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Year : 2010  |  Volume : 47  |  Issue : 5  |  Page : 109-210

Abstracts from 14 th World Conference on Tobacco OR Health (WCTOH), March 2009, Mumbai, India

Date of Web Publication9-Jul-2010

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How to cite this article:
. Abstracts from 14 th World Conference on Tobacco OR Health (WCTOH), March 2009, Mumbai, India. Indian J Cancer 2010;47, Suppl S1:109-210

How to cite this URL:
. Abstracts from 14 th World Conference on Tobacco OR Health (WCTOH), March 2009, Mumbai, India. Indian J Cancer [serial online] 2010 [cited 2022 Oct 7];47, Suppl S1:109-210. Available from:

  Bloomberg initiative to reduce global tobacco Use: Initial reports on the economics of tobacco taxation Top

Economics of tobacco taxation in Egypt

Ashraf Saleh, Ashraf Khaled, Khaled Hanafy

Arab Academy for Science, Technology and Maritime Transport, Egypt

E-mail: [email protected]

In Egypt, 5665.4 males per 100,000 population, and 4227.8 females per 100,000 population die because of smoking related diseases. The WHO has identified raising the price of tobacco products by raising tobacco taxes as one of the cost-effective solutions that have been proven to reduce tobacco use. The research aim to explore the nature of tobacco consumption and production in Egypt highlighting its negative economic and health-related impacts, and to provide policy makers with suggestions for tax reforms regarding tobacco taxation in Egypt to ultimately achieve the goal of decreasing tobacco consumption and at the same time raise the government tax revenues. The researchers' estimated the price elasticity of demand for tobacco products to prove that raising taxes on tobacco products will reduce tobacco consumption and at the same time increase the government tax revenues, under the assumption that tax increases will be totally shifted on to consumers as price increases. The expected increases in government revenues can be used to support other tobacco control efforts, alleviate the impact on poor households, and offset any negative economic effects. The study then discusses some suggestions regarding the tax structure. First, setting higher tobacco tax rates to achieve the World Bank's recommendations (2/3-4/5 of retail prices). Second, adopt any system of ad valorem taxation, which enables accounting for inflation where the real value of the tax and the real price of tobacco products will be stable, or maintaining the current excise tax structure with automatic adjustments made with reference to CPI.

Economics of tobacco taxation in Russia and Ukraine

Hana Ross, Samina Shariff, Anna Gilmore

American Cancer Society, United States of America

E-mail: [email protected]

Background: Russia has one of the highest rates of male smoking prevalence in the world with over 60% of adult males smoking. Youth smoking prevalence is also alarmingly high: 47% of young adult males and 36% of young adult females smoke. Tobacco-related diseases are responsible for between 330,000 and 400,000 premature deaths each year contributing substantially to the country's declining life expectancy and population decrease.

Objectives: To analyze an impact of higher tobacco taxes on smoking prevalence, tobacco-related mortality, government tax revenue and economic burden associated with tobacco use.

Methods: Simulation of the impact of alternative tobacco tax increases based on the existing evidence of price elasticity of cigarette demand.

Results: The scheduled tax increases envisioned under the current law are not sufficient to address the large economic burden of smoking in Russia that has been estimated to exceed $25 billion USD, or 3% of GDP a year. The tax level of 50%, 64% and 70% of the cigarette retail price is the only way to curb the tobacco epidemic in Russia with the 70% level yielding the maximum public health and tax revenue gains averting up to 2.7 million tobacco-related deaths and saving at least $3 billion USD just from reducing the productivity lost due to premature tobacco-related mortality.

Conclusions: The Russian public health community should advocate for a sizable tobacco tax increase over the level of general inflation and for earmarking a portion of the tax for public health and health care.

Economics of tobacco taxation in Indonesia

Abdillah Ahsan, Sarah Barber, Sri Moertiningsih Adioetomo, Diahhadi Setyonaluri

Demographic Institute FEUI, Indonesia

Background: Adult smoking prevalence in Indonesia is 34%, and 63% of men smoke while 4.5% of women smoke. Per capita adult tobacco consumption increased by 9.2% between 2001 and 2004. Today, up to one-half of the 57 million smokers in Indonesia will die of tobacco-related illnesses. Given the delay of up to 25 years between the time of smoking uptake and the onset of many chronic diseases, the negative health effects of increases in cigarette consumption are only now being seen.

Objectives: This study aims to systematically review existing studies in tobacco economics to provide a comprehensive report about the economic aspects of tobacco control in Indonesia.

Methods: Study literature and simulation of the health and economic impact of increasing cigarette price in Indonesia.

Results: 1. The current tax rate (37% of sales price) is low compared with the global benchmark of 70%, and the rates are below the maximum allowable by law. 2. Reaching the global benchmark of 70% through a specific, or primarily specific, rather than ad valorem tax, would have the greatest health impact, and could avert between 5.1 and 11.7 million tobacco-related deaths. 3. This increase would contribute Rp 23.8 to 75.8 trillion (US$ 2.6 to 8.3 billion) additional revenue - regardless of reduced sales volumes for cigarettes.

Conclusion: To decrease tobacco use in Indonesia, the government should increase and simplify tobacco tax system.

Economics of tobacco taxation in Vietnam

Nguyen Thi Thu, G. Emmanuel Guindon

Vietnam University of Commerce, Vietnam

E-mail: [email protected]

Background: In Vietnam, non-communicable diseases account for the largest share of mortality and morbidity, for which tobacco use is one of the leading causes. Over 55% of Vietnamese men smoke. Tobacco price increases are the most effective method of reducing tobacco consumption.

Objectives: We document recent trends in tobacco taxes and prices in Vietnam and analyze the impact of higher tobacco taxes on changes in the number of cigarette smokers, premature deaths, and revenues.

Methods: We assessed the direction and magnitude of tobacco product price changes using average prices and price indices from the General Statistics Office of Vietnam. We described the tobacco tax structure from reports and legal texts from the Vietnam Ministry of Justice and reports from the International Monetary Fund. We simulated the impact of tax increases using results from a systematic review of studies with relevance to Vietnam that examine the effect of price increases on tobacco use.

Results: Assuming a mid-range total price elasticity of -0.50, a 10% increase in cigarette prices is expected to reduce the number of smokers by 300 000, avert 100 000 premature deaths and generate VND 3000 million in new tax revenue.

Conclusions: Taxes on manufactured tobacco products should be increased regularly and uniformly across all tobacco types, so that tobacco products become less affordable relative to other goods and services. Taxes must be increased uniformly across all product types to avoid substitution among tobacco products.

Economics of tobacco taxation in Turkey

Zeynep Onder, Ayda Yurekli

Bilkent University, Turkey

E-mail: [email protected]

Turkey is among the countries that has the highest smoking prevalance rate. It is estimated as 33.8 percent among 18 years old or older adult population, and as 10.4 percent among high school students; tobacco was responsible for 13 percent of total 430,459 deaths in 2003. Even though Turkey faces huge burden of tobacco use due to premature deaths and diseases, it is one of the few progressive countries that took comprehensive and effective legal and economic measures to combat with tobacco epidemic. From the legal perspective, Turkey adopted smoke-free legislation in 2008. It bans smoking in all closed places, and requires complete ban on cigarette or tobacco advertisement, promotion and sponsorship. From the economic perspective, the average tax rate is 73.25 percent of the retail price of cigarettes. The demand analysis of cigarettes using recent data suggests that a 10 percent increase in real prices will decrease consumption per capita by 4.4 percent at the aggregate level. When the substitution among different cigarette brands is taken into consideration, a 10 percent increase in cigarette prices would reduce total consumption by 0.8 percent but the demand for cheap cigarettes will increase by 9 percent while the demand for moderate and premium brands will decrease by 7 and 14 percent respectively. Moreover, this increase in price because of increase in taxes is found to increase the government revenue by 10.6% and make the tax distribution more progressive, suggesting that there is still room for the increase in excise taxes on cigarettes.

Economics of tobacco taxation in the Philippines

Adele Casorla, Stella Luz Quimbo, Felipe Medalla, Marina Miguel-Baquilod

UPecon Foundation, Philippines

E-mail: [email protected]

Tobacco taxation is widely believed to be the most effective policy intervention to reduce tobacco demand. Thus, low tax rates partly explain why cigarettes are highly accessible in the Philippines resulting in high smoking prevalence and consequently, a high burden of smoking-related diseases. In this paper, we examine whether increased taxes can reduce cigarette consumption. Further, we investigate the implications of increased cigarette excise taxes on government revenues and on the poor. We estimate alternative models of demand using time-series and cross section data to examine individuals' smoking behavior and spending behavior of households on tobacco products. We then perform simulations to determine the possible impacts of increased taxation on consumption, tax revenues, and the tax burden. Demand analyses using various data sets consistently indicate inelastic demand for cigarettes in general, but more elastic for lower income households. Youth demand, on the other hand, is highly price elastic. Simulations indicate that a high uniform tax is more effective both in reducing consumption and increasing tax revenues than the stipulated tax increases under a multi-tiered specific tax scheme. We estimate that a P15 tax can reduce consumption by 40 percent and increase tax revenues by over 100 percent. The results point to two main policy implications (i) a P15 per pack uniform tax dominates the current multi-tiered tax structure, and (ii) shifting to a high uniform specific tax, being marginally regressive, entails some form of transfer of tax benefits to the poor. The shift will require serious implementation of tax earmarking.

The economics of tobacco taxation in Poland

Michal Stoklosa, Christina Ciecierski

Warsaw University, Poland

E-mail: [email protected]

Poland's cigarette excise tax consists of: a fixed, specific tax and a variable, ad valorem tax based on the maximum retail price. Between 2000 and 2007, the cigarette excise tax included an increasingly large ad valorem component relative to the specific tax. This structure resulted in a number of market outcomes that are unfavorable to successful tobacco control. First, a large ad valorem tax gives tobacco producers the power and incentive to lower the retail price of their products as a smaller variable tax means less tax due to the State budget. Second, for the consumer, a lower ad valorem translates into lower retail prices. Hence, a stronger specific tax would strengthen fiscal policy while curbing tobacco use more aggressively. A stronger specific tax would also find support among Poland's tobacco trade federations as fewer cigarette price wars mean less downward pressure on the price of raw tobacco and added benefit to plantations, particularly those which have invested in higher-grade production processes. Finally, statistical evidence indicates that the prevalence of illicit cigarette consumption has remained steady or decreased in recent years. This is largely due to more restrictive EU border controls with the east. This raises concern over the in-country production of counterfeit cigarettes. Since EU accession, customs officials have exposed at least thirteen counterfeit cigarette manufacturing plants in Poland. Narrowing the gap in cigarette prices between Poland and other countries in the EU (e.g. U.K., France, Germany) through increased tobacco taxes will lower incentives for counterfeit production and smuggling.

Economics of tobacco taxation in China

Teh-Wei Hu, Zhengzhong Mao

UC Berkeley, United States of America

E-mail: [email protected]

China has the highest number of smoking attributable deaths: One million deaths annually, a number that will reach 2 million premature deaths by 2020 unless effective tobacco control programs are implemented. The costs of smoking to Chinese society were estimated at 41 billion RMB (US$5.0 billion, US$1 = 8.20 RMB for the 2000 exchange rate): 14 billion RMB (US$1.7 billion) in medical treatment costs and 27 billion RMB (US$3.3 billion) in the loss of productivity (in the 2000 value). The treatment costs of smoking accounted for 3.1% of China's national health expenditures in 2000. In 2005, China's state-owned tobacco monopoly company produced 1.7 trillion cigarettes, generating a tax and profit of 240 billion RMB (US$30 billion), about 7.6% of the central government's total revenue. The overall effective tax rate of 40% measured at the retail price level in China is much lower than the international community's median tax rate, which ranges between 65% and 70%. Given the negative health and economic consequences of smoking, there is much room to raise the tobacco tax for tobacco control in China.

Myopic addiction demand models for cigarettes in Indonesia: Panel data approaches

Budi Hidayat, Hasbullah Thabrany, Teh-Wei Hu

University of Indonesia, Indonesia

E-mail: [email protected]

Background: Econometric analysis of panel data can be utilized to estimate a dynamic specification of the demand. However, arriving at the decision why a particular panel data model is the most appropriate one to estimate cigarette demand is often a difficult process and this is not well documented in health economics literature.

Objectives: This study focuses on the selection of the most appropriate econometric model to estimate the demand for cigarettes in Indonesia and to document the process by which one could choose the most appropriate panel data model.

Methods: A number of different estimators, applied to the Indonesian Family Life Survey in the period 1993-2000, were used to test a myopic addiction hypothesis. We developed a framework to select the best alternatives estimator. Empirical results obtained from different specifications are compared and the performances of econometric models are tested with several statistical criteria. Short and long run price elasticities were also calculated.

Results: A Generalized Method of Moment is the best to estimate a dynamic model of cigarette demand for male, whilst a random effect is applied for female sample. The lagged consumption coefficient term turned out to be positive with a P-value < 1%. The short-run price elasticity for male and female was estimated at -0.27 and -0.48, respectively, and the long-run one was -0.69 (male) and -0.84 (female).

Conclusions: The effect of dependence, reinforcement and tolerance is significant. The price elasticity of demand for short-run (and men) is smaller than the long-run (and women).

  Secondhand smoke and tobacco control in China and Indonesia Top

Smoking knowledge, attitudes, behavior and associated factors among chinese male surgeons

Tingting Yao, Michael K Ong, Anita H Lee


E-mail: [email protected]

Background: Chinese male surgeons have the highest smoking prevalence among all physicians, but little is known about Chinese male surgeons and smoking. Only by engaging entire health care system, including surgeons, can China make headway against the tobacco epidemic.

Objectives: To understand and assess smoking knowledge, attitudes, behavior and associated factors among Chinese male surgeons.

Methods: A total of 823 Chinese male surgeons from six cities participated in a survey of smoking knowledge, attitudes and behaviors in 2004. This study conducted descriptive statistics and logistic regression analyses of factors associated with male surgeon smoking behavior and smoking cessation activity.

Results: The current smoking prevalence for Chinese male surgeons was 45.2%, of which 42.5% reported having smoked in front of patients. Few Chinese male surgeons always asked patients about smoking status (25%) or advised smokers to quit smoking (27.2%). Male surgeon current smoking status was significantly (P<0.05) associated with their knowledge on active and passive smoking harms, and attitudes towards smoke-free hospitals and health role modeling by physicians. Smoking in front of patients was significantly (P<0.05) associated with their knowledge of active smoking harms, attitudes towards smoke-free hospitals, and cigarette consumption. Smoking cessation activity was significantly (P<0.05) associated with their knowledge about active smoking harms; and for advising, also passive smoking harms.

Conclusions: Male surgeons should actively participate in tobacco control training and education to improve their knowledge and attitudes toward smoking. Doing so will improve surgeon smoking behavior and their smoking cessation practices.

Secondhand smoke control and China

Zhengzhong Mao

Sichuan University, China

[email protected]

Background: China is the largest consumer of tobacco in the world, and nearly half of its nonsmoking population is exposed to secondhand smoke.

Objectives: This session will highlight recent work on secondhand smoke and potential policy interventions that affect China. Attendees will learn about factors in populations that may hold the key to improving secondhand smoke exposure in China, including Chinese physicians, Chinese pregnant women, and overseas Chinese in areas with successful secondhand smoke policies.

Methods: The abstracts in this session include multivariate regression analyses of specific groups that may hold the key to improving secondhand smoke exposure in China.

Results: The findings from these abstracts are discussed within each of the individual abstracts.

Conclusions: China can benefit tremendously from implementing policies to control secondhand smoke.

The economics of tobacco control in Indonesia

Hasbullah Thabrany

University of Indonesia, Indonesia

[email protected]

Background: Indonesia is one of the largest consumers of tobacco in the world, yet there has been little work done on the economics of tobacco control in Indonesia. Indonesia has not ratified the Framework Convention on Tobacco Control.

Objectives: This session will highlight recent work on the economics of tobacco control in Indonesia. Attendees will learn about the similarities and differences between Indonesia and other countries on the demand for tobacco, the costs of tobacco and benefits of tobacco control, and tobacco industry activities.

Methods: The abstracts in this session range from econometric modeling to tobacco industry document analysis.

Results: The findings from these abstracts are discussed within each of the individual abstracts.

Conclusions: Indonesia can benefit tremendously from implementing tobacco control policies.

A pilot intervention for pregnant women in Sichuan, China on passive smoking

Anita Lee, Tingting Yao

Public Health Institute, United States of America

E-mail: [email protected]

Background: 540 million people in China suffer from exposure to passive smoking, with women more exposed than men. 90% of exposure for women takes place in the home environment.

Objectives: The study aimed to reduce women's exposure to passive smoking, which has been linked to increased risk of cancer and other diseases. By exploring the knowledge, attitudes and behaviors of pregnant women with regard to secondhand smoke, a model for intervention during pregnancy was designed with the help of the intended beneficiaries and was piloted.

Methods: This intervention study at maternity hospitals in Chengdu, Sichuan in 2006/2007 had two phases. Phase 1 included focus group discussions and an iterative process to design an intervention. Phase 2 was the intervention itself, which included a series of motivational and patient communication activities, a resource booklet, clinician counseling, telephone hotline and regular telephone counseling. Pre-and post-intervention questionnaires were used to measure results.

Results: Focus group findings highlighted the barriers to a smoke-free home that women encounter, and the themes that helped design an intervention which could empower women with increased knowledge and skills to interact in the dynamics of the family environment. Post-intervention questionnaires showed a significant increase in knowledge, a change in attitudes towards stronger disapproval and an increased likelihood of taking assertive action when exposed to secondhand smoke at home. The study points to a need to give emphasis to passive smoking in the home environment and that the women's pregnancy is an effective conduit to bringing about change.

Passive smoking knowledge and anti-tobacco media exposure associated with Chinese American male smoking status in California

Elisa Tong, Hao Tang, Janice Tsoh, Candice Wong, Moon Chen

University of California, Davis, United States of America

E-mail: [email protected]

Background: Chinese male smokers comprise a third of the world's smokers. Higher quit ratios for Chinese in California compared with China are attributed to a change in social norms, like California's anti-tobacco media campaign emphasizing being smokefree.

Objectives: To determine the association between passive smoking knowledge, anti-tobacco media exposure, and smoking status in Chinese American men.

Methods: The 2004 California Chinese American Tobacco Use Survey was a statewide telephone survey of self-identified Chinese adults. Passive smoking knowledge was defined as those who "strongly agree" it causes lung cancer and harms the health of unborn babies and children. Anti-tobacco media exposure was defined as hearing or seeing a message in the past month. Two multivariate logistic regression models compared current smokers with former or never smokers, controlling for age, education, marital status, language used for the survey, and years in U.S.

Results: The survey included 153 current, 222 former, and 845 never male smokers. Chinese language was used more by current (85%) and former (84%) smokers than never smokers (62%). Current smokers were less knowledgeable about passive smoking when compared to former smokers (OR=0.44, 95% CI 0.20-0.97) and never smokers (OR=0.21, 95% CI 0.11-0.41). Current smokers, however, were more likely to report more anti-tobacco media exposure (OR=3.06, 95% CI 1.16-8.07) when compared to never smokers.

Conclusion: Chinese American male current smokers have lower passive smoking knowledge compared with former and never smokers. Current smokers reporting more anti-tobacco media exposure compared to never smokers may reflect awareness of their incongruous smoking behavior.

Kreteks: Harm reduction for Philip Morris?

Elisa Tong, Hasbullah Thabrany

University of California, Davis, United States of America

E-mail: [email protected]

Background: Kreteks (clove cigarettes) compose over 80% of the large Indonesian cigarette market, but have high tar and potentially toxic compounds like eugenol (clove oil) that have unclear health effects. In 2005, Philip Morris bought an Indonesian kretek company.

Objectives: To determine Philip Morris' understanding of kreteks.

Methods: Transnational tobacco industry documents were searched for "kretek" and "eugenol."

Results: In 2002, Philip Morris' INBIFO laboratory compared two kreteks with a standard reference cigarette (2R4F) with regard to smoke chemistry and in vitro toxicity. The tar and total particulate matter (TPM) deliveries were higher for the kreteks, but the nicotine deliveries were 40% lower than expected from the 2R4F tar/nicotine ratio. On an equal tar and TPM basis, the kreteks demonstrated lower concentrations of chemical compounds (eg. 80% lower levels of tobacco-specific nitrosamines), less in vitro cytotoxicity in the gas vapor phase, and 40-50% less mutagenicity; however, the kreteks had higher phenol levels. A 2004 Philip Morris report states pulmonary inflammation in rats was 1/4 to 1/3 (as assessed by bronchoalveolar lavage fluid neutrophils) in the kreteks compared to 2R4F, and planned for developing different prototypes to test their inflammatory and immunotoxicity properties. Pending research was considered "critical" priority to understand toxicity for "reduced exposure design."

Conclusion: Philip Morris is investigating kreteks to assist their harm reduction efforts. Their finding of higher tar in kreteks is consistent with the scientific literature, but independent research is needed regarding lower levels of chemical compounds or in vivo pulmonary inflammation compared with regular cigarettes.

Passive smoking and China's one-child policy: Chinese obstetrician-gynecologist and pediatrician knowledge and cessation practices

Michael Ong

University of California, Los Angeles, United States of America

E-mail: [email protected]

Background: China has the most smokers among the world's nations. Due to China's one-child policy, obstetrician-gynecologists and pediatricians are in a unique position to influence active smoking by parents due to passive smoking effects on children.

Objectives: Determine passive smoking harm knowledge for obstetrician-gynecologists and pediatricians, and how these influence smoking cessation advising practices.

Methods: This 2004 clustered randomized survey of 475 hospital-based obstetrician-gynecologists and pediatricians from six Chinese cities measured smoking attitudes, knowledge, personal behavior, and cessation practices. Data on obstetrician-gynecologists and pediatricians were pooled after determining there were no significant differences in smoking behavior, passive smoking knowledge, and smoking cessation activities or beliefs. Descriptive statistics and multivariate regression analyses were conducted on factors associated with advising smokers to quit.

Results: Few (6.1%) obstetrician-gynecologists and pediatricians smoke and most (84.4%) are female. Most obstetrician-gynecologists and pediatricians are aware of passive smoking effects on respiratory illnesses including childhood asthma and lung cancer (72.2% to 85.6%), but are less aware of effects on leukemia (15.6%), sudden infant death syndrome (23.8%), stroke (37.9%), and ischemic heart disease (47.8%). The likelihood of usually advising smokers to quit (44.0%) was significantly higher (P<0.05) with knowledge that passive smoking is related to bronchitis (OR = 2.45), stroke (OR = 1.81), and asthma (OR = 2.55).

Conclusions: All Chinese obstetrician-gynecologists and pediatricians should be educated on the risks of passive smoking, particularly respiratory and cardiovascular illnesses, in order to help reduce the Chinese and global burden of tobacco-related illnesses.

  Capacity building and providing cessation interventions II Top

Roles of Thai nurses on tobacco control

Pongsri Srimoragot

Nurses Network for Tobacco Control of Thailand, Thailand

E-mail: [email protected]

Background: Nurses are major human resources and backbone in Thailand health care system.

Objectives: Described Thai Nurses role on tobacco control.

Methods: Systematic review from 6 major action plans in 2007 which were implemented and more than 1,100 nurses were active participation in tobacco control included strengthen nurses and women healthy role model, create opportunity for Thai youth to be a part of tobacco control, strengthen smoking cessation services in hospital and by mobile counseling clinic in community. Nurses were active leader in tobacco prevention among various groups a long life span in urban and rural areas. In hospital, nurses were active care givers who provided care services for clients who were illness related to smoking. Nurses were active health protector by applying advocacy and education role for patients, visitors, colleagues and family members. This is a part of smoke free environment establishment in hospital, home and workplaces. In addition, Thai nurses were also active involvement in tobacco control campaign. In nurse education institutes, nurses were active development on tobacco control curriculum for bachelor program students. Moreover Thai nurses are responsible in knowledge management and sharing regarding multiple perspectives of tobacco control by applying both quantitative and qualitative approaches.

Conclusion: Thai nurses roles are responsible for effective legislation of the two Thai Tobacco Control Acts B.E.1992 and there are an essential parts for implementing and enforcement article 8, 12, 18, and 20 of WHO FCTC.

Factors influencing European GPs' engagement in smoking cessation: A 27-country literature review

Martine Stead, Kathryn Angus, David Cohen, Gayle Tait

Centre for Tobacco Control Research, University of Stirling and The Open Univers, United Kingdom

E-mail: [email protected]

Background: Smoking cessation advice by GPs is effective but not implemented as widely as it could be. There is a need to understand the full range of factors which hinder wider engagement by GPs in smoking cessation activity.

Objectives: This wide-ranging Europe-wide literature review, part of the EU PESCE project, explored the extent of GPs' engagement in smoking cessation and the factors which influence their engagement.

Methods: Searches were conducted for grey literature (conducted by researchers in each participating country using standard protocols) and for academic studies. Data were synthesised under four categories of influencing factors: GP characteristics, patient characteristics, structural factors, and cessation-specific knowledge and skills.

Results: GP cessation activity across Europe does not always follow evidence-based guidelines, and varies widely across countries. No single factor or category of factors explains the variability. Correlations with provision of cessation advice are found for GPs' own smoking status, participation in training, patient characteristics and awareness of treatment options. GPs' knowledge, skills and attitudes to preventive and cessation work are also important. Lack of reimbursement did not emerge as the most salient barrier from GPs' own perspective, but structural changes may increase cessation activity.

Conclusions: Strategies to improve the frequency and quality of GPs' engagement in smoking cessation need to address the multi-faceted influences on GPs' practice and to reflect the widely differing cultural and policy contexts across Europe.

Behavioral intervention for smoking cessation in primary health centers in Palakkad district, Kerala, India

Pradeepkumar A. S., Thankappan K.R., Mark Nichter


E-mail: [email protected]

Background: Studies on effectiveness of smoking cessation interventions from India are limited.

Objective: To find out whether non-physician health professional counseling can be effective in tobacco cessation intervention at primary health centers.

Methods: We conducted a randomized controlled trial with 875 smoking male patients from seven primary health centres and assessed quit attempts, harm reduction and quit rates at weeks 3, 6 and 12. Physician advice and a leaflet on harmful effects of tobacco were given to both intervention and control groups. A non-physician health professional provided counseling to the intervention group in addition to physician advice and leaflet.

Results: The odds of quit attempts by patients in the intervention group was four times higher compared to the control group (OR: 3.9; 95% CI: 2.4 - 6.1). Harm reduction of more than 50% at week 12 achieved by the intervention group was significantly higher than that by the control group (OR: 1.7; 95% CI: 1.2 - 2.4). Patients in the intervention group had significantly higher odds of quitting smoking at week 12 compared to that of the control group. (OR: 1.2; 95% CI: 1.0 - 1.4). Continuous smoking abstinence rate was 16.0% among patients in the intervention group and 10.0% in the control group and the difference was significant (P < 0.005).

