers, strive to continue to promote public
health, utilizing government as well as industry support to accomplish
this mission.
Sincerely,
Jed E. Rose, Ph.D.
Director, Center for Nicotine and Smoking Cessation Research, Duke
University Medical Center
Funding: The study described was funded by a grant from Philip
Morris USA, with explicit provisions allowing free publication of any
results, favorable or unfavorable.
Competing interest: The author is PI on grants funded by Philip
Morris USA, with provisions protecting independent design, conduct and
publication of studies. He is also named as an inventor on patent
applications dealing with agonist-antagonist treatments, novel nicotine
delivery systems and genetic predictors of smoking cessation treatment
outcome.
References
1. Malone RE, Smith EA. Contact me soon!! Confidential, risk-free
opportunity! Tob Control 2009; 18:249.
2. Rose JE, Herskovic JE, Trilling Y and Jarvik ME. Transdermal
nicotine reduces cigarette craving and nicotine preference. Clin Pharm
Ther 1985; 38:450-456.
3. Rose JE, Levin ED. Concurrent agonist-antagonist administration
for the analysis and treatment of drug dependence. Pharmacol Biochem
Behav 1991; 41: 219-226.
4. Coe JW, et al. Varenicline: An alpha4beta2 nicotinic receptor
partial agonist for smoking cessation. J Med Chem 2005; 48: 3474–3477.
5. Rose JE, Herskovic JE, Behm FM,Westman EC. Pre-cessation
treatment with nicotine patch significantly increases abstinence rates
relative to conventional treatment. Nicotine & Tobacco Research 2009;
11:1067-1075.
6. Rose JE, Rose SD, Turner JE, Murugesan T. Device and method for
delivery of a medicament. International Patent application No.
PCT/US2008/058122.
7. Levin ED, Slade S, Johnson M, Petro A, Horton K, Williams P,
Rezvani AH, Rose JE. Ketanserin, a 5-HT2 antagonist, decreases nicotine
self-administration in rats. Eur J Pharmacol 2008; doi:
10.1016/j.ejphar.2008.10.016.
8. Uhl GR, Liu QR, Drgon T, Johnson C, Walther D, Rose JE. Molecular
genetics of nicotine dependence and abstinence: whole genome association
using 520,000 SNPs. BMC Genetics 2007; 8:10-20.
9. Murphy SA, Collins LM, and Rush AJ. Customizing Treatment to the
Patient: Adaptive Treatment Strategies. Drug Alcohol Depend 2007; 88(Suppl
2): S1–S3.
Dr. Rose responds that the offer of confidentiality was made in
accordance with standard institutional review board procedure for human
subjects research. However, the email to which the editorial refers
offered me $1000 to act as an “expert consultant,” not as a research
subject. If its intention was to recruit me as a research subject, the
email was even less transparent than I gave it credit for.
We read the recent paper on the effects of the school-based smoking
prevention program "Mission TNT.06" in Canada with interest [1]. The
authors address an often neglected but nonetheless very important subject:
The question of potential negative side effects of interventions that try
to denormalize smoking in the classroom. To our knowledge, it is the first
study outside Europe evaluating a school-based smoking prevention...
We read the recent paper on the effects of the school-based smoking
prevention program "Mission TNT.06" in Canada with interest [1]. The
authors address an often neglected but nonetheless very important subject:
The question of potential negative side effects of interventions that try
to denormalize smoking in the classroom. To our knowledge, it is the first
study outside Europe evaluating a school-based smoking prevention program
based on contract management in which classes decide to be smokefree for a
given period of time and successful classes are awarded with prizes in a
lottery.
Kairouz and colleagues come to a very strong summarizing conclusion:
"Mission TNT.06 may encourage young smokers to misreport their smoking
status and to marginalize classmates who smoke." After reading the
complete paper we were, however, not convinced that this strong conclusion
really represents an appropriate interpretation of the data.
As we followed our Canadian colleagues they measured marginalization
of classmates who smoke with the following two items: "If you knew that
someone in your class smoked cigarettes, would you think that ... (i)
people should not hang out with him/her; and (ii) you should not be
friends with him/her".
First, this does not feel to us like a real measure of
marginalization, but a measure of general attitudes towards smoking peers.
Showing that endorsement to these statements decreases less over time in
the intervention than in the control group seems to be chiefly an
indicator that the intervention has changed students' attitudes towards
smoking people. Is this in any way a surprising (or unwanted) result? If
you - as a young student - learn that smoking is a dangerous and risky
behavior, isn't it very likely that this will change the way you see and
judge smoking people? Would we really assume (or want) the students to
answer the two questions independent of intervention status? Anyway, no
other attitudes towards smoking were assessed, so it is impossible to
further validate the assumption of the authors.