Conclusion: Non-physician health professional counseling was found to be effective in tobacco cessation intervention at primary health centers.

The PESCE project - Evidence based European policy recommendations to increase engagement of general practitioners in smoking cessation

Sibylle Fleitmann, Jean Daver, PESCE Consortium

Independent Consultant Tobacco Control, Germany

E-mail: [email protected]

Although the engagement of General Practitioners in smoking cessation is one of the most cost effective public health measures, only a minority routinely do so in their everyday work. From 2006-2008, evidence based policy recommendations were developed in the frame of the PESCE project, an EU funded project on "General Practitioners and the Economics of Smoking Cessation in Europe. The general objectives of the project is to promote increased smoking cessation interventions of General Practitioners (GPs) in Europe by addressing the socio-economic environment of their practice, highlight the economic benefit from increased smoking cessation interventions on the health care budget in Europe and motivate decision makers to change the working environment of GPs through political measures. 31 organisations from 27 countries in Europe have developed evidence based policy recommendations and practice based implementation strategies in a three stage procedure: An international literature review including academic and "grey " literature from 27 partner countries to identify factors that facilitate or hinder GP's interventions in smoking cessation A study to evaluate the economic benefit of increased advice giving by GP's with respect to smoking cessation based on a 3% and 15% reduction in smoking rates in 10 European countries. A European consensus procedure that resulted in agreement on 15 evidence based policy recommendations and practice based implementation strategies in the areas of capacity building, resources, policy framework and communication The PESCE project rationale and the evidence based policy recommendations and practise based implementation strategies will be presented in the session.

Completely smoke-free detention centres: Is the medical staff ready?

Ann Royer, Michael Cantinotti

Quebec Public Health Agency, Canada

E-mail: [email protected]

Background: Even though smoking remains highly prevalent among inmates (60% to 80%), smoking cessation interventions have so far been close to non-existent in detention centres. In February 2008, the provincial detention centres in Quebec, Canada, banned smoking in all their facilities. In order to prepare for the new regulation, members of the medical staff from 3 detention centres received a 3-day training in smoking cessation intervention.

Methods: The medical staff (N = 40) completed questionnaires before and after receiving training in smoking cessation intervention. Survey items focused on perceptions, motivations and behaviours related to tobacco use and also on tobacco cessation assistance. Their level of preparedness regarding the introduction of the smoking ban was also assessed.

Results: More than 29% of the medical staff identified themselves as current smokers, 78% reported having received no prior training in smoking cessation intervention and 75% considered the policy change to be useful. However, 79% predicted that the ban would have a negative effect on the inmates' behaviour (anger and violence). After the 3-day training, over 80% of the staff reported increased confidence and motivation in providing smoking cessation services to the inmates. Nevertheless, fear of inmates' possible aggressive behaviour following enforcement of the ban remained high (53%).

Conclusion: Before implementing new tobacco regulations in prisons, Public Security should ensure that the medical personnel have received adequate training in smoking cessation intervention. Smoking by staff members should also be addressed.

Familiarity and use of smoking cessation current care guideline among physicians, public health nurses and pharmacists in Finland

H. Patrick Sandstrφm, Terhi Kurko, Marja Airaksinen, Kristiina Patja

National Public Health Institute, KTL, Finland

E-mail: [email protected]

Background: This study looks into attitudes towards smoking cessation, cessation practices and familiarity with the Current Care Guideline on "Smoking, nicotine addiction and interventions for cessation" among general practitioners, public health nurses and pharmacists in Finland.

Objectives: To compare smoking cessation practices of health professionals having familiarized themselves with the Guideline to those who have not.

Methods: An independent cross-sectional mail survey was carried out among physicians, public health nurses and pharmacists. A national systematic random sample of 3000 physicians, 2000 public health nurses and 2291 pharmacists was drawn. Samples included 19% of physicians, 15% of Public Health Nurses and 50% of Pharmacists in Finland.

Results: Forty-four percent of pharmacists had studied the guideline carefully or were at least familiar with the basic principles. Corresponding numbers for Public Health Nurses were 36% and for GP's 25%. Twenty-eight percent of pharmacists, 19% of nurses and 18% of GP's had used the Guideline in their work but only six percent or less had distributed the patient version of the guideline to their clients. Physicians and pharmacists were most confident and nurses more modest in estimating own knowledge and skills. Asking and advising were clearly linked to how well respondents knew the Guideline.

Conclusions: Familiarity with the Guideline seems to double cessation efforts in a patient context, Nevertheless, a considerably high percentage of health professionals where not familiar with the Guideline. The challenge remains how to best reach out to all health professionals in order to provide best possible cessation advice for smokers.

Tobacco cessation training for the oral healthcare team

Sharon Compton

University of Alberta, Canada

E-mail: [email protected]

Background/Purpose: The dental practice setting provides key opportunities to address patient's tobacco use. However, many dental healthcare professionals don't address patient's tobacco use, citing lack of knowledge and confidence for providing an intervention. The dental/dental hygiene appointment provides a teachable moment for discussing patient's tobacco use and for providing guidance and support. The project assessed effectiveness of workshop training on oral healthcare professionals' behaviour and impact on changing practice for increased provision of tobacco cessation counseling.

Methods: Seven face-to-face interactive workshops were conducted in urban centres in Alberta, Canada. Dentists, dental hygienists and dental assistants participated. Workshop content included an overview of motivational interviewing, an identification of Stages of Change, basic facts about pharmacotherapy and nicotine replacement therapies, and two video vignettes of tobacco users discussing their quit attempts. Evaluation included pre and immediate post workshop surveys, 3 week post workshop telephone survey and a 3 months post workshop mailed survey.

Results: Telephone survey results indicate key changes including: 1) increased documentation in patient chart of tobacco cessation intervention; 2) increased initiation of dialogue with patients about their tobacco use and any quit history; 3) better understanding of tobacco addiction complexity; 4) increased confidence for approaching patients about tobacco use; 5) altered approach with patients from critical/judgmental to supportive/empathetic; and 6) initiated action to obtain patient resources and referral possibilities. Discussion/Implications: The workshop was successful in increasing desired practices regarding smoking cessation by dental healthcare professionals. Similar workshops should be required as part of routine education of dental healthcare professionals.

  Economics Top

Economic cost of tobacco use in India, 2004

Rijo John, Hai-Yen Sung, Wendy Max

University of California San Francisco, United States of America

E-mail: [email protected]

Background: With roughly 10% of the world's smokers, India is the world's second largest consumer of tobacco. There been no comprehensive national level study that estimated the economic cost of tobacco use in India. This paper estimate tobacco-attributable costs separately for smoked and smokeless tobacco use. Tobacco-attributable costs of tuberculosis, a disease with 1.8 million new cases in India annually, are also estimated for the first time.

Methods: The prevalence-based attributable-risk approach is used to estimate economic cost using health care expenditure data from the National Sample Survey, a nationally representative household sample survey conducted in India in 2004. Findings Direct medical costs of treating tobacco related diseases in India amounted to $907 million for smoked tobacco and $285 million for smokeless tobacco. The indirect morbidity costs of tobacco use, which includes the cost of caregivers and value of work loss due to illness, amounted to $398 million for smoked tobacco and $104 million for smokeless tobacco. The total economic cost of tobacco use ($1.7 billion) was about 16% more than the total tax revenue from tobacco. Tuberculosis accounted for 18% of tobacco-related costs ($311 million) in India. Of the total cost of tobacco, 88% was attributed to men. The cost of tobacco use was many times more than the expenditures on tobacco control by the government of India. The tobacco-attributable cost of tuberculosis was three times higher than the expenditure on tuberculosis control in India.

Impact of tobacco on economy in Bangladesh: The way out

Ahmed Iftekharul Islam, Nurul Islam

Adhunik, Bangladesh

E-mail: [email protected]

Background: Tobacco pushes to poverty by destroying health. At national level tobacco use entails aggravated health-care cost, lost productivity, loss of forex, and environmental damage. These costs overwhelm the benefits from tobacco.

Objectives: To obtain information on the economic costs of tobacco use by determining - i) prevalence of tobacco use and tobacco-induced illnesses, ii) costs covered by the health system and by households, iii) related deaths and disabilities, iv) apparent economic benefits.

Methods: 1. Calculation of opportunity costs of illnesses 2. Household and hospital survey 3. Report from the National Board of Revenue.

Results: 1. Tobacco usage significant among Bangladeshi population with 36.8% of persons aged 15, and 51.7% of persons over 30 are tobacco users - smoking, chewing or both. 2. 2.9 million cases of the eight tobacco-related illnesses recorded of which 1.2 million attributed to tobacco use. 3. The annual benefit amounted to about 25 billion Taka. The annual costs to about 51 billion Taka. The loss therefore 26 billion Taka.

Conclusions: Tobacco epidemic is expanding in Bangladesh and typically the poor bear the economic burden. It is therefore imperative to protect this vulnerable social stratum. Big tax on tobacco and tobacco products is essential to remove these from the poor's reach. Sale to under-19 group should be banned. Smoking in public places be penalized. Tobacco-menace be exposed to learners during formal education. Elimination, or at least control, of tobacco shall result in better health, and in stronger economy.

Economic impact of tobacco use in Indonesia

Soewarta Kosen

National Institute of Health Research & Development, Indonesia

E-mail: [email protected]

Prevalence of active smokers aged more than 15 years in 2004 was 34.4% or about 50 million people. Prevalence among males was 63.1% and among females was 4.5%. GYTS (2006) found that 37.3% of respondents ever smoke and 30.9% initiate smoking before 10 years of age. About 11.5% of family expenditures was spent for tobacco. In 2004, about 45.6 millions people were passive smokers, due to second-hand smoke at home. In 2005, the average of 11 sticks of cigarettes were consumed per person per day. Using the average price of Rp. 600.00 per stick, a total of 20 US Dollars was spent to buy cigarettes per person per month or equal to 20 days of minimum wages. The estimated total of 220 billions sticks were consumed with the value of 13.9 billions US Dollars. Applying the GBD Method (WHO), the economic loss due to premature mortality attributed to tobacco (3,846,373 DALYs Loss) was in the amount of 4.9 billions US Dollars. The loss due to morbidity and disability (1,502,900 DALYs Loss) was 1.9 billions US Dollars. Total medical expenditures in the same year for 11 selected diseases was 221 millions US Dollars. It can be concluded that the economic cost for purchasing tobacco and the ill impact of tobacco use in 2005 was in the amount of 20.921 billions US Dollars or 5.7 times the exised tax of tobacco received by the government in the same year (3.63 billions US Dollars).

Burden of tobacco-related diseases and health care costs of tobacco use in the Philippines

Marina Baquilod, Alvin Tan, Marilyn Crisostomo, Ernie Vera

Department of Health, Philippines

E-mail: [email protected]

Objectives: To determine the health and economic impact attributable to smoking-related diseases.

Materials and Methods: Estimation of DALY's, cause-specific mortality for lung cancer (Lung CA), cerbro-vascular disease (CVD), coronary artery disease (CAD), and chronic obstructive pulmonary disease (COPD); smoking-attributable mortality and economic costs by SAMMEC and Peto-Lopez methods; Case Fatality Ratios (CFR). Estimate of costs by review of records, literature review, and expert interviews; and productivity losses due to premature deaths, and due to diseases.

Results: CVD and CAD caused majority of the deaths. The SAMMEC 8% of mortality from all causes; 6% of all deaths (Peto-Lopez). CFR's are 67% for Lung CA, 10% for CAD and COPD. 302,104 new cases of the lung CA, CVD, CAD and COPD combined (SAMMEC) and 188,658 (Peto-Lopez). SAMMEC incorporated current smokers and former smokers in the equation thus the higher Smoking Attributable Fraction values. CAD and CVD with most DALYs. Health care costs estimate using the Phil Health data for lung cancer and COPD were greater than those using expert opinion. Annual productivity losses from premature deaths ranged from US$65.4 M to US$ 1.08B (Peto-Lopez estimates) and US$ 2.93 B (SAMMEC). Overall productivity losses from the four diseases, US$ 2.23B (Peto-Lopez) to US$ 5.00 B (SAMMEC). Productivity losses at US$ 120 M to US$ 185 M. Total costs of illness at US$ 6.05B (SAMMEC) and US$ 2.86B (Peto-Lopez).

Conclusions: Over half of cases of the major tobacco-related diseases investigated were attributable to tobacco use, thus prevention and control of tobacco use should be priority.

A simulation model to estimate the likely public health and fiscal effects of an excise tax increase

Corne Van Walbeek

University of Cape Town, South Africa

E-mail: [email protected]

Often policy makers often want 'proof' that an increase in the excise tax will increase tax revenue. The standard way to 'prove' this is to estimate the price elasticity of demand, but for some developing countries the necessary data to do this does not exist. The simulation model does not pretend to be able to estimate price elasticities of demand. It quantifies the likely public health (i.e. changes in consumption and smoking prevalence) and fiscal (i.e. tax revenue) impacts of a change in the excise tax, for a large range of price elasticities. Based on what policy makers think the price elasticity is, they can then read off the likely impact of a change in the excise tax. The relative magnitudes of the fiscal and public health effects are determined by: (1) the price elasticity of demand, (2) the initial excise tax burden (i.e. the excise tax expressed as a percentage of the retail price), (3) whether the excise tax is levied as a specific or ad valorem tax, and (4) the price reaction of the industry to the increase in the excise tax. The model quantifies the differential impact of these four aspects on the output variables of interest. The user enters the base assumptions into the model. The output consists of a variety of tables and/or graphs that can help policy makers to determine the public health and fiscal effects of a tax change, assuming different price elasticities, and differences in the other three variables identified above.

The economics of youth tobacco use in India

Renu Joseph

Univeristy of Illinois-Chicago, United States of America

E-mail: [email protected]

The tobacco epidemic has been fast spreading in many of the poorer nations of the world, including India. Though studies on adult tobacco use in India are abundant, use among youth has been largely ignored due to lack of national level data. My work aims to bridge this disparity in tobacco prevalence studies between adults and youth. For this study, I make use of a new national survey which looks at the various practices, patterns and prevalence of tobacco use among 73,356 youth in the country. I extend the two-part model of cigarette demand to model cigarette, beedi and gutka demand in India. The results from the models indicate that in the initiation and maintenance of tobacco use, cultural and environmental factors are as important as economic factors like price and income. Cigarettes not only seem to be the preferred mode of smoking among youth but also exhibit lower price elasticities than beedis Gender differences in tobacco use are fast disappearing, with more girls reporting smoking cigarettes when compared to beedis. Girls are also relatively price inelastic when compared to boys for both cigarettes and beedis. Other forms of tobacco like gutka are price inelastic, however the data highlights a strong association between parental and youth use of the same.

  Health care systems and tobacco control Top

Integrating tobacco control in healthcare and health rights advocacy

Rama Kant, Madhu Pathak, Pooja Ramakant, Bobby Ramakant

Tobacco Control Resource Centre, CSM Medical University; and Indian Society Agai, India

E-mail: [email protected]

Objectives: To integrate tobacco control in existing healthcare and health rights advocacy in UP and Uttaranchal states.

Methods: While scaling up tobacco cessation clinics in UP and Uttaranchal states, it was much more effective to build upon and add health value to existing healthcare infrastructure, and human and financial resources available within the states -Partnerships with Governments of Uttaranchal and Uttar Pradesh, key health agencies and other civil society organizations helped us in promoting the integration of tobacco control programmes. Tobacco cessation targeted at healthcare providers, building their capacity to integrate tobacco cessation counseling in their daily medical practice and sensitizing them about existing tobacco control legislations and policies proved effective and cost-effective - Three days of tobacco control education and training sessions in counseling methodologies for government school teachers at the state level - proved effective. This was sponsored by Uttaranchal government and was organized in partnership with key agencies. - Tobacco cessation clinics were formally setup in existing healthcare in private and public sector in UP and Uttaranchal states - without any external financial support. - NGOs and other networks in different cities of UP and Uttaranchal were also engaged in these workshops, and got an opportunity for sensitization on tobacco control and were involved in advocacy over a period of time - Local media was involved in these training programmes in UP and Uttaranchal, sensitized on existing tobacco control policies in India and encouraged to report the violations.

Integration of TB and tobacco programme in South-East Asia region

Niki Shrestha

World Health Organisation, Regional office for South-East Asia, India

E-mail: [email protected]

Background and Rationale: Studies have provided evidence for causal association between active and passive smoking and a range of TB outcomes. However, cigarette smoking, until recently, has not been recognized by health system personnel as an entity that can hugely impact the success of a TB control program.

Objectives: WHO, South-East Asia Regional Office aims to integrate tobacco control elements in TB control program through PAL (Practical Approach to Lung Health).

Methods: WHO Tobacco Free Initiative (TFI) and WHO Stop TB! (STB), in collaboration with the UNION, resolved to integrate TB and tobacco control activities within district-level health systems in 2004. The new Stop TB strategy has thus introduced PAL. The Key elements are to identify, counsel and treat smokers attending the PHCs for TB or other respiratory conditions in patients above 5 years of age.

Results: A PAL pilot project has been implemented in 24 DOTS Clinics of two districts of Nepal including the National TB Centre since July 2007. Training of 134 health workers on assessment of nicotine dependence and counseling for smoking cessation is completed. Management of patients according to PAL guidelines as well as detection and counseling of smokers has been started.

Conclusion: SEARO plans to implement PAL in Indonesia in 2008. Bangladesh and Thailand have incorporated activities on TB and Tobacco control in the 2008 BGI Work Plan. A policy change in TB control program for integration of PAL is being highlighted by SEARO time and again at all policy making levels in the Region.

Complex tobacco control strategy evaluation Mumbai 2: Cessation system evaluation

Nadia Minian, Robert Schwartz, John Garcia

Ontario Tobacco Research Unit, Canada

E-mail: [email protected]

Background: Reducing the burden of tobacco disease requires a comprehensive smoking cessation system with multi-level interventions (policies and programs) that address environmental, institutional, and social systems. Evaluating such a complex system presents several challenges including, but not limited to: 1) planning for synergistic effects, 2) selecting appropriate multi-level indicators, 3) determining attribution for an outcome, 4)identifying paths through which different services work to achieve smoking cessation.

Objectives: The objective of this study is to develop a methodology that will assess the impacts of multiple smoking cessation interventions working though different organizations targeting similar, but not always the same population of smokers.

Methods: We are using a multi-method approach to evaluate the smoking cessation system; path logic models are being used to represent the complex system. After identifying the paths through which interventions work to advance overall strategy objectives (done through literature review, and administrative data), we are now determining what the expected contribution of each intervention is (through literature review, and program data) and determining the actual contribution of each intervention in helping achieve the strategy's goal (program evaluation).

Results: The evaluation, which is still in progress, already shows the paths each intervention is using to help people quit smoking, as well as the paths that are being underutilized by the current interventions. Conclusions The insights that will be gained from this evaluation, including underutilized paths, and the inconsistencies between expected contributions and actual contributions, will be helpful for future planning of a comprehensive cessation system.

'Systems First': A framework of smokefree action for health care services

Carleine Receveur

Hawke's Bay District Health Board, Newzealand

E-mail: [email protected]

Background: The New Zealand Ministry of Health funded a national co-ordination project to provide a programme of support for District Health Boards (DHB's) to address the smoke-exposure of patients. This framework was adopted by the Hawke's Bay District Health Board.

Objectives: 1. Describe "Systems First" model - 5 steps for successfully implementing of smokefree action. 2. Analysis of Hawke's Bay District Health Boards performance - use of a self assessment tool. 3. A service case example - The first totally smokefree publicly funded residential addiction service in New Zealand.

Method: A case study is presented to demonstrate the implementation of the "Systems First" framework. The study involves a holistic analysis of Hawke's Bay District Health Board in terms of smokefree practice with a service specific example.

Results: The analysis demonstrates the achievement of key milestones including: - organisational commitment to smokefree strategies - closure of designated smoking rooms - increase in staff's confidence and competence to address smoking with their patients - increase of referrals to cessation services - increase utilisation of nicotine replacement therapy.

Conclusions: The "Systems First" model is of interest to those health care service managers who seek a framework that enables a successful translation of tobacco control strategies into their organisation ensuring positive patient and population outcomes."

Ways to implement smoking cessation support by health care practitioners

Dewi Segaar, Fleur Van Bladeren

STIVORO for A Smokefree Future, Netherlands

E-mail: [email protected]

In the Netherlands, in 2004, the evidence based guideline on tobacco dependence treatment in health care was published. It was developed by a cooperation of scientific institutions and professional organisations. Until 2006 efforts were put into the implementation of very specific interventions for specific patient groups, leading to enormous differences in support given by health care professionals (HP's). In 2007 we started with a multi-component program to implement the clinical guideline in health care settings.

Program objectives: Increase the number of HP's that provide smoking cessation support as recommended in the clinical guideline.

Methods: A multi-component implementation strategy was used: - Increase availability of interventions that provide health professionals with practical directions on how to treat their patients. - Increase availability of supportive (implementation) tools; manuals, patient materials, skills trainings, overview of effective treatment methods, website. -Publication of a practical translation of the guideline recommendations by The Dutch College of General Practitioners. -Media-campaign (print and internet advertisements) for health care professionals, addressing the logic of providing smoking cessation support. -Newsletters and mailings. -Presentations on conferences and meetings. -A digital knowledge centre on implementation of smoking cessation support in healthcare settings.

Results: The actions mentioned above are expected to increase the number of HP's that act according to the clinical guideline. Results of a study among HP's on their supportive behaviour will be available by the end of 2008 and can be presented at the time of the conference.

Conclusion: A multi-component strategy might increase smoking cessation support given by HP's.

The application of a coordinated systems approach to cessation by a provincial health authority

Marino Francispillai, Behnaz Somji

Alberta Cancer Board, Canada

E-mail: [email protected]

Background: Alberta Cancer Board (ACB) conducted a Situational Analysis (SA) to provide a comprehensive body of evidence and related strategies required to effectively identify, prioritize, plan, and support population health chronic disease prevention. Stemming from the SA, ACB developed the Alberta Cessation System.

Objectives: Provide efficiencies and enhanced care utilizing a systematic approach to increase capacity in tobacco control research and cessation provision in Alberta.

Methods: ACB researched best practice and consulted with health authorities, organizations, and experts to perform the SA and to address gaps identified in the SA. Cessation programming and a system to efficiently coordinate programs, initiatives, evaluation and monitoring were developed.

Results: Results of the SA were compiled into a 'Snapshot of Tobacco Facts' resource and a comprehensive, multi-tiered Alberta Cessation System was developed. A provincial triage directed teleweb cessation centre was developed as a hub and central access point for cessation services, as well as a provincial centre for IVR follow-up and nurse/counsellor support. ACB collaborated to develop provincial programming: i. Ask, Advise, Refer (AAR): health professional (HP) brief intervention; ii. Liaison Line: HP line linking to physician cessation expertise; iii. TEACH-Alberta: accredited, comprehensive cessation training for HPs; iv. Group Cessation; v. In-patient Smoking Cessation. ACB worked with national experts to develop an overarching evaluation; guide development of surveillance; and facilitate proposal of a tobacco research unit.

Conclusions: A comprehensive, coordinated, and evidence-based systems approach can be used to provide ongoing and enhanced care to smokers.

Strengthening the capacity of aboriginal health workers in Australia to deliver smoking cessation activities

Anke Van Der Sterren, Viki Briggs, Dallas Young, Terry James, Nicole McMillan

Centre for Excellence In Indigenous Tobacco Control, Australia

E-mail: [email protected]

Aboriginal Health Workers (AHWs) are community health workers who deliver primary health care in Aboriginal Health Services throughout Australia. They are expected to be involved in providing a variety of interventions to Aboriginal people, including in the area of smoking cessation, but they often lack the skills, confidence, and capacity to deliver tobacco-specific interventions. Tobacco control is not a priority for many Aboriginal communities that are overburdened by high levels of ill-health and social disadvantage. AHWs are trusted and respected members of their communities and as such can potentially have a significant impact on reducing the high prevalence of smoking in Aboriginal communities (currently 51%). This project aims to identify the factors impacting on the capacity of AHWs to undertake smoking cessation activities and to investigate how to strengthen this capacity. This paper reports on the findings of a literature review, and on interviews conducted with AHWs working in Aboriginal Health Services throughout Australia, and with key people working in the field of smoking cessation. We will report on the key barriers that AHWs face in delivering smoking cessation activities: the impact of high smoking rates amongst AHWs on their confidence to deliver advice and programs; the impact of supportive organisational environments and policies; access to training; and the lack of workers specifically dedicated to tobacco control. This project provides a more in depth understanding of these issues, and will inform the development of approaches to strengthen the capacities of AHWs to deliver smoking cessation activities within their communities.

  Inequalities and Human Rights II Top

Human right-based tobacco control: Right to health and right to life in Nepal

Hom Shrestha, Indu Amatya

Non-Smokers' Rights Association of Nepal, Nepal

E-mail: [email protected]

Background: Non-Smokers' Rights Association of Nepal NOSMORAN) introduced human right-based approach to tobacco control in Nepal since 2006 to promote and protect non-smokers' rights: right to life and right to health.

Objectives: To adopt tobacco control as human right that neglected by political parties, National Human Right Commission and Office of High Commissioner of Human Rights.

Methods: NOSMORAN brought attention of international community to establish smoke-free environment as human right through public interest on tobacco litigation, 4 th World Non-Smokes' Rights Conference held in George Washington University Law School, April 6-8, 2007, 'Smoke-free Environment - Human Rights of Non-Smokers' seminar paper and editorial articles 'Right to Smoke-free Environment' and 'Create Smoke-Free Environment' on occasion of World No Tobacco Day 2007. NOSMORAN urged stakeholder political parties to prioritize tobacco control as right to health political agenda for political solution through parties' manifesto and campaign at Constitutional Assembly Election held on April 10, 2008. Almost 70% elected new faces of parliamentarians need to be familiarized tobacco control legislation and FCTC ratification.

Results: Political parties' leaders, human rights organizations and watchdogs fail to recognize human right-based tobacco control: right to health that guaranteed by universal human right declaration; conventions device; FCTC; and international non-smokers rights treaties.

Conclusion: Smoking is not a constitutional right worldwide. The Constitutional Assembly must be guaranteed tobacco control as right to health and right to life in new Constitution Article towards tobacco-free Nepal after Bhutan in Asia.

Socio-economic profile of beedi-rollers and their preference on alternative profession

Vidhubala E, Maria Latha P

Cancer Institute (WIA), India

E-mail: [email protected]

Currently there are 700, 000 beedi-workers living in Tamilnadu of which, 500, 000 live in three southern districts namely Tirunelveli, Tuticorin and Kanyakumari.

Aim: The present study is to find out the physical, social and economical aspects of beedi-rollers living in rural areas of Tamilnadu.

Methods: Ten villages were randomly chosen from Tirunelveli District where the major occupation of those villagers are beedi-rolling. 548 women beedi-rollers were approached of which, 494 agreed to participate in the study. A structured questionnaire was used to collect the information. Descriptive statistics was employed to analyze the data.

Results: Of the beedi-rollers, 9.1% were minors and 36.8% were between the age group of 18 to 30 years. 89.2% went to school upto primary or secondary and 10.1% were illiterates. 23.5% were unmarried. 59.9% of their spouses are coolies and seldom go to work. 33.8 were earning below Rs.1000 and 28.3% earned the amount of Rs.1000-2000. Whereas, 99.6% of the beedi-rollers income was below Rs.1000/month. Only 1.4% of their children are availing scholarship from the Government. 96.2% readily expressed their willingness to shift their occupation and 44.3% reported that they are prepared for any job, 34.8% preferred cottage work and 8.7% preferred to be petite entrepreneurs. 66% complained of having health problems. When enquired, 97.8% voted for pictorial warnings, particularly skull and bone depiction.

Conclusion: The physical, social, economical condition of Beedi-rollers is dismal and these innocent victims need to be saved from the monstrous tobacco industry. Moreover, women empowerment is crucial in these areas.

Tobacco and socioeconomic factors on a Brazilian slum

Mirian Souza, Liz Almeida, Azevedo e Silva Gulnar, Costa Maria do Carmo

National Cancer Institute, Brazil

E-mail: [email protected]

Background: Poverty and cultural conservative behaviors are some of thebest-known determinants of the magnitude of the tobacco epidemic.

Objectives: To evaluate the relationship between socioeconomic factors and smoking among women.

Methods: A cross-sectional study at 18 to 59 years old women who spontaneouslyparticipate cervical cancer screening into a slum of Rio de Janeiro, Brazil from August 2006 to June 2007. The information had been collected through aquestionnaire applied by trained interviewers. Smokers are considered those whoreported smoking currently and at least 100 cigarettes in life. Estimates ofcrude odds ratio had been calculated through a logistic regression by maritalstatus, race, and groups of age, years of study and per capita income.

Results: A total of 544 women with an average age of 35 years were interviewed;37% of them had studied 7 years and more; 39% were single, 53% married and 8%widow/divorced; 70% were not white; the average per capita income was US$66 and28% were smokers. The risk to be a smoker is smaller among those with highereducation (OR=0.4, P-value=0.00) and higher income (OR=0.7, P-value=0.04). Therisk to be a smoker is 1.6 times higher among black women compared to whitewomen.

Conclusions: The prevalence found in this study is considerably higher. Thecalculated odds ratio indicates an increased risk for to be a smoker among womenwith lower socioeconomic level. Those results can be used to plan interventionsfor vulnerable groups such as poor women.

Study of health and socio-economic conditions of bidi rollers in Murshidabad district of West Bengal

Bhavna Mukhopadhyay, Karabi Majumdar

Voluntary Health Association of India, India

E-mail: [email protected]

Background: Bidi-rolling is a highly labour intensive process which is home-based. It requires less skill and employs 75 lakh people across (women and children) India. It is a hazardous occupation as it affects the user and the maker. 800 million bidis are sold in India each year. There are one million bidi smokers in India.

Objectives: Understand the conditions of bidi workers and generate public awareness on these issues. Explode the myths around the safety and viability of bidi employment. Explore alternative livelihoods to bidi-rolling and advocate to find alternative means of making a better living with safer working conditions.

Methods: -Primary source of data collection - Questionnaire, FGD, Case Studies -Fieldwork in Murshidabad, West-Bengal - 500 respondent

Result: 91% of the workers are women and children. 72% belong to Muslim community and are illiterate. Average age of initiation into bidi-rolling is 10 or younger. The wage of rolling 1000 bidis is Rs.33-35 that is paid on a weekly basis. There is thorough exploitation of bidi rollers by the middlemen. The registered Bidi workers are issued ID cards. 50% of the workers are unregistered, deprived of welfare measures. Majority have complaints about various health problems with minimal medical supports.

Conclusion: The low wages received by bidi-workers pushes them to further poverty without any alternatives putting them into a vulnerable bracket. Efforts are needed to protect and help the bidi workers earn a better livelihood that will not put them at high jeopardy.

Smoking and smuggling in England: An unequal burden

Martin Dockrell, Amanda Sandford, Deborah Arnott, Robert West

Action On Smoking and Heatlh, United Kingdom

E-mail: [email protected]

Background: Price is an important lever in tobacco control. The availability of cheap smuggled tobacco undermines smokers' efforts to quit and government efforts to reduce smoking uptake. Qualitative evidence and enforcement data has suggested that consumption of smuggled tobacco may be highest among lower income groups.

Objectives: To provide quantitative evidence that illuminates the scale and distribution of illicit tobacco use in England.

Methods: The Smoking Toolkit Study is a monthly series of national household surveys with smokers and recent ex-smokers in England. Data collection began in October 2006. Questions were added in four waves of interviews in 2008 on the purchase of tobacco from illicit sources.

Results: At the time of submission field work is still in progress. Of the 937 smokers interviewed so far 20% reported having purchased tobacco products from illicit sources. Reports of purchasing from illicit sources were highest among male smokers (26%) and younger smokers (32%) and lowest among smokers from higher socio-economic groups (4%). When expressed as a proportion of the adult population 0.5% of adults from the highest SEG purchased smuggled tobacco rising to almost 8% in the lowest SEG. Smokers also avoid duty by purchasing cheap tobacco abroad. 18% of smokers reported buying more than half of their tobacco from sources which avoided paying UK duty and 10% avoided UK duty on more than 75% of their tobacco.

Conclusion: Smuggled tobacco undermines efforts of tobacco control, especially among younger and economically disadvantaged members of society.

The burden of smoking among poor blacks in the United States

Pebbles Fagan, Alton Hart, Deidre Lawrence, Allison Rose

National Cancer Institute, United States of America

Background: Blacks have the highest rates of poverty and tobacco-related cancers in the United States. Twenty-five percent of low income blacks smoke compared to 18% of middle and 11% of high income blacks. Increasing our understanding of smoking patterns among the poor will help inform the development of interventions for persons bearing the burden of tobacco use.

Objectives: This study examines the prevalence of current smoking by gender, age, education, occupation, and employment status among low income (<$25,000) Blacks in the United States.

Methods: Cross-sectional data from the 2003 Tobacco Use Supplement to the Current Population Survey were analyzed in SUDAAN to generate weighted estimates of current smoking among low income blacks aged 18-65+ (n=5,987).

Results: Current smoking was higher among low income black males than females (31% vs. 20%). Respondents aged 45-64 had the highest smoking rates and Blacks 65+ had the lowest (33% vs. 11%). Blacks with 9-11 years of education had the highest smoking rates (32%) and respondents with 16+ years and <9 years of education had the lowest (14%, 16%). Thirty-four percent of blue collar, 27% of service, and 21% of white collar workers smoked. Thirty-six percent of the unemployed smoked compared to 24% of employed blacks and those not in the labor force.

Conclusions: These data show that among low income groups, current smoking varies by gender, age, education, occupation, and employment status. Developing gender-specific interventions and targeting multiple low socioeconomic indicators will help us reduce the burden of tobacco use among poor Blacks.

Tobacco, equity and global health: Assessing the WHO framework convention on tobacco control

Jeff Collin, Ross MacKenzie, Anna Gilmore, Kelley Lee

University of Edinburgh, United Kingdom

E-mail: [email protected]

Background: Economic globalisation has accelerated health inequalities, while initiatives like the Millennium Development Goals and the Global Fund have been criticised as reflecting the priorities of high income countries. The WHO Framework Convention on Tobacco Control (FCTC) represents an important attempt to address tobacco's increasingly inequitable health impacts.

Objectives: To examine the adequacy of the FCTC as a policy instrument designed to address health inequalities between countries.

Methods: Analysis of internal tobacco industry documents, policy documents, civil society reports, and academic literature.

Results: While the FCTC undoubtedly incorporates an equity perspective, negotiations were marked by clear tensions between high income and developing countries concerning funding tobacco control and, in particular, the FCTC's relationship with trade agreements. The FCTC's substantive silence on trade issues reflected a victory for high income countries unwilling to address core features of economic globalisation, and particularly for those that actively defended the interests of transnational tobacco companies (TTCs). The FCTC's potential to address health inequalities is further threatened by the influence of TTCs over national implementation, and by the ongoing willingness of key states to protect the economic interests of TTCs internationally despite strong domestic tobacco control policies.

Conclusions: The FCTC clearly advances capacity to address global health inequalities via accelerating comprehensive tobacco control programmes. But this capacity should be advanced via the negotiation of stringent protocols, an increased research and policy focus on the compatibility of tobacco control initiatives with trade agreements, and greater coherence of health and foreign policy objectives.

  Partnerships and capacity building II Top

Partnering to build capacity and engage priority populations in addressing tobacco-related health disparities

Joanne D'Silva, Barbara Schillo, Ann Wendling, Chris Matter

ClearWay Minnesota, United States of America

E-mail: [email protected]

Background: Despite over 40 years of tobacco control efforts in the USA, there remains a need to address tobacco-related health disparities with certain populations. Priority populations include those that have higher rates of tobacco use, higher tobacco-related morbidity and mortality, or are disproportionately targeted by the tobacco industry. Since 2000, ClearWay Minnesota has pioneered partnership models to engage priority populations in efforts to address these disparities.

Objectives: To enhance the efficacy of Minnesota's tobacco control program by involving priority populations in various partnership models.

Methods: Several partnership models were implemented to build tobacco control capacity in priority populations, including the formation of networks to foster grassroots organizing of community agencies; a leadership institute to provide training and skill building to empower individuals; support to community organizations to develop and deliver culturally appropriate cessation services; and research grant funding to encourage collaboration between researchers and community organizations.

Results: These models have facilitated information-sharing between groups, raised awareness about the harms of tobacco in communities, increased leadership, advocacy, and research capacity in community members, and helped build promising practices for cessation efforts. Through these efforts it is evident that partnership building is a continually evolving process and that simultaneous processes are necessary to have the greatest impact.

Conclusions: Involvement of individuals, organizations, and communities has widened the base of the tobacco control movement in Minnesota and serves as a model for other communities. Selection and implementation of the appropriate partnership model should be linked to the community's readiness to address tobacco issues.

Empowering local action on international priorities; a framework for action on the ground

Keith Brunett, Andy Graham

Department of Health Tobacco Control National Support Team,

United Kingdom

E-mail: [email protected]

Background: The WHO 'MPOWER' concept sets an international context for tobacco control that is reflected in some of the best-known national or state-wide tobacco control programmes. But experience in the UK shows that in making a reality of the theory, co-ordination of a truly comprehensive approach at a local level is crucial.

Objectives: To develop and identify a model summarising key tobacco control priorities for use at local level by tobacco control advocates and strategists as part of a drive on tackling health inequalities.

Methods: England's Tobacco Control National Support Team worked with a wide range of stakeholders to develop a simple but comprehensive model for local use, testing and refining this through high-level performance improvement consultancy inputs.

Results: The '7 hexagons' model for local tobacco control action has proved successful in communicating the benefits and requirements of a comprehensive approach to a range of local stakeholders. This practical presentation will briefly explain how to deploy this transferable model.

Conclusions: Localising tobacco control models increases the potential for truly comprehensive action.

Advocating political parties for tobacco control law

Lall Mulmi

Resource Centre for Primary Health Care Shanta, Nepal

E-mail: [email protected]

Background: Nepal entered into a new political transition of peace and national reconciliation after bringing Nepal Communist Party (Maoist) from arms movement to national mainstream politics that is from bullet t ballot. The mass movement of April 2006 has transformed the Executive power from the king to the people. The Seven Party Coalition government decided 10 th April 2008 for Constituent Assembly Election. With the success of the Election the 601 member Assembly will draft new Constituent of Nepal. In view of this historic opportunity to respond to FCTC obligation, series of advocacy campaigns were initiated.

Objectives: To pressurize the CA members to table and pass the much awaited 'Tobacco Control and Regulation Act.

Methods: 1.Two days consultation meeting of Members of Parliament, Speaker made his Commitment. 2.Formation of drafting Committee with legal consultants of concern ministry's 3.Mass Rally in 31 districts to pressurize the government to enact the Tobacco Control Law. 4.Memorandum to Leading Political Parties for their constituent on Tobacco Control.

Results: 1.All Political Parties agreed to take up the issues in their political agenda. They have made commitment in their Election Manifesto. 2.The Ministry of Health & Population submitted the draft to the Cabinet (Council of Ministry) to be tabled in Parliament.

Conclusion: With the success of historical Constituent Assembly Election continuous and pressure is needed to the newly formed Assembly to pass the law for enactment.

Survivors and victims of tobacco empowerment: Successfully integrating survivors of tobacco-related diseases and advocacy for tobacco control

Mary Mathew, Adam Goldstein, Katherine Hampton

SAVE (Survivors and Victims of Tobacco Empowerment), United States of America

E-mail: [email protected]

Ten years ago, tobacco control advocates in North Carolina envisioned a model program for survivors and victims of tobacco-related diseases to become statewide advocates for tobacco use prevention. Similar to the successful advocacy efforts of victims of breast cancer or drunk driving, it was felt that the experiences of survivors of tobacco use could also significantly impact policy development. The Survivors and Victims of Tobacco Empowerment Program (SAVE) originated from this vision. While many tobacco control programs have attempted to involve survivors in their advocacy efforts, SAVE is the only program that has operated with the sole purpose of bringing the voices of tobacco survivors to prevention educational and policy forums. Through funding received from various foundations, private individuals, national and state agencies, SAVE employees paid staff that are dedicated to supporting the advocacy work and empowerment of tobacco survivors, including persons with emphysema, lung cancer, and laryngectomies. The program has reached thousands of youth and adults with prevention and empowerment messages. SAVE has also successfully contributed to statewide media campaigns and tobacco-free school policy advocacy. This presentation will review the first ten years of SAVE's program activities, accomplishments and challenges. Our goal is to assist advocates and funding organizations in other states or countries who may want to consider implementing similar survivor programs to augment their advocacy efforts.

Tobacco policy networks applied to a model of agenda-setting

Patrick Cooper, Anne Lavack

Hill School of Business - University of Regina, Canada

E-mail: [email protected]

Tobacco policy networks consist of the many players who seek to have a role in policy agenda-setting (i.e., ensuring that tobacco issues get onto the legislative, regulatory, and public policy agenda). Lobbyists, interest groups, and others both within and outside government are constantly seeking to influence and collectively shape the tobacco policy agenda, including the choice of institutional venues in which tobacco issues are debated and the strategic use of how tobacco issues portrayed. This research critically evaluates an agenda-setting model developed by Stuart Soroka (2002) in the context of tobacco control. By analyzing policy outcomes of tobacco legislation in Canada from 1970 through to the present, evidence is provided to conceptually reconfigure Soroka's model of agenda-setting to better reconcile the role that policy networks play in agenda setting. We analyze how policy networks have affected and effected tobacco legislation agenda-setting and outcomes, and outline the adjustments to the model that are required to make it more flexible and productive. By analyzing both federal and provincial tobacco legislation, we demonstrate the important role that tobacco policy networks have played in defining tobacco and smoking issues for the public and the media.

Using the simsmoke model to help develop and advocate policies

David Levy

University of Baltimore, United States of America

E-mail: [email protected]

Simulation models combine information from diverse sources to examine the effects of different policies over time. The SimSmoke tobacco control policy model simultaneously considers a broader array of public policies than other tobacco policy models. Using data on population, birth rates, death rates, smoking rates, curent policies and relative risks, the model predicts smoking rates in total as well as by age and gender and estimates the number of smoking attributable deaths. The model also assesses the effect of tobacco control policies, individually and in combination, on smoking rates and smoking-attributable deaths. The model is used to examine the impact of past policies and to project the effect of future policies. In particular, the model is being shows the effect of policies required by the FCTC and the suggested in the MPOWER report. The model has accurately explained trends in smoking rates, with over 30 published articles documenting the model. Models have been or are in the process of being developed for Albania, Argentina, Bangladesh, Brazil, China, Korea, Germany, India, Indonesia, Japan, Malaysia, Poland, Thailand, Turkey and Vietnam. Using the SimSmoke Model, the purpose of this presentation will be to discuss the different tobacco control policy options, show how their impacts unfold over time, show their impacts on different age and gender groups, and discuss the impact of combining different policies. The results will be shown from the perspective of developing policy goals and plans and advocating for the new policies.

Partnership for progress: Supporting the framework convention for tobacco control in developing countries

Research Institute for a Tobacco Free Society, Ireland

Laura Currie, Phillip Karugaba, Robert Machang'u, Luke Clancy

E-mail: [email protected]

Background: 86% of global tobacco production is in developing countries, tobacco use is rising and 800 million of the 1.3 billion annual smoking-related deaths occur in developing countries. Tobacco and poverty are inextricably linked; the opportunity-cost of tobacco is high for the poor in developing countries in terms of food, health, and education. Ireland - and other countries experienced in Tobacco Control (TC) and Development Assistance - should examine how to address tobacco through development programmes.

Objectives: To assess the feasibility of supporting FCTC implementation in two Irish Aid partner countries and to assess research/support needs.

Methods: 1) Literature review, 2) Consultation with Irish, Ugandan and Tanzanian TC and Development stakeholders.

Results: Priorities for support include the implementation of existing legislation and the monitoring and surveillance of tobacco use and related mortality. Research priorities include: quantifying the link between tobacco and poverty (advocacy-oriented) and examining the feasibility of alternative livelihoods to tobacco growing (policy-oriented). Capacity and interest in TC is present, but unpredictable funding alongside a strong tobacco industry presence limits the consistency and thus effectiveness of TC efforts.

Conclusions: The European TC community should lobby their respective Development Cooperation Departments and NGOs to incorporate TC in their Development Programmes. This initial injection of support could aid in establishing an infrastructure for TC which could then more effectively compete for available grants. Research partnerships could support the development of TC research expertise and evidence documenting the impact of tobacco in the region/country and provide context-relevant, evidence-based arguments for TC legislation.

  Point of Sales Top

Tobacco marketing at point-of-sale in Buenos aires, Argentina and Guatemala city, Guatemala

Joaquin Barnoya, Raul Mejia, Debora Szeinman, Jose Carlos Monzon

Cardiovascular Unit, Guatemala

E-mail: [email protected]

Background: Point-of-sale (POS) advertising provides an opportunity for tobacco industry communication with current, former and potential smokers. In developed nations, POS has been a heavily utilized adverstising tool by the tobacco industry.

Objectives: To describe and compare current tobacco POS advertising in two different countries in Latin America, Argentina and Guatemala.

Methods: A previously validated checklist was used to evaluate POS advertising in randomly selected stores in both countries. Convenience stores, supermarkets, kiosks, and gas stations from three different socioeconomic neighborhoods were evaluated. Stores were chosen without any prior knowledge if there was any tobacco adverstising present.

Results: Data collection was completed in March 2008. A total of 120 establishements were evaluated in each city. From a preliminary analysis, POS advertising is highly prevalent in Argentina and Guatemala. Placement and type of advertising are similar between countries. The most popular brands advertised represent the market share in these countries. Brands advertised differ by socioeconomical neighborhood. In most venues, POS advertising is close to items marketed to children (e.g. candies).

Conclusions: We hypothesize that POS advertising is at least as prevalent in Argentina as it is in Guatemala. POS advertising is a marketing strategy that has been overlooked by advertising bans in these countries.

Feasibility of education of tobacco shopkeepers for enforcement of law on ban on sale of tobacco to minors

Sushma Chaudhry

Indian Cancer Society Delhi Branch, India

E-mail: [email protected]

Background: The Indian legislation mandates not to sell tobacco to minors and display a board to this effect. Due to non-enforcement, feasibility of initiating a drive through school children was assessed.

Objectives: To assess the awareness, reaction & willingness of tobacco shopkeepers to help in implementation of legislation.

Methods: The study was carried out in May 2008 at 18 shops selling tobacco products around two schools of South Delhi through a team involving volunteers of Indian Cancer Society, Delhi Branch, teacher from the school and school children. Two trained school children in school dress approached the shop and asked for tobacco product. Rest joined after this trade enquiry. The shopkeeper was educated about the purpose of exercise and his reactions and willingness to cooperate were recorded.

Results: Seventeen out of eighteen shops sold tobacco to school children. Display boards were missing at 16 shops but the shopkeepers agreed to erect the boards. Most knew about legislation and were afraid at the prospect of facing the fine and the authorities. Initial mild resistance by shopkeepers vanished on education on the consequences of tobacco use and legal implications of not following the rules.

Conclusions: A drive to enforce the legislation on ban on sale of tobacco to minors through school children seems feasible. The detailed reactions of the shopkeepers leading to the conclusion would be presented.

Outlet density: A new frontier for tobacco control

Joanna Cohen, Lise Anglin

Ontario Tobacco Research Unit, Canada

E-mail: [email protected]

Background: The convenience model of selling cigarettes was instituted before the health effects of smoking were known. This model based on maximum availability and ease of access is inadvisable for an addictive and lethal substance.

Objectives: To argue for a fundamental reconfiguration of the tobacco retail environment and propose preliminary steps towards this ambitious but necessary goal. Comparisons with alcohol give some indication as to how tobacco control might proceed.

Methods: Literature synthesis.

Results: Greater tobacco outlet density is associated with higher smoking prevalence, economically disadvantaged neighborhoods, and increased rates of youth smoking. One option for reducing tobacco outlet density is to require that businesses buy a license to sell tobacco and at the same time curtail the categories of stores permitted to apply for the license with concomitant limits on hours and days of sale. Local governments could also use zoning laws to ban tobacco sales outlets within a given distance of places where there is a significant presence of children, for example, or persons with frail health. Zoning laws could further dictate a required distance between outlets to avoid clustering. Yet another possibility would be to move the sale of tobacco products exclusively to tobacconist stores, as is done in France.

Discussion and Conclusions: Fewer tobacco outlets will reduce the convenience of purchasing tobacco, thus discouraging impulse purchases, supporting smokers in their quit attempts, and supporting nonsmokers in remaining smoke-free. The alcohol field demonstrates that such inconvenience encourages lower consumption with a subsequent net benefit to public health.

Tobacco powerwalls, do they increase smoking among children? An investigation from New Zealand

Janine Paynter, Richard Edwards, Philip Schluter, Ingrid McDuff

Action On Smoking And Health New Zealand, New Zealand

E-mail: [email protected]

Background: Much of the tobacco industry's promotional budget is spent on point of sale (PoS) promotion in many jurisdictions. Evidence suggests that PoS tobacco displays influence children's smoking-related behaviours and beliefs, and increase susceptibility to smoking. However, evidence comes largely from the US, where some tobacco advertising as well PoS displays are allowed. There is little evidence from jurisdictions where tobacco marketing apart from PoS displays is banned.

Objectives: To assess the association between exposure to PoS tobacco displays and smoking susceptibility, experimentation and established smoking in Year 10 children in New Zealand.

Methods: We used data from the ASH Year 10 Snapshot survey; a national cross-sectional survey of 14-15 year old students in New Zealand. In 2007, over 25,000 students took part. Exposure to PoS tobacco displays was assessed through self-reports of exposure and frequency of visiting retail environments (small convenience stores, petrol stations and supermarkets) where PoS displays are most prominent.

Results: The adjusted (for age, sex, ethnicity, parental smoking, peer smoking, and smoking in the home) odds ratios for smoking behaviours in children who visited the stores every day compared to children who visited less than weekly were 2.0 (95% CI 1.7 to 2.3) for susceptibility to smoking, 2.6 (2.3 to 3.0) for experimentation with smoking, and 2.0 (1.6 to 2.5) for regular smoking.

Conclusions: This is the largest study investigating whether PoS displays influence children's smoking behaviours. The findings suggest that bans on PoS displays are an important intervention to reduce uptake of smoking among children.

Tobacco point of sale in Ireland - presence, public attitudes and policy development

Ιamonn Rossi

Office of Tobacco Control, Ireland

E-mail: [email protected]

Background: Ireland's tobacco legislation provides for the removal of tobacco point of sale advertising in shops and the placing of tobacco products out of view of customers.

Objectives: In advance of the imminent commencement of this legislation, this study: (1) Estimated extent and nature of tobacco advertising in the retail environment; (2) Outlined public attitudes on the role of tobacco advertising in shops and attitudes regarding its removal.

Methods: (1) Independent audit of 1,526 Irish retail and licensed premises. Visual inspection of premises by researchers to record the extent of in-store tobacco promotion; (2) Phone survey among a nationally representative sample of 1,034 adults aged 15+ years.

Results: (1.1) 92% displayed some form of tobacco advertising; (1.2) Tobacco advertising extended beyond the tobacco display in 40% of stores; (1.3) Confectionery positioned beside the tobacco display in 45% of stores. (2.1) 73% consider cigarette packages displayed behind a shop counter to be advertising; (2.2) 61% believe tobacco advertising/displays make young people more likely to smoke; (2.3) 18% of smokers believe displays influence them to purchase cigarettes more frequently; (2.4) 75% support cigarettes being kept out of sight; (2.5) 80% think retailers should require a licence to sell cigarettes.

Conclusions: Tobacco advertising commonplace in retail environment; Extensive advertising bans recognised as effective method to address tobacco epidemic through denormalisation of product / protection of young people; Widespread public support for removal of tobacco point of sale advertising.

Banning the display of cigarettes at retail: Pre-post implementation study

Lynn Planinac, Joanna Cohen, Shawn O'Connor, Anne Lavack

Ontario Tobacco Research Unit, Canada

E-mail: [email protected]

Background: The retail point-of-sale (POS) environment is critical for tobacco industry communications with current, former, and potential smokers. In Ontario, Canada, cigarettes will no longer be visible at retail outlets as of May 2008.

Objectives: To describe changes in tobacco POS promotions in Ontario, observed in a cohort of stores at four points: (1) one year before restrictions; (2) one month before restrictions; (3) one year after restrictions; and (4) three months after the complete ban.

Methods: Stores (n=481) were randomly selected from lists of convenience stores, gas stations, and grocery stores in 20 cities. Trained observers captured the range and intensity of tobacco promotions. A promotion index was calculated for each store, measuring powerwalls, countertop displays, presence of tobacco near candy, and cigarette advertisements.

Results: At wave 1, tobacco promotions were extensive across Ontario, with significantly higher promotions in stores that were close to a school, and in low-income neighbourhoods. Although restrictions were not yet in force at wave 2, 54% of stores were already complying. At wave 3, promotions were at a minimum: only 3% of stores had indoor signs, 1% had a side/middle panel on the powerwall, and 0% had countertop displays. Wave 4 data will be collected in the summer of 2008 to document post-ban compliance and any new promotional strategies.

Conclusions: This study has documented what happens when POS tobacco promotions are restricted and then banned. Banning cigarette promotions is an important tobacco control policy that reinforces health messages about the harms of smoking.

Implementation of a total retail display ban: Lessons learned

Jolene Dubray, Gala Arh, Robert Schwartz, Shawn O'Connor

Ontario Tobacco Research Unit, University of Toronto, Canada

E-mail: [email protected]

Background: On May 31 st , 2008 the province of Ontario, Canada implemented a total retail display ban on tobacco products. The retail setting, the retail display ban aims to help protect youth from initiating smoking, decrease smoking among the general population, increase the number of quit attempts among smokers and finally, to decrease the number of relapses among former smokers.