Second, even if you interpret the statements literally, for really
judging potential adverse effects of an intervention we need observations
of adverse behaviors (or at least proxys of these like behavioral self-
reports). A recently conducted study that assessed negative behaviors in
class (i.e., bullying) did not find iatrogenic effects of a contract
management intervention. In fact, if bullying was actually reported in
classes: It was more often the smokers that bullied [2]!
Kairouz et al. [1] report another observation. They found a
considerable number of students who reported lifetime smoking at baseline
- at least just a puff - but indicated that they have never smoked at
follow-up. The percentage of such reporting was higher in the intervention
compared to the control group. What could be possible explanations for
this difference? Kairouz et al. offer the interpretation that this
difference is due to a higher tendency for cheating and concealing smoking
in the intervention classes since these pupils' wish to increase the
chance of their class to win a prize. At first sight, this seems to be a
very plausible explanation: There is a motive for cheating. However,
looking at it in more detail, this interpretation loses ground: Why should
the kids cheat six to 11 months after the end of the competition - when
all prizes have been awarded months ago? Furthermore, lifetime smoking
(before the competition) is not a relevant variable for staying in the
competition or for winning prizes.
Overall we think that Kairouz and colleagues raised important
questions that could stimulate an ethical debate on how far tobacco
control advocates should go in promoting social denormalization of
smoking. However, we have considerable concerns about their way of data
interpretation. As a side note: We guess, at least from the European
perspective, that the overwhelming majority of parents would be very happy
if their kids would say that they aren't hanging around with classmates
who smoke.
References
[1] Kairouz S, O'Loughlin J, Lague J. Adverse effects of a social
contract smoking prevention program for children in Quebec, Canada. Tob
Control 2009; 18: 474-478.
[2] Hanewinkel R, Isensee B, Maruska K, Sargent JD, Morgenstern M.
Denormalising smoking in the classroom: does it cause bullying? J
Epidemiol Community Health 2009; doi:10.1136/jech.2009.089185.
Conflict of Interest:
The authors are involved in the European Smokefree Class Competition since many years.
According to the US Centers for Disease Control and Prevention (CDC),
smoking is the single most preventable cause of disease, disability, and
death in the United States
(http://www.cdc.gov/nccdphp/publications/aag/osh.htm). Each year, an
estimated 443,000 people die prematurely from smoking or exposure to
secondhand smoke, and another 8.6 million have a serious illness caused by
smoking. And as aptly demonstrated by Lee...
According to the US Centers for Disease Control and Prevention (CDC),
smoking is the single most preventable cause of disease, disability, and
death in the United States
(http://www.cdc.gov/nccdphp/publications/aag/osh.htm). Each year, an
estimated 443,000 people die prematurely from smoking or exposure to
secondhand smoke, and another 8.6 million have a serious illness caused by
smoking. And as aptly demonstrated by Lee et al. in Tobacco Use Among
Sexual Minorities in the USA, 1987 to May 2007: A Systematic Review
(Tobacco Control 2009:18), certain specific populations continue to be
disproportionately affected. The meta-analysis documents statistically a
significant higher prevalence of cigarette smoking among sexual minorities
than among the general population. Further, within this group, the review
also reveals evidence of higher cigarette smoking prevalence among
bisexuals, non-college respondents, and black males. Since the existing
literature includes minimal information specific to gender minorities, the
authors did not, however, assess tobacco use among this particular sub-
population and cite this as a limitation. Additionally, little
information was found on the use of tobacco products other than cigarettes
among sexual minorities.
Sexual and gender minorities (SGMs) include lesbians, gay men,
bisexuals, and other persons who do not self-identify as heterosexual;
groups defined by sexual behavior, such as men who have sex with men (MSM)
and women who have sex with women (WSW); and gender minorities (i.e.,
persons who do not identify with the gender usually associated with the
assigned sex at birth), such as transgender male-to-female or female-to-
male. CDC funds efforts by the Lesbian, Gay, Bisexual, and Transgender
Tobacco Control Network (http://www.lgbttobacco.org/), a network aimed at
raising awareness about the especially high rates of tobacco use among
SGMs, and conducts activities to reduce SGM tobacco use prevalence.