Objectives: The process evaluation included two objectives: 1) document and assess the effectiveness of the processes that led to the implementation of the total retail display ban, and 2) estimate the level of compliance with the retail display ban on tobacco products among tobacco vendors.

Methods: Information included in the process evaluation was gathered through key informant interviews (e.g., government officials, trade organizations, enforcement staff), document review, and media clippings. All interviews, documents and media clippings were analysed thematically to explore the successes and challenges that were encountered. Tobacco vendor compliance with the total retail display ban was calculated based on routine province-wide inspection data housed in a government Tobacco Inspection System (TIS).

Results: Preliminary results from key informant interviews and compliance estimates will be presented.

Conclusion: This session will demonstrate the successes and challenges in implementing a total retail display ban. Participants will leave with knowledge that could assist in implementing similar legislation in other jurisdictions.

  Smokefree implementation and enforcement Top

Global breath: Secondhand Smoke resources from firsthand experiences

Dian Kiser, Theresa Boschert, Adriana Mezic

BREATH-The Global Smoke-Free Workplace Program, United States of America

E-mail: [email protected]

Since 2001, BREATH--The Global Smoke-free Workplace Program has experienced tremendous interest from countries worldwide. Our philosophy has been that "reinventing" smoke-free workplace resources is unnecessary and costly. Thus, through global technical assistance by means of in-person, materials sharing, websites, databases and conference call trainings as well as face-to-face meetings, Global breath is able to respond to countries and provinces throughout the world that may seek assistance in secondhand smoke policy issues. This presentation will focus on Global breath's activities collaborating with countries about the world and resources and materials currently available to countries that request them. Announcements of Global breath's services and resources appear on GLOBALink that continue to generate requests for assistance. Global breath can provide a variety of resources including technical assistance and materials. Thus far, Global breath has provided technical assitance and materials to 16 countries including Nigeria, Ireland, Italy, Kenya, Great Britain, Sweden, India, Australia and Vietnam. Full-service in-person trainings have been conducted in Croatia, Norway, Korea, Canada and the states of New York, Montana, New Mexico, Province of Alberta and elsewhere. Presentations have been made to the European "Smoke-Free Workplace" Conference in Berlin, Germany and the Asia Pacific Association for the Control of Tobacco (APACT) Conference in Gyeongju, South Korea.

Are restaurants prepared for the new legistlation on tobacco control? An example from Ankara, Turkey

Dilek Aslan, Murat Dellul, Ihsan Kuzucu, Emine Oflamaz, Mete Genc

Hacettepe University, Turkey

E-mail: [email protected]

Objectives: In this study it was aimed to determine the views of restaurant workers and customers located at Keηiφren 19 Mayύs and Ηiηekli districts about passive smoking and the tobacco legislation.

Materials and Methods: Ninety one workers of licensed 28 restaurants at Keηiφren 19 Mayύs and Ηiηekli districts and 139 customers who were at the restaurants on April 7-15, 2008 participated in this study. The study was cross-sectional for the workers and it was descriptive type for the customers. Questionnaire prepared by the research team was applied to the workers and customers.

Results: Eighty five out of 91 workers (93,4%) and 90 of the customers (64,7%) of the customers were males. Ten workers (11%), and 8 customers (5,8%) were younger than 18 years of age. Eighty five workers (93,4%), and 118 customers (84,9%) declared that smoking was allowed in the restaurants that they were in during the study. Fifty-six workers (60,6%), and 68 customers (47,5%) stated that they have no idea about passive smoking. Smoker participants either worker or customer supported the new Turkish anti-tobacco legislation less than the non-smokers.

Conclusions: Customers and workers should have been informed about the influences of passive smoking and the new Turkish anti-tobacco legislation. Advocacy activities are also required in this field.

Smokefree bars and restaurants:

Don't be duped by the 'Spanish Solution'

Dietmar Jazbinsek, Nick Kai Schneider, Martina Pφtschke-Langer

Unit Cancer Prevention and WHO Collaborating Center for Tobacco Control, German, Germany

E-mail: [email protected]

Introduction: After introducing smokefree workplaces and a total ban on advertising and sponsoring in 2006, Spain was considered on the right track towards a comprehensive tobacco control legislation. Its regulations for the hospitality industry however remained weak, and are currently used as a role-model by pro-tobacco front groups, politicians and the hospitality industry, i.e. in Germany and Austria.

Methods: Analysis of the Ley 28/2005, the regulatory instruments of the Autonomous Communities, as well as peer reviewed literature, tobacco industry documents and media reports.

Results: The Spanish tobacco control law includes several exceptions and vague definitions, leading to differences in regional interpretation and implementation. Within hospitality venues the ban depends on the size of the venue. Due to the strict regulations for smoking rooms and the freedom of choice given to owners of smaller venues (<100 m2), the vast majority of bars, restaurants and discotheques decided not to become smokefree.

Discussion: The regulations for Spanish hospitality industry can be considered a continuation of the widely described 'Accomodation' and 'Courtesy of Choice' programs. The weak implementation and the very low level of smokefree bars, clubs and restaurants in Spain, show that the current law does not suffice to protect employees in the hospitality industry.

Conclusions: National policy makers, advocates and researchers should be aware of the 'Spanish model', its use by tobacco industry front groups, and the consequences for smokefree hospitality industry.

Enforcement and compliance of California smoke-free laws: It works

Theresa Boschert, Dian Kiser, Narinder Dhaliwal

American Lung Association-California, United States of America

E-mail: [email protected];[email protected]

On January 1, 1998, California became the first state in the United States to prohibit indoor smoking in nightspots, bars, bar/restaurant combinations, bingo parlors, cardrooms, and casinos on a statewide basis. This abstract describes the activities which achieved this result, based on a program with three main goals: 1) Ease the transition for business owners; 2) Activate public support for the law; 3) Defeat tobacco industry efforts to undermine the law. 4) Training law enforcement officers to respond to public health concerns of enforcement and compliance issues. Important lessons learned from this campaign will be presented. Reliable estimates based upon on-site bar observations, place sustained overall compliance with Labor Code 6404.5 at 90% for all bars, taverns, gaming clubs and restaurants with bars, statewide. Enforcement activities are taking place in every county in California at municipal and/or county levels. (Compliance estimates are obtained from municipal and countywide code enforcement agencies, county health departments, and non-profit health organizations that monitor bar compliance in California). The vast majority of businesses, including California's thriving hospitality industry, have responded to the California Smoke-free Workplace Law with enthusiastic, voluntary compliance. Basically, the law is self-enforcing. After ten years, there is an expectation and the public expects places to be nonsmoking. Californian's like the law, and people do complain to management if they observe smoking indoors. However, when necessary, employees and the public may confidentially report violations of the law to local law enforcement agencies, including local health departments.

Riding the wave: Maintaining momentum after England went smokefree

Deborah Arnott, Martin Dockrell, Amanda Sandford

Action on Smoking and Health, United Kingdom

E-mail: [email protected]

Background: Gaining political support for comprehensive smokefree legislation in England required intensive campaigning and advocacy skills. After a long campaign there was a risk of "tobacco control fatigue".

Objectives: To demonstrate that political support for tobacco control measures can be maintained even after a particularly intensive campaign and successful outcome.

Methods: Working with coalition partners, ASH developed a strategy of engagement to carry the tobacco control programme onto the next level.

Results: Achieving comprehensive smokefree legislation was a major milestone in public health. Afterwards, there was a fear that politicians would feel that no further development of tobacco control was needed. Following implementation of the smokefree law in July 2007, ASH built on the enthusiasm of NGO coalition partners and launched a new campaign urging government to implement a comprehensive, sufficiently funded tobacco control strategy. Government responded by announcing it would launch a consultation on the future of tobacco control. ASH initiated a 'Round Table' of opinion-formers to help frame the consultation, produced a review of the Government's tobacco control programme so far and coordinated responses to the consultation. These and other initiatives acted as a catalyst for the Government's new national tobacco plan.

Conclusions: Pressure on governments to maintain strong tobacco control programmes is vital, particularly following the implementation of a key target policy. The risk of resources being diverted away from tobacco control can be mitigated through co-ordinated action by NGOs and other public health advocates.

Smoke free north east; a model of good practice for England?

Andrew Russell

Durham University, United Kingdom

E-mail: [email protected]

Background: Tobacco control offices are a new organizational phenomenon in the UK. The north east of England, the region with the highest proportion of smoking-related deaths anywhere in the country, was the first to establish such an office, based on precedents in California, Australia and elsewhere in the world. It thus presented a golden opportunity for multidisciplinary research that combines description, evaluation and action.

Objectives: To describe and evaluate the work of Smoke Free North East (SFNE) to date with a view to ascertaining whether, and if so how, it is a model that can work in other regions of England and for other public health concerns.

Methods: In-depth participant observation working with staff and stakeholders of SFNE, interviews and focus groups with public and professionals, action research based on emergent findings, over a three year period.

Results: SFNE has played a key role in the formulation and delivery of public policy concerning tobacco and health not only in the north east region but nationally. As a vanguard organization its position and role on the national and regional stage is changing as similar organizations are established in other parts of the country, and for other public health issues.

Conclusions: SFNE does indeed offer a model of good practice for England and other countries. Anthropological action research methods provide a dynamic and resource-full means of both evaluating and enhancing the work of an organization such as this.

Achieving high compliance with smoke free law from the first day....lessons from a stakeholder engagement programme in Northeast England

Background: On 1 st July 2007, comprehensive smokefree legislation was implemented across workplaces and enclosed public places in England.

Objectives: To ensure over 95% compliance with the legislation from day one across the whole North East region.

Methods: A comprehensive stakeholder engagement and communications strategy was devised to ensure thorough preparation and planning was undertaken across the region. This was developed with key partners including the local councils' environmental health departments, local tobacco alliances, key regional business agencies and trades unions. It included: A clear advocacy plan; delivery of a training programme for consistent enforcement; delivery of a fully integrated media and communications plan, including training of local spokespeople in key messages, range of public relations, advertising activities, dissemination of collateral, regional road shows; pre and post implementation air quality monitoring; ongoing business support and media activity in first few months.

Results: One week before the law was implemented support for the law was highest within the country at 83%. Nine months after the implementation the North East had the highest compliance rates in the country (of 26,877 premises inspected- 98.7% non-smoking). Levels of PM2.5 in the nine venues tested had reduced by 86%% and levels of cotinine had reduced by 75% in the non-smoking bar staff within one month.

Conclusions: Very high levels of compliance can be achieved from day one if a thorough and comprehensive stakeholder engagement programme is implemented in the months preceding the introduction of the law.

  The role of media in promoting and reducing tobacco use: Findings from the National Cancer Institute's Tobacco Monograph 19 Top

Introduction and Overview

K Viswanath

Harvard School of Public Health, United States of America

[email protected]

This presentation will provide an overview of the development of the research Monograph 19, 'The Role of Mass Media in Promoting and Reducing Tobacco Use' under the National Cancer Institute's Tobacco Monograph Series. The presentation will discuss the review process and the major conclusions of the monograph and introduce the speakers.

Tobacco in the entertainment media

Barbara Loken

University of Minnesota, United States of America

E-mail: [email protected]

American youth are exposed to several hours per day of entertainment media from television and other sources. This presentation describes portrayals of tobacco products and tobacco use in movies as well as other entertainment channels (e.g. television, music, magazines, and the Internet). Most of the entertainment research includes research on the movie industry, with a variety of research techniques employed such as content analyses, cross-sectional studies, longitudinal studies, and experiments. Content analyses show that depictions of tobacco and tobacco use are pervasive in movies, occurring in three-quarters or more of contemporary box-office hits, and identifiable cigarette brands appear in about one-third of movies. Health consequences of smoking are rarely shown. Cross-sectional and longitudinal studies show that among adolescents, exposure to smoking in movies is associated with initiation of smoking and more positive attitudes toward smoking among never-smokers. Experimental studies show that tobacco depictions in movies can influence adolescent and adult viewers' beliefs about social norms for smoking, beliefs about the consequences of smoking, and intentions to smoke. The total weight of evidence indicates a causal relationship between exposure to movie smoking depictions and youth smoking initiation. Experiments also show that anti-tobacco advertisements screened prior to films can partially counter the impact of tobacco portrayals in movies. Efforts to reduce media exposure to tobacco include restrictions on tobacco advertising and product placements, media literacy targeting the general public, and dialogue regarding tobacco-related ratings by the movie industry.

How mass media campaigns can reduce tobacco use

Melanie Wakefield

The Cancer Council Victoria, Australia

E-mail: [email protected]

Mass media interventions, most often using televised media messages, have been a key component of state and national tobacco control programs in the past four decades. This presentation summarises evidence that mass media campaigns can reduce tobacco use, drawn from four chapters of the US NCI Monograph 19 on 'The Role of the Media in Promoting and Reducing Tobacco Use'. A variety of study methodologies have been used to assess campaign effects, including controlled field experiments with school and/or community-based program activities, and population-based cross-sectional or cohort studies. Evidence from controlled field experiments and population studies shows that mass media campaigns designed to discourage tobacco use can change youth attitudes about tobacco use, curb smoking initiation, and encourage adult cessation. Additionally, there has been a range of experimental and qualitative studies of immediate responses to different types of anti-tobacco television advertisements. Overall, advertisements that elicit negative emotional responses (such as loss, disgust, sadness, dread or anger) perform well, whereas advertisements that are emotionally neutral or humorous are less likely to do so. Emotionally evocative advertisements tend to perform well among many population subgroups. Tobacco industry efforts to impede mass media campaigns have included lobbying to prevent or reduce campaign funding or to weaken messages, attempting to reduce the size of the target audience to small population subgroups, and creating their own mass media campaigns and arguing that government-run campaigns are duplicative. However, studies show that tobacco company-sponsored smoking prevention advertisements generally perform poorly and may have adverse effects on youth.

Tobacco marketing

K Viswanath

Harvard School of Public Health, United States of America

E-mail: [email protected]

A significant contributor to the ability of the tobacco industry to continue to thrive despite intense efforts to control it is its marketing and marketing communication strategies. Drawing on sophisticated marketing principles and manipulation of key marketing elements of product, pricing, places and promotion, the industry has been successful in establishing a strong brand identity and market position countering efforts to control tobacco use. Using sophisticated messaging and audience segmentation strategies across different marketing communication platforms, tobacco companies manage to associate tobacco use with positive images such as athleticism, glamour and social status among others. Partial efforts to regulate tobacco marketing practices are unlikely to be effective as tobacco companies work to undermine them by shifting their strategy and tactics. The total weight of evidence from multiple types of studies using data from many countries, demonstrates a causal relationship between tobacco advertising and promotion and increased tobacco use -initiation and increased per capita tobacco consumption in the population. This presentation will review studies that extensively examined key principles and themes used by the industry in promoting tobacco use, the extent of tobacco advertising and promotion, its public relation efforts to improve its public image in the face of criticism, and the impact such strategies had on tobacco use among consumers as well as in resisting regulatory efforts. The chapter will end with a constitutional and legal perspective on tobacco marketing restrictions and its implications for future tobacco control efforts.

The role of media in promoting and reducing tobacco use: India perspective

Prakash Gupta, Karthik Subbaraman

Healis Sekhsaria Institute for Public Health, India

E-mail: [email protected]

Media intervention is invaluable to both the tobacco industry and the tobacco-control advocates in advancing their respective agendas. Two factors that appear to contribute to the growing media influence are (1) media volume and (2) paid media and industry diversification. The carefully-planned move of diversification into several non-tobacco products is one such example where the industry uses media to promote their brand identity. A quick glance at media adspend suggests the possible correlation between media bias toward specific sectors, and their similarity with the sectors that the industry has diversified into. This combined with a systematic increase in the growth of print and television (23%), and web-media (16 times increase since 2000) suggests that paid media may influence media-favorability toward tobacco-related issues. Tobacco-control advocates have used media to demystify the industry and advance specific policies. The pictorial warning campaign is one such example highlighting the importance of media. We undertook an intensive media campaign that included integrated media efforts, nationally-coordinated ground events, and the use of new-age media including SMS polling and web-portals. Thus, media can play a crucial role in advancing the tobacco control agenda in India. While there is obvious need for technical and financial expertise, there is a greater need to influence media opinion through diverse means, and rural India could be one of them. The increasing rural penetration of diverse media outlets hints at the mass support that media may be able to garner from this population in advancing tobacco control agenda.

  Tobacco industry monitoring I Top

FUSADES: An air quality research laboratory supported by philip morris in EL Salvador

Carlos Enrique Kummerfeldt, Joaquin Barnoya, Lisa Bero

Aldo Castaneda Foundation, Guatemala, Guatemala

E-mail: [email protected]

Background: The tobacco industry has organized research institutions to generate misleading data on indoor air quality, including secondhand smoke exposure and health effects.

Objectives: To describe tobacco industry involvement in the organization and financial support of an air quality research laboratory in El Salvador.

Methods: We systematically searched tobacco industry documents on the internet from August 2007 to February 2008. Furthermore, we searched for air quality studies done in El Salvador.

Results: Philip Morris sought to establish a network of air quality laboratories throughout Latin America. In El Salvador, in 1997, through Tabacalera de El Salvador (Philip Morris' subsidiary) and the Salvadoran Foundation for Economic Development (FUSADES) the industry organized an air quality research laboratory. FUSADES was part of the industry's Latin American Scientific Network, which consisted of physicians hired as consultants who would send air samples from their research studies to FUSADES. Philip Morris Scientific Affairs personnel hired LabStat, a Canadian based laboratory, to implement, validate, and transfer, air quality analytical assays to FUSADES. In addition, Washington based HMS Group assisted in searching for sustainable funding options and implementation of a working plan to upgrade the laboratory. International aid for Hurricane Mitch was a potential source of funding. FUSADES is now ISO certified and has conducted air quality research for the country's Ministry of Environment.

Conclusion: Philip Morris contributed to establish an air quality research laboratory in El Salvador. This well-recognized laboratory would generate air quality data that minimizes the relevance of secondhand smoke as a pollutant.

The tobacco industry activities in the EMR region

Fatimah El-AWA, Heba Fouad

Worled Health Organization EMRO, Egypt

E-mail: [email protected]

For long the tobacco industry has been heavily involved in undermining tobacco control efforts in the Eastern Mediterranean region, the release of the WHO report "voice of truth" in the EMR region changed this fact, the tobacco industry activities were for the first time under the spot light in the region countries and regional organizations were alert to their tactics and strategies. The legislation that were adopted recently in many of the region's Member States strained the hands of the industry and their capabilities in combating tobacco control, yet they are still trying and coming up with strategies more than ever that would influence decision makers and the public. Activities of the tobacco industry in the region as highlighted in the WHO/EMR publications; how member states of the region can face the tobacco industry, and how WHO regional and country offices can assist countries in their activities will be the focus of this presentation; taking into account that the FCTC obligated all its parties to take the needed action to stop any influence of the tobacco industry over tobacco control national policies. The role of regional organization and how they can support the process will be also highlighted in this presentation.

History of tobacco control legislation in South Africa and tactics of the tobacco industry in undermining, delaying, weakening, subverting and abusing tobacco control legislation

Peter Ucko

National Council Against Smoking, South Africa

E-mail: [email protected]

Tobacco Control and public health policy has progressed in South Africa with the usual, expected and unexpected obstacles of fighting the strong and rich tobacco industry and the difficulties of legislation drafting and parliamentary political processes. It was as early as 1986 when the author, as the Mayor of Edenvale introduced a smoking ban in all municipal buildings. There is now a rich history to be told of, and lessons to be learned from the NCAS lobbying, the parliamentary and legislative process, the introduction of tobacco control laws in SA in 1993, amendments in 1999, the coming into operation of the law in 2001, further amendments in 2007 and 2008, the colourful and wonderful people involved. There were constant threats, contraventions and ingenious tactics from a killer industry. A timeline with details of events, with photographs, newspaper clippings and stories of difficulties and successes will serve not only as a record of events but as valuable lessons for countries, especially in Africa, in how to deal with the tobacco industry, politicians and introducing their own tobacco control policies. This is an exciting look at vital aspects of tobacco control and health promotion in South Africa.

Accountability of tobacco companies in Philippine courts

Deborah K Sy, Charadine Bandon

FCTC Alliance Philippines, Philippines

E-mail: [email protected]

In the Philippines, where over one-third of the population is exposed to health risks caused by tobacco, an analysis of the legal theories available to tobacco victims, to seek redress for injuries, can help the government deal with tobacco industry liability, consistent with Article 19.1 of the FCTC.

Objectives: To explore and evaluate legal grounds available under Philippine laws and jurisprudence to exact accountability from the tobacco companies for damages arising from tobacco-related deaths and diseases.

Methods: A systematic search of related local laws and jurisprudence, and a survey of related American cases were utilized. Data were collected from news, reports, interviews with health advocates and lawyers.

Results: The study shows that the basic provision on quasi-delict/torts, the violation of the Constitutional right to health and the Consumer Protection Law, are among the legal theories available to tobacco victims. However, the dearth of local jurisprudence on these theories causes the fate of the victims' claims to rest largely upon the sound exercise of the judiciary's discretion.

Conclusions: The path to success in this field of tobacco litigation depends on the judiciary's liberal stance in interpreting the Constitutional rights. The legislature should pass specific laws in order to provide clearer legal basis for redress, to formulate rules that shift the burden of evidence, and to make administrative remedies available.

Communication in Finland to prevent smoke-free legislation

Satu Lipponen

Cancer Society of Finland, Finland

E-mail: [email protected]

Background: Communication strategies for lobbying purposes by the tobacco industry take place globally. Intensive lobbying and versatile communication strategies were used in Finland as the tobacco industry reacted with alarm to the further development of smoke-free legislation. In the early 1980΄s activities were targeted towards decision-makers, journalists and the media. Now, after two decades, it is possible to grasp, how tobacco companies influenced the mass media.

Methods: The influence of the tobacco industry is examined from three different angles: Industry documents, unofficial documents from a private communications consultant and media analysis to determine how the tobacco industry framed messages. Outcomes Based on documents and the media, seven strategies to frame messages were identified. These include exaggeration and shrinking to distort communication in favour of the tobacco industry΄s goals. In addition, key journalists were approached. The monitoring of Parliament was also a crucial element of the lobbying strategy. All activities in Finland were derived from global strategies, coordinated at the European or Nordic level and adapted to suit various local environments.

Conclusions: Framed messages can be identified by communcation research. Comparison to globally-applicable documents enable a better understanding of the tobacco industry tactics. The unlimited resources and powerful means of persuasion employed by the industry - especially rhetoric concerning notions of freedom - should be carefully weighed and not underestimated.

Research on Ti's advertising, sponsorship and philanthropy activities in Vietnam

PhI DoThi, Hai PhanThi

Center for Research And Community Development Services, Vietnam

E-mail: [email protected]

Objectives: To assess the real situation of the TI's advertising, promotion and sponsorship activities in Vietnam; and to recommend to the policy makers and tobacco controllers the feasible measures to effectively enforce the Ad ban.

Methodology: Various interactive data collection methods were used, combining qualitative (in-depth interviews) and quantitative techniques.

Results: Direct ad activities on big scale have almost stopped. Indirect ad activities on small scale happened at different levels and at different times. Violations using other objects for advertising still happen at POS, pubs and restaurants. Direct advertising to invite people to smoke still continues. POS advertising with display counter and shelves with logo or brand name color is at a high level. The display of more than one package/carton is very common. The handling to the violations is not strict. Promotional activities on big scale have stopped since 2006. There were no sponsorship for sports and cultural activities. There appeared sponsorship under the name of school smoking prevention program. CSR activities are still conducted with limitation in using the brand name logo or color.

Conclusion: TIs violations were identified; recommendations for measures to effectively enforce the Ad ban were made and sent to responsible government officials for legal document improvement.

  Warning labels II Top

Are morbid graphic tobacco pack warnings likely to be effective deterrents to tobacco consumption in India?

Aditi Shastri

ACT-India, India

E-mail: [email protected]

Background: The MOH, Government of India, notified that graphic warnings on tobacco packs would be mandatory from July 5 2006. Intense pressure from the tobacco lobby has watered down and delayed the implementation of this act till date.

Objectives: 1) To assess public perception on tobacco associated illness; 2) To determine the level of public awareness regarding tobacco pack warnings; 3) To gather public opinion on the likely effect of selected pictorials as effective deterrents.

Methodology: Cross-sectional study of 400 adult Mumbai metropolitan railway commuters, selected at high-density spots through convenience sampling. The subjects were interviewed using a questionnaire that included the pictorial warnings. Data was entered in Epi Info version 3.3.2 and analyzed using Intercooled Stata 8.2 for Windows.

Results: Over 84% were aware that tobacco caused a number of diseases; 91% felt that graphic warnings would be more effective; 72% of tobacco users were more likely to consider quitting if they saw particularly gruesome graphic warnings on tobacco packs; 71% felt that both graphic and written warnings should occupy over 50% of the face of the pack and should be on both sides to be effective deterrents.

Conclusion: Gruesome pictorial warnings on tobacco packs are likely to be effective deterrents to the habit. The MOH, Government of India should generate and seek specific scientific information on their efficacy before accepting the current watered down versions.

Effectiveness of tobacco health warning in cigarette package in Indonesia

Rita Damayanti, Agustin Kusumayati, Amri Ismail, Fitrianur

Center for Health Research University of Indonesia, Indonesia

E-mail: [email protected]

Background: Indonesia ranks fifth in tobacco consumption globally, with smoking prevalence among males from 53.4% to 65.2%. Furthermore, smoking prevalence among adults 15 years or older increased from 26.9% in 1995, to 34.5% in 2004. Although it has a policy of text health warning, this does not seem effective to deter smoking.

Objectives: To evaluate the effectiveness of existing health warning, and to find out community preference on types of the health warning.

Methods: Study was conducted by using an accidental sampling design covering 1239 urban and rural respondents in various segments of the population in 2007.

Results: Over 90% of respondents had ever read the messages. However, it had no effect that would encourage quiting in 45% of low and 37% of high socio economic respondents. About 42.5% of the respondents did not believe in the messages, 26% were not motivated to quit smoking by the message, 25.8% were careless due to addiction, and 19.7% stated that warning was too small. Over 76.3% of smokers preferred combined text and pictorial, besides the respondent also preferred on 50% of the wide panel (78.2%) compared to 30%. Smoker had higher preference on informative (29.7%) and specific messages (31.7%), but non-smoker preferred scary messages (40.7%).

Conclusion: Our findings suggest large, specific and informative messages with pictorial health warning would affect smoking behaviour and will be used in amending the existing regulation.

Canada's experience in renewing its labelling requirements

Christine Belle-Isle

Tobacco Control Programme, Health Canada, Canada

E-mail: [email protected]

In 2000, Canada introduced the first pictorial tobacco product labelling regulations. Not only did the new regulations require graphic health warnings to be displayed, they also mandated the inclusion of health messages containing information to help people quit smoking and expanded the requirements for presenting toxic emission/constituent levels. Since 2001, research and evaluation results show that the current requirements for tobacco product labelling have achieved a good measure of success but could be improved. Additional research indicates that some of the health warnings are not as equally effective at reaching all current and potential smokers, in particular, adults with lower literacy skills, older smokers and hard-core smokers. Studies also indicate that health information messages are not sufficiently noticed or read by smokers and toxic emission/constituent statements are not always well understood. In 2004, Canada initiated the process of renewing the current labelling regulations. A consultation document was released with proposed changes to the labelling requirements. A large number of pre-market tests to assess the effectiveness of proposed health warnings, health information messages and toxic emissions statements with tobacco users followed the consultation process. The presentation will provide an overview of proposed changes to the tobacco products labelling regulations for smoked, sniffed, sucked and chewed tobacco products. Tobacco labelling design elements will be discussed such as the use of pictorials, message content and rotation. The process followed in the development of the proposed labelling requirements, results of pre-market testing and lessons learned will also be presented.

What is the short and longer-term impact of graphic health warning labels on adolescents' smoking related beliefs and behaviours?

Victoria White, Geoff Smith, Melanie Wakefield

The Cancer Council Victoria, Australia

E-mail: [email protected]

Background: Although graphic health warning (GHW) labels on cigarette packs promote quitting among adult smokers, their effects on adolescents are studied infrequently.

Objectives: To assess the immediate and longer term impact of the introduction of GHW labels on adolescents' smoking-related behaviours and cognitions.

Methods: Three cross-sectional surveys of secondary school students (Aged 13-17) in the Australian state of Victoria were undertaken: 1) prior to GHW introduction (Baseline); 2) approximately 6-months after GHW introduction (1 st follow-up), and 3) two years after GHW introduction (2 nd follow-up). Students answered questions on smoking involvement, exposure to cigarette packs and cognitive processing of warning labels. Data from 2432 students at Baseline and 2050 students at the 1 st follow-up were used for analyses. The 2 nd follow-up will survey around 3000 students aged 13-17 in 2008.

Findings: At Baseline, 72% of students had seen cigarette packs in the previous 6-months, while at 1 st follow-up, 77% had seen packs and 88% of these had seen the new GHWs. Students more frequently read, attended to, thought and talked about warning labels at 1 st follow-up. Experimental and established smokers thought about quitting more at 1 st follow-up. Analyses examining students' awareness and processing of warning labels between 1 st and 2 nd follow-up will be presented.

Conclusions: The introduction of cigarette pack GHWs increased immediate attention to and cognitive processing of warning label messages. Understanding whether the effect of GHWs on adolescents' smoking-related cognitions is maintained will provide information on the need for their review and update.

Impact of the removal of misleading terms on cigarette pack on smokers' beliefs about light cigarettes: Cross country comparisons from the ITC four country survey

Ron Borland, Hua Yong, Geoffrey Fong, Ann McNeill

The Cancer Council Victoria, Australia

E-mail: [email protected]

Background: In compliance with Article 11 of the FCTC, a number of countries have banned the use of misleading brand descriptors such as "light" and "mild" on cigarette packaging. There are also initiatives to remove misleading ISO tar, nicotine, and carbon monoxide yields.

Methods: We evaluated how smokers' beliefs about cigarettes changed in Australia and the UK where the terms were banned compared to Canada and the USA where they remain. The 2003 ban in the UK was followed by implementation of the 10-1-10 EU regulation that established limits on ISO yields, but with the misleading yields remaining on packs. In Australia, the 2006 ban was closely followed by removal of ISO yields from packs. Data come from six waves (2002-7) of the annual ITC Four Country cohort surveys of adult smokers.

Results: Misperceptions about "lights" (e.g., that they are less harmful), which were common among smokers in all four countries, have declined over time, except in Canada, where they have been lowest. There was a significant reduction in misperceptions in the UK following its ban, but it was not sustained. Reductions in misperceptions in Australia following the ban were sustained, and by 2 years after, considerably larger than in the UK, and at levels similar to Canada (with no bans).

Conclusions: The results suggest that bans on 'light' and 'mild' are insufficient on their own to effectively eliminate misperceptions. ISO yields on packaging may undermine the positive effects of a ban or educational campaigns, and should be removed.

Reactions to health warning labels with graphic imagery among smokers in four countries: Does fear arousing content matter?

James Thrasher, Victor Villalobos, Geoff Fong, David Hammond

University of South Carolina, United States of America

E-mail: [email protected]

Background: Cigarette package health warning labels (HWLs) with graphic imagery appears to have a more sustained impact on adult smokers than text only warning labels. However, no research has been conducted to determine whether the impact of graphic imagery on HWLs is independent of whether the imagery is fear arousing or not.

Objectives: Assess whether smokers reactions to HWLs with graphic imagery differ in countries where warnings includes gruesome, fear arousing imagery (i.e., Thailand, Australia, Canada) compared to countries where it does not (i.e., Uruguay)

Methods: Data were drawn from the International Tobacco Control Policy Evaluation Project, using cross-sectional assessments taken within a year (i.e., Uruguay, Canada, Thailand) or two (i.e., Canada) after the implementation of graphic warning labels.

Results: In bi-variate analyses, no cross-country differences were found in indicators of low-level cognitive processing of HWLs (i.e., frequency of noticing HWLs; frequency of reading HWLs); however, fewer Uruguayan smokers reported deeper cognitive processing of HWLs that are closer to behavioral change (i.e., frequency of thinking about health risks because of HWLs; HWLs make you more likely to quit) and avoidance (i.e., frequency of not looking at HWLs). In multivariate models, these differences remained statistically significant.

Conclusions: Gruesome graphic imagery on HWLs appears to promote deeper cognitive processing of health warning labels; however, more gruesome imagery also promotes more avoidance behavior. Longitudinal data are needed to determine differences in downstream impacts of different HWLs and experimental studies are needed to illuminate the effects of specific HWL message content.

Awareness of warning labels among tobacco users in India: Findings from the international tobacco control (ITC) India pilot survey

Maansi Bansal-Travers, Geoffrey T. Fong, Prakash Gupta, Dhirendra Sinha

Roswell Park Cancer Institute, United States of America

E-mail: [email protected]

Background: India currently has text-based warnings but set guidelines for graphic warnings in 2006. India was obligated by their ratification of the FCTC to enhance their warnings in 2007. Graphic warnings have been contentious, leading to repeated delays in their implementation. In March 2008, the Group of Ministers proposed a revision. It is not clear when new FCTC-compliant warnings will appear in India.

Methods: 763 adults (18+) participated in the ITC India Pilot Survey in the urban and rural regions of Maharashtra and Bihar in 2006. Respondents of this face-to-face survey included smokers (n=249), smokeless tobacco users (n=248), and non-tobacco users (n=266).

Results: Overall awareness of the current text-only warnings was low: only half of all tobacco users and non-users knew that warnings even exist on cigarette packs. Knowledge of health risks from tobacco use was low: only 77% of smokers and 85% of smokeless tobacco users believed that smokeless tobacco causes mouth cancer, and less than half of smokers believed that smoking causes stroke, coronary heart disease, and impotence in male smokers. Additionally nearly 75% of smokers said that the current text-based warnings did not make them more likely to think about the health risks of smoking or to quit.

Conclusions: ITC surveys conducted in Canada, Australia, and Thailand show that graphic warnings significantly increase awareness of the health risks from smoking. Given the low literacy rate in India, graphic warnings are an effective and inexpensive method to educate Indians about the health risks from tobacco use.

  Women and tobacco Top

Knowledge, attitude and behaviour of Malaysian female adolescent smokers

Mohamad Haniki Nik Mohamed, Zaswiza Mohamad Noor, Swinder Jit Kaur, Sallehudin Abu Bakar

International Islamic University Malaysia (IIUM), Malaysia

E-mail: [email protected]

Background: Smoking among Malaysian female 13 to 18 years is 4.8% (NHMS 2, 1996). However, assessment of knowledge and perception regarding smoking in this group is lacking.

Objectives: To determine smoking-related knowledge, attitude and behaviour among female adolescent smokers.

Methods: 56 female adolescent smokers selected randomly at a shopping mall were given questionnaires to self-administer upon consent. Questionnaires contain demographic data and 30 smoking-related questions.

Results: Mean age is 17.85 ΁ 1.1 (range 16 to 19) years. Of 56 girls, 40% smoked everyday. 32% of the subjects smoked more than 20 sticks, 50% smoked 2-20 sticks and 18% smoked less than 2 sticks per day. 78% bought cigarettes from convenient stores or restaurants. 66% smoked at public area and 62.5% smoked without family acknowledgement. 18% also tried shisha, bidis, cigars and chewing tobacco. 21.4% will still smoke in the next 5 years. 69.6% agreed that quitting is difficult. 71.4% agreed smoking makes appearance less attractive. Only 23.2% thought smoking makes one become more outstanding. 55.4% disagreed that smoking reduces their weight vs. 42.9% who agreed. 91.1% realized inhaling other person's tobacco smoke is harmful. Only 23.2% admitted that smoking is wasteful. 87.5% agreed with the 'No Smoking' signs at the public places. 60.7% wanted to quit smoking if possible.

Conclusion: Smoking among female adolescents in Malaysia is a serious problem. Adolescent smokers need to be educated further regarding the harmfulness of smoking and provided assistance with quitting.

Smoking in girls and young women in Vietnam

Thi Kieu Thanh Ha Tran, Hoang Anh Pham, Dinh Quan Nguyen, Pham Nguyen Thanh Vu

Health Bridge, Vietnam

E-mail: [email protected]

This research was to facilitate the development of gender-sensitive TC policies in Vietnam by investigating smoking behaviour of young women, their awareness of and support for TC policies and exposure to and perception of tobacco advertising, promotion, sponsorship.

Methods: The research combined quantitative (cross-sectional survey) and qualitative (focused-group discussion) data collection methods. The study population included female students aged 13-25 in Hanoi (urban) and Thai Binh (rural). Participants were recruited through random sampling.

Results: The proportion of ever-smoking girls was much higher in urban than in rural areas and increased incrementally with age groups. Most of them were not regular smokers. Half of the ever-smoking girls first tried a cigarette at the ages of under 13. A majority of the girls had negative attitude toward smoking. There remained some myths on smoking among the girls. Their knowledge of tobacco's harms was limited in a narrow group of diseases. Lower-secondary schoolgirls were more sensitive to cigarette advertisement than older girls. Over 5% of the upper-secondary and university girls were offered cigarette samples in the past year. 50% of the girls could mention women targeting cigarettes. They were unaware of tobacco industry's marketing tactics. Many girls did not think current implementation of TC policies were successful, however, they strongly support the policies and believe in their effectiveness.

Conclusions: Deterring the smoking initiation among youth females should be included in TC programs' targets and could be reached by comprehensible communication modules and TC policies in line with FCTC recommendations.

Diminishing the impacts of secondhand smoke on women and children health in Vietnam: The role of Vietnam women's union and networking

Anh Duong Kim, Anh Pham Thi Ngoc

Center for Women's Studies (Vietnam Women's Union), Vietnam

E-mail: [email protected]; [email protected]

Vietnam has a high smoking rate since it is one of the top 15 countries with high proportion of smokers accounted for more than ΍ smoking people all over the world. According to a recent national survey, the rate of children under 5 living in the households with smokers is 71.1%, millions of women living in the families with husbands or relatives smoking. Secondhand smoke has been found to have deep impacts on female reproductive health and children health. The Vietnamese Government has issued regulations and rules on tobacco control and prevention. However, the results are still limited as there is lack of necessary enforcement; communication and education on impacts of passive smoking to women and children are still inadequate; the cooperation among concerned organizations and ministries is not close enough to pool in the social sources. As a member of Vietnam Steering Committee on Smoking and Health (VINACOSH), every year Vietnam Women's Union (VWU) organizes workshops, training courses, communication campaigns on tobacco affects to protect women and children against passive smoking exposure. My presentation tends to address following issues: (1) Role of VWU and concerned parties in struggling for diminishing secondhand smoke on women and children in Vietnam; (2) Experiences learned; (3) The issues of enhancing networking to protect women -children rights. The presentation shows update data on situation of secondhand smoke impacts on women and children in Vietnam. Secondary and primary data are shown with qualitative and quantitative evidences to strengthen author's point of views.

Characteristics of Chinese young women who used quitline services in Hong Kong

Sophia Chan, David Wong, Yim-Wah Mak, Tai-Hing Lam


E-mail: [email protected]

Background: The smoking prevalence among women is increasing in Asia, and smoking cessation hotline is an effective means to assist smokers quit smoking. Despite the booming of quitline services globally, few focus on young female smokers.

Objectives: To examine the characteristics and needs of young female smokers who called the Quitline

Methods: A Youth Quitline has been initiated in Hong Kong since 2005, managed by peer counselors, to provide smoking cessation counseling for youth smokers aged 12 to 25 years. Callers were invited to complete a 15-minute survey over the phone to assess their smoking history and profile before counseling.

Results: During 2005-2007, 130 young women (mean aged 18, SD = 4.2) received telephone counseling. The mean age to start smoking was 13 years (SD = 2.1), and Fagerstrom test showed low level of nicotine dependency in the majority (60%). Nearly two-third lived with smoking family members and 76% responded half or more of their friends smoked. Most wanted to quit due to concerns of their health, intention to become pregnant (58%), and requested by school teachers, parents or friends to quit smoking (33%). However, 51% responded they were temped to smoke when they saw others smoke, and 19% would smoke if they are bored.

Conclusions: Smoking cessation intervention on young female smokers can focus on strengthening their self-efficacy to resist smoking temptation from others, and to emphasize gender specific health consequences of smoking during pregnancy and to their new born babies.

Worksite and home smoking bans among employed adult female smokers in the United States: A promising approach for women and girls worldwide

Allison Rose, Deirdre Lawrence, Alton Hart, Pebbles Fagan

SAIC-Frederick, Inc., United States of America

E-mail: [email protected]

Background: Tobacco use rates are increasing among women and girls worldwide. U.S. data suggests comprehensive smoke-free work and home policies may help slow this rising epidemic.

Objectives: This study examines smoking and quitting behaviors of U.S. employed indoor female smokers (ages 18-64) by four smoke-free policy levels: Both complete worksite and home smoking bans; complete home ban only; complete worksite ban only; no complete ban at work or home.

Methods: Cross-sectional data from the 2003 Tobacco Use Supplement to the Current Population Survey were analyzed in SUDAAN to generate weighted estimates of cigarette consumption, quit attempt length, and quitting intentions by the four policy variables (n=8573).

Results: Approximately 24% reported both worksite and home bans, 9% reported home bans only, 47% reported worksite bans only and nearly 20% reported neither worksite nor home bans. Light smoking rates

(< 5 cigarettes/day) were highest among women with both worksite and home bans (41%) and women with home bans only (37%) compared to women with work bans only (18%) or no complete bans (15%). Longer quit attempts (4+ months) and intentions to quit in the next month were also highest among women with both bans (9%, 20%) and home smoking bans only (9%, 16%) compared to those with work bans only (4%, 12%) or no complete bans (5%, 12%). Multivariate analyses will be presented.

Conclusions: Incorporating complete home smoke bans as part of smoke-free policy efforts is an effective and necessary strategy for slowing the tobacco use epidemic among girls and women worldwide.

Susceptibility to smoking initiation among rural and urban young Chinese women

Shaojun Ma, Michael Ho, Gonghuan Yang, Thomas E. Novotny


E-mail: [email protected]

Background: China has the largest population of cigarette smokers worldwide. Recent epidemiologic studies suggest that the prevalence of smoking among young women in China is rising. Tobacco industry document research indicates specific market segmentation and product development targeting young women in China.

Objectives: This study aims to understand not only the risks for uptake of smoking by a well-recognized vulnerable population, but also the potential for prevention programs among young Chinese women. This is a collaborative project with the Chinese CDC (CCDC) and Johns Hopkins University to understand susceptibility to smoking initiation among Chinese women aged 14-24.

Methods: In 2008, we implemented a cross-sectional behavioral survey of rural and urban Chinese high school and college-aged women (n=10,000) accessed through the China CDC and provincial educational systems (n=6). Institutional review board approvals from UCSF and PUMC were obtained. Training workshops for surveyors were held in Beijing in June and field studies will be completed in July 2008.

Results: We will analyze demographics, knowledge, attitudes, and practices regarding smoking and health risks. We will also ascertain recognition of women's brands and their advertising and marketing. We will stratify the results according to rural and urban residency status and conduct multivariate analyses of the data collected to identify primary predictors of current smoking, experimentation, intention to smoke, and positive attitudes toward smoking.

Conclusions: In-depth population-based research is helpful to monitor the knowledge, attitudes, behaviors, and beliefs of young Chinese women in order to develop appropriate prevention measures in this vulnerable group.

Mixed methodology in the development of a culturally relevant tobacco control approach among Brazilian women: Lessons learned

Isabel Scarinci, Andrea Silveira

University of Alabama at Birmingham, United States of America

E-mail: [email protected]

The focus on factors associated with smoking among Brazilian women in worksites is timely since an increase in the numbers of working women is occurring in parallel to a suggested increase in the incidence of smoking among Brazilian women; an increase that is not matched by prevention and cessation interventions in the workplace. The purpose of this presentation is to discuss the methodology used to develop a culturally relevant approach based on contextual variables that contribute to smoking initiation, maintenance, and cessation among Brazilian women in worksites. In order to accomplish this task the present study used a mixed methodological approach. We began with 22 focus groups among current smokers, former smokers, and never smokers in order to identify potential sociocultural variables that contribute to smoking initiation, maintenance, and cessation among Brazilian women in worksites which was conducted in parallel to the examination of smoking policies at participating worksites. Based on the obtained information, a theory-based, culturally relevant questionnaire was developed to quantitatively confirm the qualitative findings. This questionnaire was administered to 1,066 Brazilian women in private and public worksites. Based on the findings an intervention model was developed. This presentation will provide participants with detailed information on how an international collaboration was established and maintained, the rationale for choosing the corporate approach rather than the community approach, how the mixed methodology was developed and implemented (including analytical approaches), development of the intervention approach, how capacity building has been established, and lessons learned.

  Youth tobacco use I Top

Prevalence of tobacco use in youth as confirmed by cotinine test

Saddichha Sahoo, Christoday RJ Khess

National Tobacco Control Program, India

E-mail: [email protected]

Background: Prevalence of tobacco use in India is reaching alarming proportions, despite efforts by both WHO and GOI in controlling it. Part of the problem has been lack of available data on tobacco use in various groups. Although GYTS and NFHS III have focused on adolescents and adults respectively, data on use among young adults is still lacking. Another problem has been use of questionnaire method to determine tobacco use which may not reveal exact prevalence.

Aim: To study prevalence of tobacco use among young adults in Ranchi, as confirmed by serum cotinine levels.

Methods: 500 students selected through systematic randomized process to represent 5 universities in Ranchi. After informed consent, students administered tobacco and other substance use questionnaire. Subsequently, all respondents were subjected to one-Step Rapid Nicotine Test in urine to improve sensitivity and biologically confirm prevalence. All tobacco users were then administered Fagerstrom's Scale for Severity of Nicotine Dependence.

Results and Conclusion: Biologically confirmed prevalence of tobacco use was 55.6% revealing high degree of prevalence in this age group. Predominant form of tobacco use was cigarettes (78%) followed by khaini (20%) and gutkha (2%), showing that most young adults use cigarettes due to the 'cool image' associated with it. 77% of all tobacco users want to quit, thereby giving a strong opportunity to carry out cessation services in this group. There was higher mean FTND score in smokers (2.6 + 0.2) compared to chewers (2.2 + 0.3), revealing higher severity of dependence among smokers than chewers.

Do adolescents underreport tobacco consumption in studies based on self-report? A validation study using cotinine

Ana Maria B. Menezes, Maura C. Malcon, Maria C. Assuncao, Pedro C. Hallal

Federal University of Pelotas, Brazil

E-mail: [email protected]

Background: To validate self-reported data on smoking in adolescents in comparison to cotinine concentration.

Methods: 2209, 7 th and 8 th grade students from 32 public schools in Pelotas, Brazil. Adolescents were contacted twice, before and after an educational intervention, and samples of urine for cotinine analyses were taken. The technique for cotinine analysis was the high performance liquid chromatography. Two cutoff points for cotinine were used: 10 ng/ml and 30 ng/ml. Two self-reported smoking variables were used: at least one cigarette smoked in the previous 30 days; and daily smoking.

Results: The self-reported prevalence of smoking in the previous 30 days was 7.4% both at baseline and post-intervention. For daily smoking, the prevalence increased from 0.9% at baseline to 1.2% at the post-intervention phase. Those who reported smoking in the previous 30 days presented mean cotinine values 10 and 15 times greater than those who reported to be non-smokers at baseline and at the post-intervention phase, respectively. Using a cutoff of 10 ng/ml for cotinine, sensitivity values for self-reported smoking were 16.3% (95% CI 11.7; 20.9) and 17.6% (95% CI 12.9; 22.3) at baseline and post-intervention, respectively. Specificity values were 93.9% (95% CI 92.8; 95.0) and 94.0% (95% CI 92.8; 95.2), respectively. Using a cutoff of 30 ng/ml, sensitivity values were 22.6% (95% CI 15.6; 29.6) at baseline and 26.3% (95% CI 18.4; 34.2) at the postintervention phase. Specificity values were almost identical (93.7% and 93.8%).

Conclusion: Self-reported smoking presents low agreement with cotinine concentration, indicating that adolescents underestimate tobacco consumption.

Factors related to smoking behavior among youth in east Java, Indonesia

Santi Martini

Faculty of Public Health, University of Airlangga, Indonesia

E-mail: [email protected]

Backgroud: In Indonesia, smoking rates among youth have been increasing, smoking prevalence among males aged 15-19 years increased dramatically from 4% in 1995 to 24% in 2001. Indonesia is the fourth most populous nation in the world with over 217 million people, and 30 percent of the population is under 15 years of age.

Objectives: The goal of the research was to identify factors related to youth smoking that can be potentially altered by public policy interventions.

Methods: The Surabaya youth survey used a modified version of the Global Youth Tobacco Survey questionnaire concerning smoking among 1,630 students in 40 high schools in two cities and two districts. Variables that appeared related to smoking status (current smoking) were then analyzed using multivariate logistic regression analysis.

Results: Having family members who smoked increased the risk of being a current smoker (OR=1.73; 95%CI 1.04-2.89). Perceiving that you would get in trouble with your parents if you smoked was highly associated with a reduced risk of being a current smoker (OR=0.36; 95%CI 0.22-0.59). Smokers, in particular, affirmed many social and personal reasons to smoke (OR=12.98; 95%CI 7.18-23.46). Reporting that your peers smoked increased the risk about 75% (OR=7.85; 95%CI 5.09-12.11), but perceiving that peers were supportive of smoking increased the risk by nearly 22 fold.

Conclusion: Any policy that can reduce the perception that smoking is normal and acceptable will likely reduce youth smoking. Enforcing laws and regulations to make smoke-free could reduce both the acceptability (norms) and availability of tobacco to youth.

An overview of flavoured cigarettes use among Brazilian adolescents and young adults

Valeska Figueiredo, Frances Stillman, Leticia Casado, Ana Lucia Mendonηa

Brazilian National Cancer Institute, Brazil

E-mail: [email protected]

Background: Tobacco companies have been using special flavouring in their products. The tobacco industry documents showed that young people are the main target of this tobacco product innovation. Until now, no study has assessed the use of flavoured cigarettes in Brazil: a country of almost 23 million of smokers.

Goal: To describe the magnitude and characteristics of flavoured cigarette use among Brazilian adolescents and young adults.

Methods: The data analysed came from 2 surveys: (a) a cross-sectional school-based survey with, 13-15 years old students, in 12 Brazilian cities that participated in GYTS in 2004-2007 (n=2225) and (b) a first and 7 th term college student's census conducted in 2007 with 18-25 years old students from Rio de Janeiro State University (n=2280).

Results: For the GYTS data, the median percentage of flavoured cigarettes use among adolescents who smoked in the last 30 days was 44.7% (range 28.0% to 63.0%) for boys and 44.3% (range 29.8% to 62.2%) for girls. Among university students, 44.0% of male smokers and 61.9% of female smokers used this type of cigarette. An inverse association between age and use of flavoured cigarettes was observed among university men but not in women.

Conclusions: These data suggest that the use of flavoured cigarettes is high among adolescents and remain high among young adults. However, this type of cigarette is not the main choice of older university males. Policies aimed to ban or limit flavoured cigarettes in Brazil may be important to reduce tobacco use among young people.

Tobacco use amongst out of school youth in a local government area in Nigeria

Akindele Olupelumi, Adebiyi Adesola O, Sangowawa Eme. T, Owoaje, Babalola Faseru

College of Medicine, Nigeria

E-mail: ad[email protected]

Background: Nigeria is finally realizing the importance of advocating for Tobacco control with many organizations making concerted efforts. However, there exist few local studies to guide decisions on direction for action.

Objectives: This study sets out to describe tobacco use amongst a high risk group such as out of schol youth.

Methods: A descriptive cross sectional study was done amongst 215 out of school youths in two communities in a Local Government Area in Nigeria using a multi-stage sampling technique.

Results: Males were 53% and females 47%. Only 20.5% had ever used tobacco while 11.6% were current users. Males accounted for 60% of current users compared to 40% amongst females. Of current users, 84% believed that tobacco is not harmful to health. In addition, the two important sources of introduction to tobacco use were friends 72% and relatives 20%. Surprisingly, in one case respondent was introduced to tobacco use by mother. Use of tobacco amongst significant others were: fathers 3.7%, mothers 0.5%, relatives 4% and friends 7%. The most common sources of supply were garages 52% and friends 16%.

Conclusion: The study showed that peer influence is an important source of introduction to tobacco use while buying of tobacco is easily accessible to youth in garages. Prevention programmes may need to consider point of sale restriction and peer education interventions.

Changes in teenage smokers's involvement in other risk behaviours 1972-2007

Marianne Lund, Karl Erik Lund

National Institute for Alcohol And Drug Research, Norway

E-mail: [email protected]

Background: Smoking prevalence has declined among Norwegian adolescents the last 30 years. The social symbolism of smoking has becoming more negative with time, and remaining smokers are overrepresented among the low educated.

Objectives: The purpose of the study is to test a hypothesis that involvement in problem behaviour among adolescent smokers has increased as smoking has become more denormalised.

Methods: Repeated cross-sectional sample of Norwegian adolescents aged 15-20 years, living in the capital city, Oslo. Smoking, alcohol and drug use has been monitored every year since 1972. Sample size between N = 700 - 2 500. Response rate was 50%-70%. Logistic regression analysis.

Results: Daily smoking prevalence went down from 40 percent in 1972, to 8 percent in 2007. At the same time the mean consumption of pure alcohol in litre per year increased, from 3,6 in 1973 to 5,6 in 2007. Ever use of cannabis was stable at 20% to the middle of 1990, with a peak in 2000 at 30%, decreasing to 20% in 2007. Preliminary results show that the odds for being both an ever user of cannabis, and having experienced several episodes of clearly intoxication from alcohol use, was significant higher for daily smokers compared to non-smokers. The odds ratio was higher in the period 1997-2007 (OR=15.2), compared to 1985-1996 (OR = 9,9) and 1973-1984 (OR=7,4).