As with other historically hard-to-reach populations, SGM research is
known to face notable but surmountable methodological challenges. Some
national probability surveys, such as the National Survey of Family Growth
and parts of the National Health and Nutrition Examination Survey--both
conducted by the CDC National Center for Health Statistics--periodically
collect data on sexual orientation (i.e., whether respondents self-
identify as heterosexual or as straight, homosexual or gay, or lesbian,
bisexual, something else, or not sure) but do not ask questions about
gender identity. Likewise, some states have sometimes included questions
on sexual orientation on their CDC-supported Behavioral Risk Factor
Surveillance Survey or Youth Risk Behavior Survey. Survey questions about
sexual behaviors such as MSM and WSW are more commonly found, but again,
this information is not universally collected. And overall, sexual
minority and tobacco use variables are not being consistently defined.
Because of documented higher smoking prevalence among sexual
minorities, CDC supports concerted and sustained efforts to enhance the
methodological rigor of SGM tobacco-related research. To further document
SGM tobacco use disparities, reduce tobacco use initiation, target tobacco
cessation efforts, and monitor progress towards reducing tobacco use
prevalence, routine collection of both sexual and gender minority
demographic data as part of tobacco prevention and control efforts is
needed--using consistent and comparable methodologies and definitions. We
further agree with the authors that there is a need for additional
research to assess reasons for SGM smoking prevalence differences by
studying
-Causes of differences in tobacco initiation (e.g., violence, stress,
discrimination)
-Tobacco use by sexual identity development
-Tobacco use in SGM social spaces
-Barriers among SGMs to tobacco use cessation (e.g., access to care),
and
-The impact of tobacco marketing targeted to SGMs.
Suzanne M. Marks, MPH, MA, Epidemiologist and Chair
CDC/ATSDR Sexual and Gender Minorities Work Group
Heather Ryan, MPH
Health Scientist
CDC Office on Smoking and Health
Bridgette E. Garrett, PhD, MS
Senior Health Scientist, Advisor for Health Disparities
CDC Office on Smoking and Health
We have read with interest the paper by Williams et al.(1) assessing
the prevalence of smoke-free hospital campuses' policies in the United
States. In addition to the data and wise comments in the paper, we want to
share some reflections from Europe. There is general consensus that health
organizations should be an example in developing and implementing tobacco
control policies(2,3). Many hospitals have become tobacco free...
We have read with interest the paper by Williams et al.(1) assessing
the prevalence of smoke-free hospital campuses' policies in the United
States. In addition to the data and wise comments in the paper, we want to
share some reflections from Europe. There is general consensus that health
organizations should be an example in developing and implementing tobacco
control policies(2,3). Many hospitals have become tobacco free by
implementing indoor smoking bans. However, research conducted to evaluate
the impact of smoke-free indoor policies in hospitals shows that the
benefits obtained are lower and slower than in other organizations(4-6).
Thus, when smoking restriction bans are implemented in hospitals, there is
a small decrease in tobacco cessation rates, poor implementation and support
by the employees, and low satisfaction among patients and
visitors(4,7). There are two main hypotheses that could explain this
problem. First, hospitals have provided outside areas
where people go to smoke and this continues in the
absence of out-of-doors bans(8,9). In addition, due to the lack of
systematic smoking cessation interventions, smokers still use those areas
to satisfy their nicotine cravings(6,10,11). Consequently, there is an
intense debate over what a hospital should provide in terms of being
considered a comprehensive tobacco-free organization.
In the 1990s, the paradigm of tobacco-free hospitals was limited to
implementing indoor policies with or without offering tobacco cessation
programs. In this millennium, a new paradigm has emerged: the Tobacco-free Hospital Campus. The rationale is that tobacco-free outdoor spaces set a clear
example of good health practices, providing clear messages to patients,
visitors, and employees that tobacco consumption is dangerous to health and therefore not allowed in all the
grounds of the institution; encouraging them to quit tobacco; and
maintaining a clean and neat environment.
Almost half of the American hospitals surveyed by Williams et al(1)
have adopted a smoke-free campus policy (n= 865). In Europe, approximately
1,400 hospitals have joined the European Network of Tobacco-free Health
Care services (ENSH- Global Network for Tobacco-free Healthcare Services),
but only a few of them have extended the tobacco-free policies to outdoor
places. This extension is vital since healthcare services have an
important role to play in reducing tobacco consumption generally within
society. A professional understanding of addictive diseases treatment and
clinical practice indicates that healthcare services must offer, in
addition to a ban on tobacco use, a systematically integrated tobacco
cessation program that includes motivation and counseling. These are core
elements within the ENSH Code and standards which support the
implementation of Tobacco Free Healthcare Services (http://www.ensh.eu).