Conclusions: As the prevalence of smoking is declining in society, daily smoker's involvement in other problem behaviour seems to increase.

Characteristics of adolescent smokers and snus users

Ingeborg Rossow, Karl Erik Lund

Norwegian Institute for Alcohol And Drug Reserach, Norway

E-mail: [email protected]

Background: It has been suggested that oral moist snuff (snus) use may serve as a means to quit smoking as well as a gateway to smoking. In Norway snus is just as available as cigarettes, and among young people the prevalence of snus use has increased significantly whereas daily smoking has decreased over the past few years.

Objectives: To explore the extent of concomitant and alternate use of snus and cigarette smoking among Norwegian adolescents and to explore social and life-style characteristics of adolescent smokers and snus users.

Methods: School survey conducted in 2004 among junior and senior high school students (13-19 years), net sample = 20,700. Discriminant analysis was applied to explore social and life-style characteristics.

Results: 25% of the students reported tobacco use. Among the smokers (19% of total sample) almost a third (both among daily and occasional smokers) used snus, but daily snus use and high intake of snus was more prevalent among occasional as compared to daily smokers. Non-smokers were much less likely to use snus and they consumed less snus compared to smokers. A clear social class gradient and a life-style gradient in tobacco use were observed; both smoking and snus use were more prevalent among those in lower SES groups and those with more frequent alcohol and cannabis use and involvement in problem behaviour. Differences were most pronounced between smokers and non-smokers, irrespective of additional snus use.

Conclusion: Social and life-style characteristics of tobacco users suggest that smokers are less advantaged compared to snus users.

  Narghile waterpipe tobacco control research by the AUB tobacco control prevention research group Top

Exploring attitudes towards women's waterpipe smoking in the Eastern Mediterranean region

Rima Afifi, Fouad Fouad, Maha Ayad, Yara Jarallah

American University of Beirut, Lebanon

E-mail: [email protected]

Background: Despite its detrimental effects on health, waterpipe smoking is re-emerging as a trend in the Eastern Mediterranean region and is expanding into the West as well.

Objectives: To identify social norms and attitudes that make waterpipe use a more acceptable form of tobacco smoking for women than cigarettes in the Eastern Mediterranean region.

Methods: A total of 120 focus groups and in-depth interviews were conducted in Egypt, Lebanon, Palestine and Syria in 2007. Data was collected from waterpipe and non-waterpipe smokers across gender, age groups, urban/rural regions and socio-economic, marital, and employment status. The interviews and focus groups were transcribed in Arabic and thematic analysis was conducted.

Results: Results indicated that waterpipe smoking has deep rooted socio-cultural dimensions. Waterpipe smoking was perceived to bring together smokers in an ambiance of leisure, stress relief and dissociation from the present. The older generations tended to perceive water pipe smoking as a sign of status, while in some contexts, the younger generation emphasized its sexual connotations. The smell, volume of smoke produced, and the sound of the bubbling water enhanced the experience of smoking. Waterpipe smoking was not perceived as leading to dependence and was not seen to be as readily available as cigarettes. As a result, people saw it as less harmful and, thus, more acceptable.

Conclusion: Waterpipe smoking is socially acceptable and is gaining ground, especially among youth and women. Interventions to decrease waterpipe use among women and youth need to focus on changing social attitudes.

Lebanese media and waterpipe smoking

Robin Heath, Joanna Khalil, Mayda Kanj, Rima Nakash

American University of Beirut, Lebanon

E-mail: [email protected]

Background: Tobacco consumption by waterpipe in a domestic setting has been long associated with oriental culture, particularly the Islamic holy month of Ramadan. At the same time that waterpipe is increasing in popularity among young people and spreading to the west, recent studies suggest that waterpipe smoking is more harmful than cigarettes. The aim of the study was to assess the representation of waterpipe in Lebanese print mass media in order to inform future intervention programs.

Methods: The print media were selected on the basis of readership, circulation, reach, political affiliation, frequency of printing, and language. The print media were screened for any item related to waterpipe. All identified items were reviewed for cross cutting themes. The themes were then developed into a codebook and applied to all items.

Results: A total of 154 newspapers and magazines were collected during Ramadan, mid September to mid October, 2007. Waterpipe smoking was depicted most frequently as a festive social activity practiced outside the home in the context of Ramadan activities. The penetration of waterpipe smoking into Lebanese society was demonstrated in print and graphic images that carried across age, sex, and socioeconomic strata. Beyond the evident social acceptance of the practice, further inducements to smoke waterpipe included advertisements offering discounted prices and home delivery.

Conclusion: The media analysis demonstrated that core Lebanese cultural values were embedded in tobacco consumption by waterpipe; therefore counter advertising will require a different approach than used for cigarette smoking.

Labeling practices for narghile water-pipe tobacco products

Rima Nakkash, Alan Shihadeh

American University of Beirut, Lebanon

E-mail: [email protected]

Narghile (aka shisha, hooka) water-pipe smoking is increasing in popularity particularly among youth and women. Though water-pipe smoking is often perceived to be safer than cigarette smoking, growing evidence indicates that it poses similar health hazards as cigarette smoking. Health warnings on cigarette packages have been shown to increase awareness of health risks and decrease consumption. Initial observations by the authors found that water-pipe tobacco products are generally sold either without health warning labels, or with labels containing false or misleading data about health hazards. The objective of this research was to evaluate waterpipe tobacco product labeling practices. The research team acquired and cataloged waterpipe tobacco products by visiting a representative sample of retail outlets in Beirut. In addition, samples from Syria, Jordan, and Egypt were obtained through local collaborators. A systematic internet search on availability to consumers of waterpipe tobacco products and labeling of those products was also conducted. Current labeling practices in terms of content (health risk message, if any) and size of warning (as% of surface area of package), location on package (front, back, bottom) were evaluated. An appropriate health warning label for waterpipe tobacco products is presented. Finally, the applicability of labeling guidelines proposed for Article 11 within the Framework Convention on Tobacco Control (FCTC) to water-pipe products was evaluated.

Is water-pipe replacing cigarettes? A comparative study of smoking behavior among university students one decade apart

Monique Chaaya, Nabil Tabbal, Ziyad Mahfoud


E-mail: [email protected]

Introduction: The recent upsurge in smoking in general and water-pipe in particular in the Middle-East has lead to a drastic change in smoking patterns among young people, crossing social, cultural and age boundaries. This study aims to explore the change in the prevalence of cigarette and arghileh (water-pipe) smoking in the last decade in Lebanon among university students at the American University of Beirut.

Methodology: The study is a comparison between the results from the SIBER project in 1998 and the YBRF project in 2007. Both studies were cross-sectional, covering a wide array of health risk behaviors; however the focus for this paper was only on smoking prevalence. 954 freshmen and sophomore students were selected for the 1998 study and 222 for 2007 one.

Results: The prevalence of cigarette smoking has decreased from 65% to almost 50%. On the other hand, the prevalence of water-pipe smoking has drastically increased in one decade from 30% to 63%. These results showed no significance in the difference of increase between both genders. As for patterns of water-pipe smoking, out of the 140 ever water-pipe smokers from AUB in 2007, 41% smoked during the previous month and 3% were daily smokers.

Conclusion: Over one decade, the prevalence of water-pipe smoking has increased drastically among university students. This increase is due mainly to its accessibility, its innovative types and ways of delivery and the upsurge of water-pipe lounges, making the water-pipe smoking the new epidemic in the Middle-East in general and Lebanon in particular.

An update on the hazards of narghile water-pipe smoke: Toxicant delivery and particle deposition in the lung

Alan Shihadeh, Najat Saliba, Elizabeth Sepetdjian, Ezzat Jaroudi

American University of Beirut, Lebanon

E-mail: [email protected]

Prompted by the alarming increase in waterpipe smoking in recent years, particularly among youth and women, members of the American University of Beirut (AUB) Tobacco Research Group have been engaged in measuring the toxicants and physical properties of the mainstream smoke issuing from the narghile waterpipe. Methods have included measuring and modeling smoking behavior, conducting laboratory smoking machine studies, and most recently, chemically characterizing smoke captured in real time from smokers in cafιs. We will present an update on our ongoing quantification of the "Hoffmann list" of causative agents in tobacco-related diseases. In particular, yields of "tar", nicotine, polyaromatic hydrocarbons (PAH), carbon monoxide, and volatile aldehydes will be reported for ma'assel tobacco smoke generated in the AUB Aerosol Research Lab and for smoke generated by real smokers in cafιs in Beirut, Lebanon. In addition, we will present measurements of the particle size distribution of waterpipe smoke, and its implications for deposition of carcinogens in the human lung. The results are compared to those for cigarettes, and will be discussed in terms of the health hazards posed by this potentially lethal though poorly studied method of tobacco smoking. It is shown that contrary to current perceptions, the narghile waterpipe likely represents a highly hazardous smoking method.

  Development of guidelines for WHO FCTC article 12: Education, communication, training and public awareness Top

'Quo vadis' education, communication, training and public awareness?

Nick Kai Schneider, Martina Pφtschke-Langer, Margaretha Haglund

Unit Cancer Prevention and WHO Collaborating Center for Tobacco Control, German, Germany

E-mail: [email protected]

Objectives: The development of guidelines for the implementation of the WHO Framework Convention on Tobacco Control (FCTC) offers extensive possibilities to governments, public health researchers, educators and advocates. In February 2008 experts, government and NGO representatives of the Article 12 working group met in Berlin to discuss the prospects of potential guidelines on 'education, communication, training and public awareness.' This session will present the results of the working group and the research basis behind it.

Methods: We reviewed and analized the published data relevant to Article 12.

Results: A comprehensive tobacco control approach is needed to ensure the denormalisation of tobacco production, sale, marketing, consumption and exposure to tobacco smoke. Sustainable national tobacco control programmes are necessary and should address the deceptive strategies and practices of the tobacco industry, and ensure that different measures are offered to different population groups--in particular to address gender-specific risks. Effective education and training of key professions is paramount. All programs must be independent from and protected against the vested interests of the tobacco industry. To ensure that the detrimental effects of tobacco use are communicated to all people, national coordinating mechanisms are as crucial, as the central and active involvement of civil society.

Conclusion: Ongoing communication between civil society, researchers and policy makers is crucial to make best use of limited resources and develop research-based programs leading to best practices.

Disarming a deadly weapon: How Sweden has changed the social norms article12-FCTC disarming a deadly weapon: How Sweden has changed the social norm of smoking.

Margaretha Haglund, Mathias Jansson

National Institute of Public Health, Sweden

E-mail: [email protected]

Background: Despite a shoe-string budget Sweden has made good progress in its struggle against the harmful effects of tobacco use. Starting in 1963, a comprehensive programme has been developed and implemented and has evolved into the present day's tight legislation, smoke-free environments, ban on tobacco advertising and promotion, public information and education activities and smoking cessation facilities

Objectives: To contribute to the development of Guidelines for Article 12 by presenting examples from Sweden

Methods: This presentation will focus on different examples in mobilizing support to address the tobacco epidemic by examples in several sectors, ranging from working with the civil society, NGO`s as well as women's media, exploring the tobacco industry's working methods and among others.

Results: The result been very encouraging as demonstrated by the steadily falling smoking rates for some decades. Since 1980 there is a 50 per cent reduction in the prevalence of smoking also among women. In recent years smoking has also decreased substantially among women and during the last decade the rate of decrease among women has been slightly bigger among women than among men.

Conclusion: The long-time tobacco control tradition in Sweden has resulted in very encouraging outcomes, and many lessons learned about changing social acceptability of tobacco with a shoe-string budget which can be important for countries in other development stages of the tobacco epidemic but also for those within the same stage.

Key role of public education and awareness campaigns

Karen Gutierrez

Global Dialogue for Effective Stop Smoking Campaigns, United States of America

E-mail: [email protected]

Background: While Article 12 of the FCTC states that parties must conduct tobacco control public education and awareness campaigns, governments must be convinced that spending resources on campaigns is worthwhile and that campaigns play a critical role in changing community norms, attitudes and individual behaviors related to tobacco use and secondhand smoke.

Objective: This presentation will use international data to help participants understand the importance of including comprehensive public education and awareness campaigns in each country's tobacco control program.

Methods: Published and unpublished studies were analyzed and synthesized to determine what is known about the impact of tobacco control public education campaigns.

Results: The scientific evidence is strong: 1) Campaigns conducted through the mass media have been proven to reduce tobacco use and make communities more supportive of tobacco control measures. 2) Stop Smoking Campaigns increase quit attempts and tobacco cessation rates. 3) Mass media public education campaigns can be very cost-effective. 4) Successful campaigns have the following characteristics: adequate media weight over time; variety of targeted messages; synthesis between paid, earned media (news media coverage), public relations, community-based events, and school programs; thorough evaluation; and incorporation of lessons learned from other campaigns. The presentation will include specific examples for each of these points.

Conclusion: Governments need to devote adequate resources to conducting comprehensive public education campaigns or the impact of the other tobacco control program components will be undermined.

The colombian experience. Youth as agents of change are very powerful to communicate effectively to all age groups, related to the effects of tobacco exposure. They can bridge the gap between scientific evidence and policies/norms/culture than shape behavior

Beatriz Londoρo, Fernando Ramirez, Alice Grainger-Gasser, Diego Munevar

World Heart Federation, Colombia

E-mail: [email protected]

Background: Most Colombian youth do not see tobacco as a threat; many groups are engaged in sexual/reproductive health, violence/drugs, few have activities related to tobacco exposure. The tobacco control movement does not have a broad base of support. Colombia just became 154 th country to ratify the FCTC, and now is the time for decisive action. Working with a group who attended Global Youth Meet (India 2006), the World Heart Federation΄s Project has helped mobilize Colombian youth.

Objectives: To empower youth as agents of change, helping them challenge policies, norms, cultural perceptions, attitudes and practices related to tobacco.

Methods: Organize activities and workshops that stimulate youth leaders' critical thinking and commitment to action, communication skills, leadership, networking. Develop materials by youth, speaking the language of youth (songs/video clips/theater/dance and games/you-tube/the web). Use these materials in a variety of venues/channels: festivals/ concerts/parades, as well as in professional meetings.

Results: Youth have designed and produced songs/dances/skits/video clips, and presented/used them to communicate with youth, children and adults through different media. Youth participated successfully in the National Congress of Cardiology, World Congresses of Echocardiography and Cardiology, engaging professionals and officials (First time in history). Core group of youth has developed leadership and advocacy skills and is linked to other youth in a latinamerican network.

Conclusion: Youth are powerful communicators and can bridge the gap between scientific evidence and the policies/norms/culture that shape behavior. They are the main actors transforming Colombian society to achieve the aims of FCTC.

Education, communication, training and public awareness for tobacco control: The Ghana experience

Edith Koryo Wellington, Kofi Wellington, A. B Yakubu

Ghana Health Service, Ghana

E-mail: [email protected]

Ghana has signed and ratified the WHO FCTC. Article 12 requires parties to "promote public awareness of tobacco control issues using all available communication tools as appropriate".

Objectives/Methods: This paper highlights progress that Ghana has made in implementing Article 12. It is based on review of literature and observation.

Results: Ghana has made modest progress implementing Article 12 through these initiatives: Advocacy through workshops and petitions to parliamentarians which led to the signing and ratifying of the WHO FCTC; Awareness creation activities undertaken in line with World No Tobacco Day, Quit and Win Ghana - a cessation programme; Sensitization activities for parliamentarians, schools, media, health professionals, non-governmental organizations on the health risk of tobacco use and exposure to tobacco smoke and the need for strong tobacco control legislation; Research studies (FCTC, GYTS,) are disseminated through seminars to key stakeholders; Variety shows including video shows, drama, songs, poems and talks for schools; Activities received media coverage; Production and distribution of 15,000 copies of WHO Smoker's body; NGOs have been supportive in the process; Challenges: Lack of adequate trained professionals to engage in communication activities; Limited financial resources to develop and produce materials and to undertake nation-wide programme; Lack of research to determine the effectiveness of current efforts.

Conclusion: These efforts have created some awareness among the public. However, we need a well organized strategy supported by adequate human, financial and other resources for Ghana to fulfill the goals of the FCTC.

  Tobacco use cessation in India: The Bihar school teachers' study Top

Overview and preliminary findings of the Bihar school teachers study

Glorian Sorensen

Dana-Farber Cancer Institute, United States of America

E-mail: [email protected]

Background: Bihar is one of the highest tobacco-using states in India. Teachers are key opinion leaders who influence community norms, and serve as role models in shaping children's tobacco use prevention.

Objectives: This abstract is meant to provide an overview for a session including five bundled abstracts presenting findings from the Bihar School Teachers Study. This study is developing and testing a comprehensive tobacco control intervention for teachers in Bihar. Findings from the Global School Personnel Survey (GSPS) from Bihar (Pednekar et al.); an overview of intervention development (Nagler et al.); focus group results (Gupteshwar et al.); and message testing results (Viswanath et al.) will be the other parts of the session.

Methods: Government schools (n=80) will be randomly assigned within two strata (rural/urban) to an intervention or delayed intervention control condition. The intervention will include promotion of tobacco control policies, educational programming and cessation assistance for teachers. The primary outcome is six-month continuous abstinence from tobacco use among teachers.

Results: According to the Bihar GSPS, over three-quarters of Bihar teachers use tobacco. A systematic process is being employed for intervention development. Preliminary focus group findings point to the key themes, which have been incorporated into a creative brief and draft intervention messages. Results of message testing will be reported.

Conclusions: This systematic intervention development process and related findings provide a solid foundation for the design and future testing of this tobacco control intervention for school teachers, one of the first of its kind to be tested in India.

Perceptions on the use of tobacco among teachers in Bihar: Implications for intervention

Gupteshwar Singh, Mira Aghi, Joshua Gagne, Mangesh Pednekar

School of Preventive Oncology, India

E-mail: [email protected]

Perceptions and misconceptions can be modified by effective intervention, which can alter health cognitions and prepare one to quit the use of tobacco. Using focus group discussions to understand how teachers in Bihar perceive tobacco use with a view to designing effective intervention. Four focus group discussions were conducted - two each in urban and rural areas. Each group had about 14 participants, one-third being females. The participants were teachers from schools around the city of Patna for the urban focus groups and from villages near Patna for the rural focus groups Most participants thought tobacco was harmful and wanted to quit; although some saw advantages in terms of increasing concentration and as aid in socializing. There was pressure from female teachers on males for quitting tobacco. Few participants recommended punitive measures against those who continue to use it in school while others suggested more humane and emotional approach. Will power emerged as an important concept in helping to quit. Respondents wanted to get appropriate advice in quitting. Fear, appeal by family members and other emotions emerged as helpful motivators for quitting. Banning tobacco use in schools and promoting tobacco free-schools emerged as productive policies. Participants welcomed the idea of a center in school where print and audio-visual material could be available and agreed that a teacher could be given responsibility to look after the center. The data that emerged had clear implications for production of material for effective intervention for teachers in schools of Bihar.

Testing message effects among Bihar school teachers: An empirical analysis

K Viswanath, Shree Mukesh, Mira Aghi, Lorraine Wallace

Harvard School of Public Health, United States of America

E-mail: [email protected]

Background: Effective interventions to promote tobacco control must meet three conditions. The target audiences must: (a) first be exposed to the messages, (b) attend to them, and (c) understand them in their social and cultural contexts. While much work exists on effective channels to reach the audience, only limited research exists on the structure and format of messages that attract audience attention, facilitate information processing and influence communication effects. More recent work in health communication on message effects provides a useful framework to design effective messages to promote cessation.

Objectives: To describe a process to systematically design and test messages to promote tobacco cessation among teachers in Bihar, India, drawing from theoretical work on message effects.

Methods: Using a two-phased approach, in Phase 1 we developed 12 advertisements drawing on two focus groups with the teachers. Two formats, fear appeals and narratives were used to influence key antecedents to behavior change: risk perceptions, self-efficacy and social norms. In Phase 2, affective reactions of target audience to the messages and the messages they discriminate from the advertisements will be elicited using both semantic differential scales and open-ended questions.

Results: Results will be used to revise and finalize the advertisements to be used in the intervention.

Conclusions: We foresee substantive contribution to the literature on tobacco control in two ways: (1) delineate a systematic and scientific way of testing messages for their effectiveness before their large scale deployment and (2) assess the cross-cultural applicability of message testing scales.

Bihar school teachers study's intervention development process

Eve Nagler, Amruta Milind, Adam Gerberick, Harry Lando

Harvard School of Public Health, United States of America

E-mail: [email protected]

Background: To maximize tobacco control efforts within communities, interventions are needed that are responsive to the social context in which tobacco use occurs. The Social Contextual Model provides a useful framework to guide intervention development, since it defines the ways in which social context may influence tobacco use and helps build on communities' assets and resources to quit tobacco.

Objectives: To describe how the social contextual model was used as a framework to guide the development of a tobacco control intervention for teachers in the Indian state of Bihar.

Methods: Based on our conceptual framework, we created a guide which was used to conduct focus groups with teachers in Bihar. Key themes from the groups were incorporated into a creative brief and used to craft messages related to school teachers' risk perception, social norms, self-efficacy, and support to quit tobacco. These intervention messages and components were tested at a Teacher's Conference in Bihar. Following revision of the materials, we are using our framework to guide pilot testing of the intervention prior to the study launch in June 2009.

Results: Results from focus groups and pilot testing, presented in other abstracts in this session, will be used to finalize the intervention messages, survey instruments and material production.

Conclusions: The Social Contextual Model is an effective framework for developing a tobacco control intervention that responds to teachers' lives in Bihar. This systematic intervention development process will aid the design of interventions for teachers in other parts of India and the developing world.

Tobacco use among school personnel in Bihar, India

Mangesh Pednekar, Dhirendra Sinha, Gupteswar Singh,

Anne Stoddard Healis, Sekhsaria Institute for Public Health, India

E-mail: [email protected]

Background: Tobacco use often starts in adolescent years when school teachers form important role models, potentially influencing tobacco use. To plan effective interventions, it is essential to have information on the extent and the type of tobacco use among teachers, their attitudes towards tobacco control, and the existence of school polices.

Methods: The Global School Personnel Survey (GSPS) was a cross sectional survey (using anonymous self-administered questionnaire) using a cluster sample design conducted in 2000.

Results: Out of 637 participating school personnel, 73% were men. The majority of school personnel were teachers (84%). Over 78% men and women teachers reported using tobacco in some form. Although smoking among women in India is taboo, prevalence of smoking among women teachers was quite high (32%). Almost all school personnel agreed that tobacco was addictive (91%), it had serious health consequences (85%), and environmental tobacco smoke was harmful (87%). Nearly everyone replied (>99%) that there was no policy on prohibiting tobacco use either for students or personnel and almost everybody expressed a need for such policies. Over 80% thought that tobacco companies deliberately encourage youth to use tobacco and 95% wanted a complete ban on tobacco advertisements. Everyone (>99%) expressed that they neither had received any training nor had any access to teaching and learning material to prevent tobacco use.

Conclusion: This study has clear implications for implementation of tobacco control policies in Indian schools and further underscores the need for infrastructure support for tobacco use prevention in developing countries such as India.

  IARC Handbook on the effectiveness of smoke-free policies Top

Smoke-free policies: An international assessment of the effects on exposure to secondhand smoke and health outcomes

Alistair Woodward, Sally Haw, The IARC Working Group

University of Auckland, Newzealand

E-mail: [email protected]

Background Smoke-free policies are a core element of the Framework Convention on Tobacco Control: evidence of their implementation and effectiveness is critical to tobacco control internationally.

Objectives: To examine the effect of smoke-free policies world-wide on exposure to second hand smoke (SHS) and health outcomes

Methods: Literature review carried out by a working group convened by the International Agency for Research on Cancer (IARC). Information obtained from databases such as Medline (PubMed) and Web of Science and also grey literature sources such as government reports.

Results: Voluntary restrictions on smoking have uneven coverage, are generally not applied in some of the highest-exposure settings, typically offer little protection for groups in the working population with the poorest health status and therefore increase the likelihood of widening health inequalities. Smoke-free legislation consistently reduces exposure to SHS in high-risk workplaces by 80-90%, the largest absolute reductions occurring among those with the highest pre-legislation exposures. Population-wide, exposures post-legislation have fallen by up to 40%, and studies show no increases in exposure to SHS in the home. There have been improvements in the respiratory health of workers after smoking bans, and reductions of between 10 and 20% in hospital admissions for acute coronary events in the general population in the first year post-ban.

Conclusion: Implementation of workplace smoke-free policies has led to a substantial decline in exposure to SHS, reduced social inequalities, decreased respiratory symptoms in workers, and an accelerated decline in heart disease morbidity.

Evolution of smoke-free policies around the world and tobacco industry's global efforts to defeat smoke-free policies

Jennifer Ibrahim, Armando Peruga


E-mail: [email protected]

Background: Early restrictions on exposure to secondhand smoke focused on restricting where smoking was allowed, rather than completely eliminating smoking indoors. Increased scientific studies and authoritative reports beginning in the early 1980s provided the information needed to advance 100% smoke-free policies. Beginning in the late 1980s and continuing today, national and subnational jurisdictions are developing and implementing 100% smoke-free policies.

Objectives: To highlight key successes in the development of smoke-free policies around the world.

Methods: We searched peer-reviewed literature and governmental and inter-governmental reports regarding the development of smoke-free policies.

Results: The early experiences in the United States, Australia and Canada provide case studies on the development of effective smoke-free policies, while more recent experiences in Spain, Sweden and France provide examples of mixed support and compliance with the policy. India and Uganda provide examples of how countries can turn to the court system to uphold the integrity of smoke-free laws. In 2004, Ireland became the first country in the world to implement a 100% smoke-free policy in all indoor workplaces and public places, including restaurants and bars. As of Spring 2008, twenty countries have implemented legislation that is in accordance with Article 8 of the World Health Organization's Framework Convention on Tobacco Control, with policies pending in several other locations.

Conclusions: Policy makers and public health advocates can learn from the early experiences of governments that have passed smoke-free policies and use these lessons to expedite the successful passage and implementation of smoke-free policies in other countries.

The Impact of smoking restrictions in the home on secondhand smoke exposure and smoking behaviour

Sally Haw, Elizabeth Gilpin, For the IARC Working Group

NHS Health Scotland, United Kingdom

E-mail: [email protected]

Background: Exposure to secondhand smoke (SHS) in the home poses a considerable threat to the health of children and adult non-smokers.

Objectives: To summarise available evidence on: the impact of home smoking restrictions on child SHS exposure; the effectiveness of interventions to reduce child SHS exposure in the home; and the effect of home smoking restrictions on smoking behaviour in adults and children.

Methods: Literature review carried out by a working group convened by the International Agency for Research on Cancer (IARC). Using appropriate search strategies papers published between 1990 and 2008 were identified from Web of Science and PubMed.

Results: The level of exposure to SHS in children is related to parental smoking, but can be reduced by adopting smoke-free home policies. Population-based strategies, including public education campaigns on SHS in homes and laws prohibiting smoking in public and workplaces, are more effective in reducing child SHS exposure than smoking cessation programmes targeted at parents. When smoke-free public and workplace policies become common, smokers show increased adoption of smoke-free homes. Home smoking restrictions lead to reduced tobacco consumption and increased quitting but there is insufficient evidence on their impact on youth smoking initiation. Smoke-free home policy are more effective in reducing smoking than partial restrictions. They also have a greater impact on adult smoking behaviour than restrictions on smoking in the workplace.

Conclusions: The adoption of smoking restrictions in the home can reduce the threat posed to children's health by SHS, and discourage adult and possibly youth smoking.

Economic impact of smoke free policies

Frank Chaloupka, for the IARC working group

University of Illinois at Chicago, United States of America

E-mail: [email protected]

The spread of smoke-free air policies in many countries has been slowed by fears that restrictions on smoking may have an adverse impact on businesses. It is clear, however, that allowing smoking in the workplace adds considerable costs for businesses. This presentation reviews the evidence on the costs to businesses of allowing smoking in the workplace and of the potential costs and benefits to businesses of policies that restrict or ban workplace smoking. Smoke-free policies impact businesses in numerous ways, from improving the health and productivity of their employees to reducing their insurance, cleaning, maintenance and potential litigation costs. Experience to date suggests that there are minimal short-term costs to businesses of implementing comprehensive smoke-free policies and that the net economic impact of such policies is positive. Much of the debate over the economic impact of smoke-free policies-and as a result, much of the research-has focused on the hospitality sector. Methodologically sound research studies from high-resource countries consistently conclude that smoke-free policies do not have an adverse economic impact on the business activity of restaurants, bars or establishments catering to tourists, with many studies finding a small positive effect of these policies. Very limited evidence from South Africa is consistent with these findings; it is likely that the same would be true in other low- and middle-resource countries. Few studies exist on the impact of smoke-free policies on gaming establishments, and their results are mixed; more research is needed on these venues.

Effects of smoke-free policies on smoking behaviour

Esteve Fernandez, Elisabeth Gilpin, IARC Working Group

Catalan Institute of Oncology, Spain

E-mail: [email protected]

Background: While the primary aim of having smoke-free policies is the protection of nonsmokers from secondhand tobacco smoke, it is expected that smoking restrictions will tend to reduce smoking consumption and prevalence among smokers by limiting the opportuinities to smoke.

Objectives: To revise the evidence whether and how smoke-free policies in various settings might reduce smoking consumption and prevalence.

Methods: Literature review carried out by a working group convened by the International Agency for Research on Cancer. Using appropriate search strategies papers published between 1990 and 2008 were identified from Web of Science and PubMed. Most studies came from developed countries where smoke-free laws have been implemented in the last decade.

Results: In localities where new smoke-free laws were part of multiple tobacco control efforts, there was clear and consistent evidence for a decline in prevalence from prior ongoing trends. Studies of workers subject to restrictions in the workplace indicate that new restrictions increase quitting and reduce the prevalence as well as cigarette consumption, as compared to workplaces with partial restrictions or no restrictions. Studies that adjusted for worker characteristics found that smoke-free workplaces were more associated with decreased smoking than only partial restrictions.

Conclusions: Smoke-free workplaces reduce cigarette consumption among continuing smokers and lead to increased successful cessation among smokers. The decline in smoking is greater when smoke-free policies are part of a comprehensive tobacco control programme. Further research on this topic is needed that involves multiple nations in different stages of the tobacco epidemic.

IARC handbooks on cancer prevention in tobacco control

Maria Leon, Paolo Boffetta

Iarc, France

E-mail: [email protected]

Background: As the WHO FCTC goes into effect in a progressively increasing number of countries globally, policy-formulated tobacco control initiatives will proliferate becoming the main interventions driving changes in tobacco use. Hence, the importance of reviewing and assessing what is known on their impact.

Objectives: To prepare a series of handbooks aimed at providing authoritative assessments of the evidence on the known effects of tobacco control policies as enforced.

Methods: The evidence gathered, presented, critically discussed and synthesized by a group of world-class experts is assessed, during a one-week meeting at IARC in Lyon, to generate the final Handbook.

Results: For the first time in the collection, the evidence on the effectiveness of a policy intervention was evaluated in April of 2008 (aimed at protecting the population from exposure to SHS). In evaluating the strength of the evidence, five levels are proposed: sufficient, strong, limited, inadequate or no evidence and evidence of lack of an effect. The results are presented in the preceding seven abstracts in the handbook Mumbai series submitted. The Handbooks will assist policy makers, government officials, evaluators and researchers working in tobacco control and/or health effects derived from the use or cessation of tobacco.

Conclusions: The IARC Handbooks in Tobacco Control will evaluate, data availability allowing so, each of the WHO FCTC provisions intended to curve tobacco use, exposure to tobacco smoke, tobacco toxicity, product supply and concomitant health effects by providing assessments of the evidence on the known effects of implemented and documented tobacco control policies.

  Project quit tobacco international: Developing tobacco cessation in India and Indonesia Top

Smoking by tuberculosis patients in Kerala, India: Proactive cessation efforts are urgently needed

K R Thankappan, AS Pradeepkumar, Mark Nichter

Achutha Menon Centre for Health Science Studies, India

E-mail: [email protected]

Background: The objectives of this study were to document smoking patterns among former Tuberculosis (TB) patients at eight different points of time before, during and after treatment, and to investigate the frequency and content of quit smoking messages received by them.

Methods: A stratified random sample of 215 male TB patients who had completed directly observed treatment, short course (DOTS) in the last six to nine months was surveyed from two districts of Kerala using a pre-tested semi structured interview schedule.

Results: Six months prior to diagnosis of TB, 94.4% male TB patients were ever smokers and 71.2% were current smokers. Although 87% of patients quit smoking soon after diagnosis, 36% relapsed by six months post treatment. One third relapsed during the first three months of treatment and another one third during the next three months of treatment. Two thirds of all smokers received cessation advice from primary health centre physicians, but less than half received advice from others. Content analysis of quit messages showed that less than half of all messages were TB specific, the rest being very general short instructions to quit smoking. Smoking more than 15 sticks at the time of diagnosis was significantly associated with fewer quit rate during treatment (Odds Ratio 8.0, CI: 2.1 - 30.9)

Conclusion: Messages not to smoke often go unheeded because they tend to be very general and do not specifically tie smoking to TB incidence or relapse. Proactive efforts are needed to give strong cessation messages at all times of treatment.

Tobacco use pattern and cessation practices among diabetes patients in Kerala, India

K R Thankappan, A S Pradeepkumar, C U Thresia, Mark Nichter

Achutha Menon Centre for Health Science Studies, India

E-mail: [email protected]

Background: Reports on tobacco use among diabetes patients, their cessation practices and perceived risk of tobacco use associated with diabetes complications are limited.

Objectives: (1) To document the prevalence of tobacco use among male diabetes patients (2) To investigate whether patients receive quit messages from their physicians (3) To investigate patients' sense of perceived risk of tobacco use as a factor associated with diabetes complications.

Methods: All the 644 male diabetes patients who attended the outpatient department of three public sector health care institutions and two private clinics in Trivandrum district Kerala, India were surveyed to ascertain their present and past tobacco use. They were also asked about the frequency and content of quit messages received from health staff at the time of diagnosis and during routine treatment.

Results: A significant proportion (62%) of diabetes patients were tobacco users prior to diagnosis and more than half of them continued to use tobacco, many daily, even after diagnosis. A lack of awareness exists regarding the linkages of tobacco use and diabetes complications.

Conclusions: Given the magnitude of tobacco use among people with diabetes there is clearly a need for more proactive tobacco cessation efforts. The times of illness diagnosis, illness flare ups, and emerging illness complications are teachable moments when patients are primed to change their behavior and motivated to quit tobacco.

Project QTI: Developing culturally appropriate tobacco cessation in India and Indonesia

Mimi Nichter, Mark Nichter

University of Arizona, United States of America

E-mail: [email protected]

Background: Project QTI is an ongoing tobacco cessation project in Kerala, India and Jogyakarta, Indonesia. Both countries have an unusually high prevalence of tobacco use. To date, however, there has been little involvement in tobacco cessation efforts among health professionals.

Objectives: Project QTI is increasing the visibility of tobacco-related morbidity and mortality as a high priority medical and public health issue in these countries. Tobacco education is being integrated into medical curriculum and health professionals are being trained in cessation skills to ensure that doctors talk to their patients about quitting. Multi-site studies and interventions in TB and diabetes clinics are being conducted to determine tobacco use patterns among patients and to develop tobacco cessation appropriate for these populations. Tobacco cessation efforts in households and occupational sites are also discussed.

Methods: Three partner medical colleges have been identified in South India and in Indonesia and tobacco curriculum is being implemented as normative practice. Papers in this session discuss specific findings from cessation interventions in TB and diabetes clinics.

Results and Conclusions: The next generation of health care providers in India and Indonesia must inform patients that they need to quit smoking. Examples of disease-specific cessation interventions for TB and diabetes patients are highlighted as examples of community outreach in cessation. Findings in these clinical settings reveal an urgent need for better training for clinicians and education for patients on the harm of tobacco use.

Smoking behavior and smoking cessation counseling for diabetes patients in Yogyakarta, Indonesia

Retna Siwi Padmawati, Nawi Ng, Yayi Suryo Prabandari, Mark Nichter

Center for Bioethics And Medical Humanities, Faculty of Medicine, GMU, Indonesia

E-mail: [email protected]; [email protected]

Background: Smoking is a major risk factor for diabetes complications and smoking cessation reduces these risks. In Indonesia, one of the main times for quitting is during illness. Therefore, doctors have a great role in promoting smoking cessation among diabetes patients.

Objectives: This study documents the prevalence of tobacco use among male diabetes patients and describes smoking cessation counseling developed for this clinical population.

Methods: The study was carried out in Yogyakarta Province, Indonesia. A survey of 778 male diabetic patients in clinical settings was conducted to determine smoking prevalence before and after diagnosis. A pilot intervention with intensive smoking counseling and doctor's advice is being carried out with an expected sample size of 60 diabetes patients.

Findings: Sixty-five percent of diabetics smoked before being diagnosed, and 32% had smoked in the past 30 days. Even though patients perceived that smoking lower levels was safe for diabetics (mean of 3.6 cigarettes), the median range of cigarettes smoked per day was 4-10 cigarettes. In the ongoing pilot intervention, out of 40 diabetes patients who visited the clinic, only 18 (45%) have entered counseling clinic and 11 have stopped smoking after one week follow up. Among the reasons for not quit smoking was the low level of cigarettes smoked per day and the widespread belief that there is no association between smoking and diabetes complications.

Conclusion: Many diabetic patients continue to smoke despite the hazards of smoking. Doctors need to promote smoking cessation as a routine activity in diabetes counseling.

DOTS providers' involvement in smoking cessation activities for TB patients

Retna Siwi Padmawati, Nawi Ng, Yayi Suryo Prabandari, Mark Nichter

Center for Bioethics And Medical Humanities, Faculty of Medicine, GMU, Indonesia

E-mail: [email protected]

Background: Indonesia has the third highest number of TB cases and one of the highest rates of smoking in the world. Smoking is a major risk factor for getting TB and for dying from TB. Continuing smoking following short course TB treatment also increases the risk of TB relapse. Although DOTS TB management has been adopted by health-care providers worldwide, to date, no programs have trained DOTS providers in smoking cessation for TB patients.

Objectives: To document smoking patterns among TB patients prior to diagnosis and following treatment; and to examine the role of DOTS providers in cessation activities for TB patients.

Methods: A cross-sectional survey was done on 239 male TB patients who had completed the DOTS treatment during 2005-06 in 5 lung clinics in Yogyakarta. A longitudinal pilot study is underway, comparing 50 patients who receive cessation intervention and 50 patients (control group) with baseline and four follow-up measures.

Results: Most TB patients quit smoking when under treatment, but over one third relapsed at 6 months post-treatment. About 30% were never asked about their smoking behavior nor advised for quitting. Ex-TB patients believed that regardless of their level of smoking it was not harmful to their health. DOTS providers, whom are mostly women, have concern about patient's withdrawal symptoms after quitting and doctor's ability to give advice during and post TB treatment. The data collection and cessation intervention is ongoing.

Conclusion: Physicians and DOTS providers should be actively involved in smoking cessation for TB and ex-TB patients.

  Cessation for health professionals Top

Evolution in tobacco consumption and attitude towards smoking in clinicians working in the tumor hospital

Shihong Ma, Qinjiang Liu

The Tumor Hospital of Gansu Province, China

E-mail: [email protected]

Objectives: To study the evolution of smoking prevalence and personal attitudes towards smoking among clinicians working in the tumor hospital of Gansu Province, China.

Material & Methods: Study population was all clinicians working in the tumor hospital of Gansu Province (n=458). By systematic sampling we select a random sample of 300 clinicians. We designed a self-administered questionnaire with items measuring the prevalence of smoking, the degree of smoking dependence, and their opinion about the new anti-smoking law.

Results: The prevalence of tobacco use was 45% (CI:95%: 35.5-48.9), below the figure we obtained in 2000 (56.3%; P<0.001). Clinicians between 30-55 years had the highest rates of tobacco consumption ( P<0.01). 92.5% clinicians believe that smoking was unhealthy and 80.3%clinicians accepted the risk derived of smoking. 90.7% of smokers used to smoking in working atmosphere of hospital. 80.5% of clinicians thought that the new free-smoking law in public places must be implemented. Clinicians smoke more often (68.5%) when they are on call and 20.4% clinicians with smoking recognize to smoke when they inform the patient's family.

Conclusions: We highlight a reduction of the prevalence of smoking among clinicians. It show a high number of clinicians who smoking in working atmosphere of hospital, although the figure have significantly decreased. It is essential that Health Bureau should make laws to prohibit smoking clinicians promoting a higher office and encourage their efforts to quit smoking. Clinicians should become the model of smoking cessation.

Comparing attitudes toward smoking between physicians and smokers in Asia: Analysis from a global survey of 16 countries

Chi Pang Wen, Meng Chih Lee, Shan Pou Tsai, Min Kuang Tsai

National Health Research Institutes, Taiwan, United States of America

E-mail: [email protected]

Objective: To assess and compare physician's and smoker's views on smoking and quitting.

Methods: A standard questionnaire was randomly administered to a total of 3,760 smokers and 2,836 physicians in general practice in 16 countries through web-based telephone interviews. In Asia, 500 smokers and 296 physicians from Japan and South Korea were surveyed. Various weightings were applied making the results nationally representative.

Results: Most smokers and physicians agreed that smoking was a lifestyle choice, with quitting believed to be the responsibility of smokers themselves. They disagreed on how frequently smoking issues were discussed or recorded: many Asian physicians (61%) discussed smoking at least occasionally, but only 7% of Asian smokers recalled such an encounter. Majority of Asian physicians (60%) believed they were not appropriately trained to treat smoking. Differences between smokers and physicians were seen globally, with a wider disparity in Asia.

Conclusions: Most physicians report having offered counseling to smokers, but most smokers recall limited discussions with few receiving quitting plans. Physicians ranked smoking as the most harmful behavior, but, in reality, physicians indicated they had more important things to do than providing quitting advice. Most Asian physicians, unlike non-Asian physicians, felt their cessation training was inadequate. Asian smokers were less concerned with smoking hazards, showed less faith in medications, and expressed less desire to quit. Overcoming the pervasive attitude that smoking is a lifestyle choice and quitting is up to individual will power not requiring medical assistance, is a major challenge globally, and particularly in Asia.

A successful reduction of doctors' smoking habits in Sweden - a 37 years survey

Gunilla Bolinder, Gφran Boλthius

Doctors Against Tobacco, Sweden

E-mail: [email protected]

Gunilla Bolinder MD, PhD, DDS. Karolinska University Hospital, Stockholm, Sweden Gφran Boλthius, MD, PhD, Doctors Against Tobacco, Sweden Tobacco habits in doctors have been monitored by the Swedish Medical Association since 1969.

Methods: Postal questionnaires have been sent to a random sample of 5% of all Swedish doctors. Response rates have approximated 80%. Age, sex, speciality, tobacco habits, knowledge of health effects, treatment practices and attitudes have been investigated.

Results: Daily smoking has declined from 46% in 1969 to 3% in 2006 (male doctors 4%/female 2%). Daily use of oral smokeless tobacco (OST) has remained unchanged since 1989 - 7% in 2006 (male 11%/female 3%). Thus, every tenth doctor is a regular user of a tobacco product. Smokers and OST users advise smoking patients to quit to the same extent as other doctors - close to 80% - but twice as often as their colleagues they recommend smokers to change to OST use. General practitioners constitute the least tobacco using and the most patient supportive category. Female doctors give more cessation advice than male doctors. A majority of doctors favours stronger tobacco control measures and believes that their medical association should influence tobacco control politics.

Conclusion: Tobacco use among Swedish doctors is today considerably less than in the general population. However, female doctors use OST to the same extent as women in general. Personal use of cigarettes or OST does influence risk assessment, given advice and attitudes to tobacco control measures.

Smoking cessation in hospital workers: effectiveness of a coordinated programme in 33 hospitals. The catalan network of smoke-free hospitals.

Cristina Martinez, Montse Ballbe, Jose Maria Martinez-Sanchez, Esteve Fernandez

Catalan Institute of Oncology, Spain

E-mail: [email protected]

Background: The Catalan Network of Smoke-free Hospitals coordinates a smoking cessation programme addressed to hospital workers. The programme included training in tobacco cessation, a common software for programme implementation, and free access to pharmacological treatment.

Objectives: To evaluate the effectiveness of the Catalan Network of Smoke-free Hospitals smoking cessation programme.

Methods: 930 hospital workers (in 33 hospitals) attended the cessation units between July 2005 and December 2007. The programme included active follow-up with 3 visits until the 6 th month after quitting. We calculated 6-months abstinence probabilities by means of Kaplan-Meier curves according to sex, age, years of tobacco consumption, profession (doctors, nurses, other), Fagerstrφm Test Nicotine Dependence (FTND) score, and use of pharmacotherapy (no drug, bupropion, nicotine replacement, and both drugs combined).

Results: Overall abstinence probability was 0.486 (95% CI: 0.427-0.544) at 6 months of follow-up. Abstinence was higher in men (0.543, 95% CI: 0.431-0.654) than in women (0.463, 95% CI: 0.392-0.533). There were no differences in abstinence by age and years of tobacco use. Doctors had higher abstinence (0.659, 95% CI: 0.506-0.811) than nurses (0.463, 95% CI: 0.349-0.576) and other professions (0.474, 95% CI: 0.393-0.554). Workers with high nicotine dependence (FTND >6) had lower abstinence probability (0.376, 95% CI: 0.256-0.495) than workers with FTND score ≤6 (0.529, 95% CI: 0.458-0.599). We observed the highest abstinence probabilities in workers treated with combined pharmacotherapy (0.761, 95% CI: 0.588-0.933).

Conclusions: The results show the feasibility and success of a smoking cessation programme for hospital workers coordinated at a regional level. Funded by the Department of Health, Government of Catalonia (Spain).

  Legal/litigation/regulation II Top

For enforcing tobacco control policies in India, sensitizing lawyers is a must

Manu Shresth Mishra, Bobby Ramakant, Amit Dwivedi, Rama Kant

Court, Lucknow and Convener of Lawyers for Public Health (LPH), India

E-mail: [email protected]

Objectives: India has relatively strong existing tobacco control policies, but due to insensitive lawyers and lack of mechanisms to engage lawyers in tobacco control, the enforcement and litigations against policy-violations are minimal.

Methods: In partnership with ISAS and other social organizations, Lawyers for Public Health (LPH) had organized sensitization programmes for practicing high court lawyers in two districts of Lucknow and Hardoi. Personal testimonies of those who were suffering from life-threatening health hazards or had lost their loved ones to tobacco-related causes, were instrumental in giving a human face to such interactions Lawyers were reminded of existing tobacco control policies including The Cigarette and Other Tobacco products Act (2003) A documentary film was made in collaboration with LPH to document violations of tobacco control policies in Lucknow and 19 legal notices sent to the offenders Leading film star Amitabh Bachchan who smoked cigar in 'Family' film was sent a legal notice by LPH. LPH has been actively working with Citizen News Service (CNS) to mobilize local media support to report on violations with evidence in Hindi, Urdu and English newspapers and electronic media.

Results: After 4 years of voluntary activity, LPH is a strong body with over 100 supporting member-lawyers. Without any funding support, litigations couldn't take place so far but over 430 legal notices were sent to offenders of The Cigarette and Other Tobacco Products Act (2003) in Uttar Pradesh state including one to Amitabh Bachchan.

The use of litigation as an impeding tool against youthful exploitation by the tobacco industry.

Veronica Ivoke

Environmental Rights Action, Nigeria

E-mail: [email protected]

Background: With looming health disaster due to tobacco use amongst the Nigerian population, the tobacco industry has turned attention on the youths of the country. They are more than ever daring with the use of attractive innovations and incentives to lure the youths into smoking addiction. The youths are faced with greater force compelling them to yield, while the killer stick is taking its' toll on them, in their thousands. All possible means to reduce, impede and totally stop tobacco use needs to be harnessed of which litigation is a creative tool.

Objectives: To use litigation to prohibit tobacco use in all its' negative forms.

Methods: Our organisation slammed litigation against the BAT, Philip Morris and Japan Tobacco compelling them to pay for damages caused by their products, adhere to ban of smoking in public places, access prohibition of selling cigarrette in stiks and the enforcement of FCTC agreement. These actions have progressed in court.

Results: The results were tremendous as four states, Lagos, Kano, Oyo and Gombe states as well as the Federal Government have sued the tobacco companies. Bans on various forms of advert amongst other positive policies have been enacted.

Conclusion: The use of litigation has proved to be an effective instrument to compel the tobacco industry from targeting the young people through their various marketing means. The Tobacco industry facing legal actions in courts are now removing various advertisements that targets the youths from the streets. This has helped in reducing smoking among youths in Nigeria.

Collection of lawsuits against the tobacco industry in Brazil: An overview of court case rulings on litigation cases against the tobacco industry

Clarissa Homsi

Alliance for The Control of Tobacco Use, Brazil

E-mail: [email protected]

A research on Brazilian's Courts has showed the tobacco industry having more legal successes in Brazil than plaintiffs and/or their families. Only 7 out of the 108 court decisions found in favour of the plaintiffs, and of the 7 decisions only one favoured a smoker. The remaining decisions favoured people who had lost a relative. Furthermore, the Brazilian judicial system does not seem to favour awarding compensatory damages. The reasons for that is the object of the research. The session will explore the arguments still being used by the industry in Brazil today and how distant they are from the scientific findings and judicial evidence found abroad against the industry, its product and its practices. It will also show how they have been accepted by the Brazilian Courts. It is worth mentioning that the few decisions that are favourable to plaintiffs are rich in arguments against the industry. In the reasons for these decisions, there is ample use of internet information, particularly on secret industry documents, particularly those discovered through American lawsuits. These decisions show that a few members of the Brazilian judiciary are aware of industry strategies and recognize the role played by advertising as well as the addictiveness of cigarettes for smokers. For the above-mentioned reasons, it is clear that the provision of better information to the courts is likely to result in more favourable decisions for plaintiffs in lawsuits filed against the tobacco industry.

Brazilian labor prosecution vs tobacco industries: Child labor exploitation

Guilherme Eidt Almeida

Alianηa De Controle Do Tabagismo - ACTbr, Brazil

E-mail: [email protected]

Tobacco growing in Brazil is based on contracts, which function as a regiment with rules defined unilaterally by the tobacco companies. The production system used by tobacco farmers is highly labor intensive and requires a considerable amount of pesticides and other agrochemicals. This production system problems includes health risks and environment harms resulting from inappropriate use of pesticides and deforestation, employment of child labor associated with extensive use of family labor in tobacco growing and indebtedness of small family producers to big tobacco companies. The objective of this work is to present the case filed by the Brazilian Labor Prosecution against several tobacco industries located in the southern region of the country, regarding all of the aspects mentioned above. To support the case against child labor a study about child nicotine exposure will be presented. The research was done in a partnership between the University of Brasilia and the Institute for Global Tobacco Control at the Johns Hopinks School of Public Health. The results have demonstrated a relation between age, hours of work and nicotine level. The older the child is the greater is the time spent on tobacco growing activities (plantation, cleaning the fields, sprout control, application of chemicals, harvest, drying of tobacco leaves and leaf classification). The more hours a child spends working with tobacco the higher are the levels of nicotine in the body. The complaint against the industries opens an opportunity for the Brazilian State to implement international standards of human rights and safety of children.

  Population based surveys/prevalence II Top

Use of alternate tobacco products in a multiethnic youth sample of Argentina: patterns and predictors

Ethel Alderete, Gregory Nah, Steven Gregorich, Eliseo Pιrez-Stable

National Council of Scientific and Technological Research (Conicet), Argentina

E-mail: [email protected]

No information is available on types of tobacco products other than cigarettes used by Latin American youth. A self-administered baseline survey was completed in 2004 by 3131 8 th graders enrolled in a random sample of 27 urban and rural schools in Jujuy, Argentina. A follow up survey was conducted in 2005. 70% of respondents self-identified as Indigenous, 23% as of mixed ethnicity and 8% as of European descent; 24% used any alternate product, 2% chewed tobacco leaf, 15% smoked hand-rolled cigarettes, 8% smoked cigars, and 2% smoked a pipe. Compared to Europeans, in multivariate logistic regressions Indigenous youth were less likely to smoke cigars (OR 0.6 95% CI 0.4-0.8) but more likely to smoke a pipe (OR 10.5; 95% CI 2.1-51.2), and indigenous language spoken in the family was a risk factor for smoking hand-rolled cigarettes (OR 1.3; 95% CI 1.1.-1.7). Currently working in any occupation (OR 1.3; 95% CI 1.1-1.7) and ever working in tobacco sales (OR 1.5; 95% CI 1.1-2.0) were risk factors for smoking hand-rolled cigarettes, whereas having parents with lower education levels was protective for cigar smoking. Youth who smoked hand-rolled cigarettes (OR 1.8; 95% CI 1.0-3.2) or a pipe (OR 2.8; 95% CI 1.1-7.1) were more likely to transition from experimenting to current smoking. Different tobacco products appeal to youths with different ethnic and socioeconomic characteristics. Alternate tobacco use constitutes a risk factor in the smoking trajectory. Findings provide evidence for conducting product specific surveillance, and for developing targeted prevention strategies and tobacco control policies.