Since its creation in 1999, the ENSH has developed a practice based
and continuously evaluated focus on establishing comprehensive tobacco free
policies in hospitals and healthcare facilities. The concept is based on a
10 point European Code which includes tobacco free campuses. Through a
consensus driven procedure, ENSH experts have developed various
implementation tools including an implementation guide for tobacco free
standards in health services, a self-audit questionnaire, and an
accreditation process (www.ensh.eu)
The ENSH is taking valuable steps towards encouraging
the implementation of tobacco free campuses. In May 2009, the German 'Reha
-Zentrum Todtmoos' Hospital was honored with the first Gold Level Award
for having implementing all the ENSH standards, on the basis of a tobacco-
free outdoors. Five other hospitals from Ireland, Spain, and Belgium were also
nominated for the Award.(12) Encouragement of hospital managers to adopt
these policies is a necessity. However, strong support from national
governments, quality agencies, and national and international networks is
required. As organizations that foster tobacco control policies, we need to
find new incentives to stimulate and consolidate this shift, such as
rewards, training, reimbursements and appreciation. In addition,
implementation of tobacco-free hospital campuses needs a careful monitoring
and evaluation of its impact in terms of treatment quality, training
standards, acceptability, observance, and tobacco consumption reduction
among hospital workers and users.
Fortunately, we have two similar overseas strategies that are working
on the same direction. The comparison between these two initiatives could
enrich the knowledge of the effectiveness and efficacy of policies in
different health systems. The opportunity to exchange,
collaborate and learn from this new policy change process in tobacco
control is in our hands.
Cristina Martinez, Esteve Fernandez, Begona Alonso, David Chalom,
Jacques Dumont, Miriam Gunning, Florian Mihaltan, Ann O'Riordan, and
Christa Rustler.
ENSH-Global Network for Tobacco-free Healthcare Services
Corresponding author: E. Fernandez (e-mail:
efernandez@iconcologia.net)
References
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We agree with the authors of this letter that closing the gap between the smoking prevalence in Indigenous and other Australians is possible, but we do not agree how this is most likely to be achieved.
Many health clinics in remote Indigenous communities in Australia are better at providing brief advice than is implied by the authors. An audit of records in 56 health clinics found that 43% of diabetics and 25% th...
In our study in remote Indigenous communities in Arnhem Land we have now interviewed 305 smokers. Of these, 181 had quit intentions and 37 were trying to quit at the time of interview. The effectiveness of more intensive support compared with brief advice has not been evaluated in these populations. However, the need for more intensive support is highlighted in smokers’ own words, for example:
“I’m trying to...
The authors’ response to my comments fails to disqualify my criticism. A large part of their response consists of a misinterpretation of some of my points. This appears to be due to confusion about terminology. Unfortunately, terminology practices are not as perfectly unequivocal as would be desirable. If the authors had been well enough familiar with the international scientific literature in this field, they should ha...
In "Tobacco-related disease mortality among men who switched from cigarettes to spit tobacco" Tob Control 2007; 16: 22-28, Henley, et al compared mortality rates for smokers who switched to spit tobacco to the rates for those who quit all forms of tobacco. This is useful information. However, the fact that the number of smokers in the US has remained relatively unchanged for the past 20 years tells us that there are t...
Innovative opportunities and strategies should be considered for reducing the harm of tobacco in the 21st century. Since the mid 20th century, governmental approaches have evolved from a laissez-faire attitude to active NIH funding for tobacco research, aggressive promotion of nonsmoking environments and, now, congressionally mandated regulation of the tobacco industry. The tobacco industry itself has also evolved fro...
Dr. Rose responds that the offer of confidentiality was made in accordance with standard institutional review board procedure for human subjects research. However, the email to which the editorial refers offered me $1000 to act as an “expert consultant,” not as a research subject. If its intention was to recruit me as a research subject, the email was even less transparent than I gave it credit for.
We read the recent paper on the effects of the school-based smoking prevention program "Mission TNT.06" in Canada with interest [1]. The authors address an often neglected but nonetheless very important subject: The question of potential negative side effects of interventions that try to denormalize smoking in the classroom. To our knowledge, it is the first study outside Europe evaluating a school-based smoking prevention...
According to the US Centers for Disease Control and Prevention (CDC), smoking is the single most preventable cause of disease, disability, and death in the United States (http://www.cdc.gov/nccdphp/publications/aag/osh.htm). Each year, an estimated 443,000 people die prematurely from smoking or exposure to secondhand smoke, and another 8.6 million have a serious illness caused by smoking. And as aptly demonstrated by Lee...
We have read with interest the paper by Williams et al.(1) assessing the prevalence of smoke-free hospital campuses' policies in the United States. In addition to the data and wise comments in the paper, we want to share some reflections from Europe. There is general consensus that health organizations should be an example in developing and implementing tobacco control policies(2,3). Many hospitals have become tobacco free...
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