Socio-demographic characteristics and determinants of tobacco use among 1,18,772 individuals from urban cohort in Trivandrum, Kerala, India

Leena K B, Shenoy K T, Shenoy Sheela T, Richard Peto

Population Health And Research Institute, India

E-mail: [email protected]

Objectives: To study the sociodemographic and other characteristics among the tobacco users in Trivandrum, S India

Design: Population-based, cross- sectional, house-to-house survey with face-to-face interviews in Corporation of Trivandrum during 2000-2002. Data were collected from 1,18,772 permanent resident adult males aged 25 and above. Using a structured questionnaire, trained social investigators collected data on the house hold possessions, education, occupation, habits (smoking; smokeless tobacco; alcohol consumption).

Results: 48.8% were ever smokers and 35.1% were current smokers. Smoking was more in the age group 40-69 years (54%) and in the young (25-29 Years), it was 32%. Current use of smokeless tobacco was 12.8% and ever use was 16.7%. 42.2% consumed alcohol in any form. Tobacco habits were associated with low levels of schooling (p 0.00001) and the prevalence rate of smoking was 65% in the illiterate; 68.8% in the primary (1-5 Years of schooling); 63% in the secondary (6-9 Years of schooling); 47% in the matriculate and 35% in the educated group (11 years or more of schooling). 37% did not have any habits; 25% had at least one habit and 28% had 2 habits and 8.4% had all the three. There was inverse relation with income, type of housing and possessions

Conclusions: High prevalence of tobacco use in the urban Trivandrum is different from other states in India.

Population attributable fraction of mortality associated with tobacco smoking in Japan: A pooled analysis of three large-scale cohort studies

Kota Katanoda, Tomomi Marugame, Kumiko Saika, Hiroshi Sato, Kazuo Tajima, Takaichiro Suzuki, Akiko Tamakoshi, Shoichiro Tsugane, Tomotaka Sobue

Center for Cancer Control & Information Services, National Cancer Center, Japan, Japan

E-mail: [email protected]

Background and Objectives: Quantitative measures of the burden of tobacco smoking in Asian countries are limited. We aimed to estimate the population attributable fraction (PAF) of mortality associated with smoking in Japan, using pooled data from three large-scale cohort studies.

Methods: In total, 296,836 participants (male: 140,026, female: 156,810) aged 40-79 years underwent baseline surveys during the 1980s and early 1990's. Average follow-up period was 9.6 years. PAFs for all-cause mortality and each tobacco-related disease were estimated from smoking prevalence and age-adjusted relative risks.

Results: The prevalence of current and former smokers was 54.4% and 25.1% for males, and 8.1% and 2.4% for females. The PAF of all-cause mortality was 27.8% (95% confidence interval 25.2: 30.4) for males and 6.7% (5.9: 7.5) for females. The PAF of all-cause mortality calculated by summing the disease-specific PAFs was 19.1% (16.0: 22.2) for males and 3.6% (3.0: 4.2) for females. The estimated number of deaths attributable to smoking in Japan in 2005 was 163,000 for males and 33,000 for females based on the former set of PAFs, and 112,000 for males and 19,000 for females based on the latter set. The leading causes of smoking-attributable deaths were cancer, ischemic heart diseases and stroke, chronic obstructive pulmonary diseases and pneumonia.

Conclusions: The health burden due to smoking remains heavy among Japanese males. Considering the high prevalence of male smokers and increasing prevalence of young female smokers, effective tobacco controls and quantitative assessments of health burden of smoking need to be implemented in Japan.

Mentholated smokers in the US: National patterns and correlates

Deirdre Lawrence, Pebbles Fagan, Eric Moolchan, Cathy Backinger

National Cancer Institute (NCI/NIH), United States of America

E-mail: [email protected]

Background: Menthol is added to 90% of commercial cigarettes, accounts for 27% of the cigarette sales market in the United States, and menthol cigarettes have higher levels of tar and nicotine than non-mentholated cigarettes.

Objectives: This study examines the correlates of menthol cigarette smoking in the United States.

Methods: Cross-sectional data from the 2003 Tobacco Use Special Cessation Supplement to the Current Population Survey adults were used to estimate the prevalence rates and examine sociodemographic and smoking-related variables associated with current smoking among adult menthol and non-menthol smokers (n=183,003).

Results: Of the current smokers, 26.7% smoked menthol, 69.8% non-menthol, and 3.5% no usual type of cigarette. For each sociodemographic category, menthol smoking was highest among women (31%), those ages 18-24 (31%), African Americans/Blacks (71%), those whose country of birth is in a US territory (49%), those making < $25,000 per year (29%), those with 9-11 years of education (30%), and the unemployed (33%). Menthol smokers were more likely to be "light" smokers (<10 cigarettes per day) than non-menthol smokers (50% vs. 41%, respectively), but no significant difference was found in reporting cigarette use within 30 minutes after waking. Results from logistic regression analyses will also be presented.

Conclusions: Given the importance of menthol in the cigarette market, and the higher tar and nicotine content of menthol cigarettes, it is critical that researchers continue to examine the prevalence of menthol cigarettes use among diverse sociodemographic groups. Examining these factors will help to design interventions to reduce smoking among these groups.

  Tobacco control policy impact and public perception II Top

Health and policy impact of tobacco control programmes on railway stations

Amit Dwivedi, Bobby Ramakant, Alok Kumar Dwivedi, Rama Kant

Indian Society Against Smoking, India

E-mail: [email protected]

Objectives: 1) To add health-value to the time of waiting passengers or those coming to receive or drop passengers 2) To bridge partnership with Indian Railways, to sensitize and integrate tobacco control policies on the railway stations 3) To provide on-site tobacco cessation counseling to passengers, and register them for follow-up by Tobacco Cessation Clinic (TCC) 4) To raise awareness about existing tobacco control policies in India

Methods: ISAS partnered with the Indian Railway authorities to dedicate one-day a month for each of the 4 railway stations in Lucknow to provide on-site tobacco cessation counseling by experts and raise awareness about existing tobacco control policies. Youth from different schools and colleges displayed their poster exhibits on tobacco control issues. Local media was involved to provide coverage, document experiences of using tobacco, health hazards and tobacco cessation of those passengers who were willing to speak-up. Railway authorities, staff including porters were sensitized on an ongoing basis, to enforce existing tobacco control policies and also quit tobacco use themselves.

Results: During January 2004 - January 2008, more than 150,000 passengers signed the petition demanding enforcement of existing tobacco control policies in India. Media, railway staff including porters and railway officials are proactively involved in enforcing tobacco control policies on the 4 railway stations in Lucknow. Passengers waiting have time to engage. Enforcement of ban in public places more effective when assistance to quit tobacco is available. However we don't claim that this could be better than auditorial approach.

Stakeholders' opinions about a tobacco policy in Lao PDR

Tanja Tomson, Hans Gilljam

Karolinska Institutet/Stockholm Center for Public Health, Helath Promotion And E, Sweden

E-mail: [email protected]

Background: The global epidemic of tobacco smoking is expected to impact hardest in low- and middle- income countries (LMIC). There is a lack of understanding regarding the policy environments within which tobacco control policies are being introduced particularly in LMIC. This study aims at exploring key stakeholders' beliefs about a national tobacco policy in the Lao People's Democratic Republic a low-income country.

Methods: This is a qualitative case study with a standardised open-ended questionnaire answered by eleven stakeholders in leading positions within different ministries and actors including the media, donors and NGOs. Themes included the perception of tobacco among professionals, awareness of tobacco as a public health issue, importance of inter-sectoral cooperation, and obstacles faced in implementing policies. Analysis was done using the case and cross-case method.

Results: The refusal to participate by tobacco industry is noteworthy. Among the respondents there was consensus regarding the positive impact of a tobacco policy with the exception of representation for the Ministry of Agriculture. Stakeholders identified education, awareness creation through media and law enforcement as important interventions, followed by taxation. Education should be diversified in the way it should be delivered. It was emphasized that people in rural areas and minority groups need tailored made approaches. A major limiting factor in moving tobacco control forward in LMIC was stated to be the lack of funding.

Conclusions: It is essential to draft a national tobacco policy that can help the government to increase taxes, and create adequate provisions for the enforcement of tobacco laws.

CHEAP fags: perceptions from smokers and recent quitters in the North East of England

Ailsa M Rutter, Lisa Holland, Colin Shevills

Fresh- Smoke Free North East, United Kingdom

E-mail: [email protected]

Background: The northern regions of England have a particularly high demand and supply of cheap and illicit tobacco products, which is undermining other tobacco control policy.

Objectives: To better understand the purchasers and their knowledge and attitudes towards cheap tobacco; determine a target market for future marketing activity; establish potential, impactful messages; and feed this into the North of England Cheap and Illicit Tobacco Action Plan

Methods: Four focus groups held with peripheral buyers of cheap and illicit tobacco and recent quitters. This built upon six previous focus groups undertaken with a range of buyers.

Results: Consumer language is key to communicate messages around this issue; buying these products is seen as 'the norm' and legitimately exploiting the tax system; to reduce demand, the messenger/s are key- local leaders are more acceptable than central government agencies; there are some opportunities to: challenge perceptions around tax loss, and the links to organised crime: challenge buyers' faith in their cheap cigarette supplier and their product (and for some introducing the idea of fakes for the first time); educate them as to how distasteful (in their mind) fakes really are with substandard quality of tobacco and processing.

Conclusions: Before embarking on any marketing and communications activity around cheap and illicit tobacco, it has been vital to understand the target audience views and perceptions. An integrated campaign is now being developed for roll out across the North of England from Spring 2009.

What predicts beliefs about 'light' and 'low tar' cigarettes among chinese smokers? Findings from the international tobacco control (ITC) China survey

Tara Elton-Marshall, Geoffrey Fong, Yuan Jiang, Mark Zanna, David Hammond

University of Waterloo, Canada

E-mail: [email protected]

Cigarettes labeled as "low tar" or "light" exist in China, but there has been no research to date that has examined whether Chinese smokers think these brands are less harmful and what predicts the belief that these cigarettes are less harmful. As Chinese smokers become more health concerned, these cigarettes may provide smokers with a rationale to continue smoking. In addition, it is important to understand factors that predict these beliefs to ensure that the Framework Convention on Tobacco Control (FCTC) can address these issues. We analyzed data from Wave 1 of the International Tobacco Control (ITC) Survey in China, a face-to-face survey of a probability sample of smokers in 7 cities in China. More than 60% of Chinese smokers believed that "light" cigarettes are less harmful, the highest prevalence across 11 other countries in the ITC Project. The strongest predictor of the misperception that "light" and "low tar" cigarettes are less harmful was the belief that these cigarettes are "smoother on the throat and chest" ( P<0.001). With 300 million smokers in China, it is imperative that media and regulation address the misleading sensation of "light" and "low tar" cigarettes. These findings also suggest that banning the terms "light" and "low tar" under FCTC Article 11 may not be sufficient and that product regulation under Article 9 should also address the misleading sensory experience of "light" and "low tar" cigarettes in order to dampen perceptions that these cigarettes are actually less harmful.

  Youth advocacy, attitude and media Top

Smoking, media and risk perception among university students: A qualitative approach

Maria de Fαtima Batalha de Menezes, Frances Stillman, Elaine Masson, Andrι Szklo

Brazilian National Cancer Institute - INCA, Brazil

E-mail: [email protected]

Background: Smokers΄ risk perceptions are closely linked to their social environment, thus also reflecting actions developed by governments to raise individual and social awareness of purported risk behavior΄ dangers.

Objective: To understand determinants of smoking initiation and smoking cessation related to selected university environment.

Methods: Among 2280 students who answered a previous quantitative survey conducted at Rio de Janeiro State University, we carried out two focus groups composed of 10 students each, smokers and non-smokers altogether, stratified by gender. Students talks were recorded and then transcripted. An "analytic map" was constructed aimed at grouping main issues which araised from focus group.

Results: Three major categories were chosen: "smoking at university", "smoking risk perceptions", "tobacco and media". University teachers who smoke either inside and outside the buildings were considered to be the most important role models to smoking initiation and maintenance of behavior. Peer pressures and tension related to exams may contribute to smoking initiation as well. Mouth and lung cancer were described as being the most important smoking risks by students, mainly by men; however, they do understand that those are long-term health risks and depend, basically, on individuals΄ susceptibility and lifestyle. Finally, students considered that tobacco industry advertisements usually have more impact than governmental actions, as the former look more real for them.

Conclusions: Multi-directed strategies should be developed to university students taking into consideration both eligible population age and risk environment which may act as triggers to start and maintain smoking behavior.

"SMOKEFREE AT WORK" youth advocacy pilot program

Sylvana Rochet-Belleri

American Cancer Society, United States of America

E-mail: [email protected]

Background: The American Cancer Society has embarked on a pilot youth advocacy initiative in North Africa, to engage young leaders in the fight for smokefree workplaces. This unique program combines youth education with direct advocacy as youth serve as lead spokespeople for the right to breathe smokefree air. The program includes both youth and adult advocates working together on a joint campaign; if successful, the model could be replicated in other regions. The session provides insights on developing the program and advice on getting youth motivated for such campaigns.

Objectives: Learn about developing a regional youth advocacy strategy - Understand how youth can become advocates for smokefree policies - Understand the importance of involving youth in tobacco control campaigns - Find out more about using the internet and videos to get youth involved

Methods: Oral presentation - Showing of a video highlighting the youth at their first seminar for this program.

Results/Expected outcomes: Increasing involvement of youth and organizations in smoke-free campaigns - Expanding the reach of the Global Youth Advocacy Training (GYAT) Network. - Increasing the number of Youth leading tobacco control actions in local events, fairs, sports meets. - Influencing the amount and quality of media coverage of youth smoke-free activities.

Conclusions: Tobacco control advocates should move beyond tobacco education in schools and into programs that engage youth in this issue. Empowering and engaging youth as active participants in the fight against tobacco is one way that non-governmental organizations can ensure successful smokefree campaigns.

Campaign to mobilize young Montrealers against tobacco marketing

Monique Lalonde, Anne Chabot, Christine Demers, Christine Poisson

Direction De Santι Publique De Montrιal / Montreal Public Health Department, Canada

E-mail: [email protected]

Since the ban on tobacco sponsorship in Quebec (Canada) in 2003, tobacco ads produced by the industry have invaded corner stores, many of which are located close to schools and patronize by youth. Huge cigarette walls have been used to promote tobacco products and encourage young people to start smoking. In 2008, the Tobacco Act prohibited in-store displays. Draft regulation has been submitted for other forms of marketing. The Montreal public health department made use of this situation to launch a campaign entitled Say it loud! No more tobacco ads in stores. The goal of the campaign was to make young people (aged 14 to 17) aware of the influence of advertising and to give them the tools they need to take a stand and voice their beliefs, in particular through advocacy. To reach these objectives, the strategy included a survey of convenience stores, a creative design contest on the campaign theme, a day of training and mobilization for young people and professionals, activities organized by and with youth in schools, and a theatrical action in Montreal's subway intended for the media. In this presentation, we will discuss the various campaign components and their results in terms of the role they played in mobilizing young people and professionals. A significant spillover effect of the campaign was the media's marked interest in covering the theatrical action, which caused the industry to respond and the youth to obtain a formal meeting with a senior public servant from the ministry of health.

Smoking is rank! but, not as rank as other drugs and bullying say New Zealand parents of pre-adolescent children

Marewa Glover, Sandar Min, Chris Bullen, Vili Nosa

Auckland Tobacco Control Research Centre, Newzealand

E-mail: [email protected]

Background: Children whose parents engage in anti-smoking socialisation have significantly lower rates of smoking onset, even if parents are currently smokers.

Objectives: Changing parental smoking behaviour and attitudes towards smoking uptake by children is a key component of Keeping Kids Smokefree, a community intervention trial in South Auckland, New Zealand aimed at testing if uptake of smoking among 11 and 12 year old children can be reduced primarily by changing parental smoking behaviour and attitudes. Maori (indigenous New Zealanders) and Pacific Islands people are the key target for the intervention because of their high smoking prevalences and the widening disparity in prevalence compared with European New Zealanders.

Methods: Surveys of parents were conducted in Years 1 (2007) and 2 (2008) across five schools in which they were asked to rank a range of problems in order of how serious they thought the problem was from most serious to least serious. Mean ranking was calculated and ANOVA used to examine the differences in mean ranking among the problems and among different ethnic groups.

Results: In order of seriousness the parents ranked: P (crystal meth) and other drugs, Marijuana smoking, Alcohol drinking, Bullying, Cigarette smoking, Sex, and Obesity. There were some significant ethnic differences in the ranking.

Conclusions: Parents over-estimate the health risk of P, Marijuana, Alcohol and other drugs compared to tobacco which could make it harder for interventions aimed at reducing smoking initiation among children.

  Killing us softly: Tobacco industry corporate social responsibility as a public health challenge Top

"Women might be …our natural enemies": Tobacco companies' efforts to improve their image among women

Patricia McDaniel, Ruth Malone

University of California, San Francisco, United States of America

E-mail: [email protected]

Background: Since the 1970s, tobacco companies have used corporate contributions and sponsorships to enlist women's organizations as allies to promote the tobacco industry's perspective to policymakers. Recently, women have become a primary target audience of tobacco industry corporate social responsibility (CSR) initiatives.

Objectives: To explore why and how the tobacco industry crafts CSR initiatives to appeal to women.

Methods: Review and analysis of publicly available internal tobacco industry documents and relevant secondary data.

Results: The tobacco industry regards women as an influential group with the potential to play an important role in tobacco policy debates due to their interest in health issues, the importance they place on corporations behaving responsibly, and their status as mothers. These characteristics suggested a "natural" tendency towards criticism of the industry. To improve their image among women, tobacco companies re-organized corporate contributions policies around issues likely to appeal to women, such as assistance for domestic violence victims. They also inserted CSR themes into women's cigarette brand promotions. Some tobacco companies also sought to appeal to women by capitalizing on the presence of women executives in the top levels of their companies. Although these strategies initiated in the United States, Philip Morris has begun to internationalize them.

Conclusions: The importance of women's opinions to the industry suggests that women are key to advancing tobacco control objectives. To preserve women's support for tobacco control policies and to counter the tobacco industry's women-focused image-enhancement campaigns may require industry delegitimization campaigns with messages aimed at women.

Revitalising the political authority of the tobacco industry: British American tobacco's CSR Programme

Gary Fooks, Anna Gilmore, Katherine Smith, Jeff Collin

University of Bath, United Kingdom

E-mail: [email protected]

Background: During the late 1990s British American Tobacco (BAT) began to develop a comprehensive programme of Corporate Social Responsibility (CSR). BAT claims the programme is underpinned by a number of laudable beliefs ranging from the importance of adding value to the communities where it operates to the imperative of ensuring that the company markets its brands and products responsibly. Measured in terms of the number of awards it has received, the programme has been a roaring success and the available evidence strongly suggests that it has been instrumental in opening up access to civil society groups and public officials.

Methods: Analysis of BAT's internal documents made publicly available as a result of US litigation.

Objectives: To explore the limits of BAT's claims of responsibility and the motivation behind its activities by examining the origins of the company's CSR programme.

Results: The documents indicate that CSR, both as a field of governance and as a platform of corporate communication, was regarded as providing the firm with a new set of techniques capable of relegitimating the company in the public imagination and enhancing its capacity to influence the policy-making process. BAT executives used the field of CSR to pull together a range of socially responsible practices and reframe existing techniques of corporate political activity to alter the pattern of alliances that make-up the field of tobacco control policy, and reshape how the company was publicly perceived.

Conclusions: Public officials should reconsider plans of re-engagement formulated on the back of CSR.

Rallying around responsibility: Philip Morris's societal alignment strategy

Joshua Yang, Ruth Malone

University of California San Francisco, United States of America

E-mail: [email protected]

Background: A key element of Philip Morris's (PM) effort to change its public image is "societal alignment," defined by the company as "strategies and programs to meet society's expectations of a responsible tobacco company."

Methods: To explore the role of societal alignment in PM's public affairs strategies, we searched for and analyzed approximately 375 publicly available PM documents. We used an iterative process to categorize themes and summarize findings.

Results: In 1999, PM set becoming and being perceived as a responsible tobacco company as a global corporate goal. It planned to reach its goal of responsibility by identifying society's expectations of a responsible tobacco company through public opinion research in every market it operated in and developing programs and activities to meet those expectations. It both reframed existing programs and policies, such as its youth smoking prevention and compliance to the Master Settlement Agreement (MSA), and created new ones to be seen as responsible. The purpose of becoming societally aligned through these programs and policies was to gain social and political trust to create an environment that enabled policy makers to support positions favorable to the company's business objectives.

Conclusions: PM engages in numerous activities in order to be perceived as responsible - a key characteristic in its evolving public image - and gain public trust to achieve its business objectives. Tobacco control advocates must continue their efforts to denormalize PM's efforts at appearing responsible to ensure strong and effective tobacco control measures.

Intro: Is the tobacco industry legitimate?

Ruth Malone, Patricia McDaniel

University of California San Francisco, United States of America

E-mail: [email protected]

Background: Organizational theory suggests that businesses require legitimacy: basic public acceptance of their right to exist. For more than two decades, tobacco control advocates have suggested that the tobacco industry is not legitimate, as no other business promotes addictive products that kill half their users. The industry thus faces a legitimacy crisis, and has sought to improve what it calls "credibility" by engaging in corporate social responsibility (CSR) initiatives.

Objectives: To explore how the tobacco industry defines and addresses credibility, and analyze why it is important.

Methods: Review and analysis of publicly available internal tobacco industry documents and secondary material.

Results: The tobacco industry identified many reasons for its lack of credibility: its denials that smoking caused disease, youth-oriented advertising, activities in developing countries, and the credibility of its public health 'opponents'. Companies undertook numerous credibility-enhancing projects, including CSR programs such as youth smoking prevention, corporate advertising, and philanthropy. Tobacco companies conceptualized credibility primarily as a matter of altering public perceptions. "Truth" was largely absent from industry conceptions of credibility, which incorporated notions of "responsibility," frequently characterized as 'reasonableness.' However, industry research found that the public regarded credibility and responsibility differently, expecting these to entail truth-telling, advertising reductions, less harmful products, making amends, apologies for deception, or exiting the tobacco business altogether. Overall, industry credibility-building projects failed repeatedly.

Conclusions: Challenging tobacco industry legitimacy is strategically important and should be a continuing part of tobacco control worldwide.

Tobacco industry relations with arts and culture organizations

Elizabeth Smith

University of California San Francisco, United States of America

E-mail: [email protected]

Introduction: Tobacco control advocates frequently seek to denormalize smoking and delegitimize the tobacco industry. One tobacco industry response to these efforts is for companies create an image of "corporate social responsibility," usually by developing relationships with other organizations and institutions, who thereby become the industry's explicit or implicit allies. Although tobacco control advocates have known for decades that the tobacco industry supports arts organizations financially, no previous research has examined these relationships.

Methods: Search and analysis of internal tobacco industry documents, released as a result of the Master Settlement Agreement and available at

Results: The industry has, through philanthropy and sponsorship, developed many such relationships with arts institutions, such as Philip Morris International's Art Awards in Japan and the ASEAN countries, and BAT sponsorship of arts and opera in Russia and film festivals in the Czech Republic. The tobacco industry's pragmatic reasons for philanthropy are usually not directly about selling cigarettes, but rather about keeping the policy environment favorable to the industry. Arts philanthropy provides tobacco companies with goodwill from numerous publics, image enhancement, association with artistic qualities, improved employee morale, and a variety of allies in the policy arena.

Discussion: Arts organizations could be allies of tobacco control, instead of assisting the tobacco industry's social responsibility image campaign. However, in order to counter the influence of the tobacco companies, advocates must understand and address the issues and concerns of arts organizations.

Corporate philanthropy, lobbying and public health policy

Laura Tesler, Ruth Malone

University of California San Francisco, United States of America

E-mail: [email protected]

Background: To counter negative publicity about the tobacco industry, Philip Morris (PM) has widely publicized its philanthropy initiatives. While corporate philanthropy is primarily a public relations tool, contributions may be viewed as offsetting the harms corporate products and practices cause. That such donations themselves have harmful consequences has been little considered. Drawing on internal company documents, we explore the philanthropy undertaken as part of Philip Morris's "PM21" image-makeover in the United States, and its usage as a model for overseas initiatives.

Methods: Analysis of internal PM documents released through litigation, triangulated with media coverage obtained from newspaper databases and with publicly available government archives of legislators' bill sponsorship and voting records.

Results: PM explicitly linked philanthropy to government affairs, using contributions as a lobbying tool against public health policies. Through advertising, covertly solicited media coverage, and contributions to legislators' "pet causes", PM improved its image among key voter constituencies, influenced public officials, and divided the public health field as grantees were converted to stakeholders.

Conclusions: PM's donations clearly operated as a substitute, tax-deductible form of lobbying, designed to thwart taxation and avert sales and marketing restrictions. Philanthropy advertising enabled PM to circumvent the ban on televised tobacco advertising by promoting its name through its "good works." Implementation of the World Health Organization's Framework Convention on Tobacco Control should include banning philanthropic and image advertising as well as product advertising, and developing guidelines to address negative public health consequences of tobacco industry corporate philanthropy.

Corporate social responsibility and international and national standardization bodies: What is the role of tobacco control?

Tobacco Policy International, United States of America

Stella Aguinaga Bialousm Ruth Malone

E-mail: [email protected]

Background: The International Organization for Standardization (ISO) is a non-governmental network of 157 national standardization bodies. Amongst its best known standards is ISO 9000 (quality management). In tobacco control, ISO, until recently dominated by the tobacco industry, is known for the standard establishing machine-measured levels of tar and nicotine.

Objectives: To examine the ISO standard setting process for social responsibility and its potential impact on implementation of the WHO FCTC.

Methods: Review of publicly available sources on the development of ISO Social Responsibility Standard (ISO 26000).

Results: ISO 26000, in development since 2005, received no apparent direct tobacco industry influence at the international level, while at the national level the industry's involvement in the process is clearer. With few exceptions, there has been no involvement of the tobacco control community nationally or internationally. The involvement of consumers' groups and a few public health advocates led to the language evolving from an exclusive business focus to an attempt to include health, community welfare and sustainable development as core concepts of social responsibility. The standard is to be published in 2010.

Conclusions: In the past, tobacco industry involvement, and the public health's absence, from ISO's standard-setting process led to international tobacco-related standards that are either inadequate or harmful. As ISO 26000 evolves, a stronger tobacco control presence could assist in safeguard the standard from tobacco industry interests, create a movement to reject the concept of tobacco industry social responsibility and contribute to the implementation of the WHO FCTC, especially Article 5.3.

Transnational tobacco corporations and global philanthropy: Charitable donations in southeast Asia

Ross MacKenzie, Jeff Collin

University of Edinburgh, United Kingdom

E-mail: [email protected]

Background: In line with broader trends in corporate philanthropy, charitable donations by transnational tobacco companies (TTCs) have been characterised by strategic refocusing and globalization.

Objectives: To examine the strategic utility to TTCs of donations made across Southeast Asia, including following the 2004 tsunami.

Methods: Analysis of tobacco industry documents and a review of corporate websites and publications, academic and grey literature and media reports.

Results: Following the 2004 tsunami, TTCs reported substantial donations to regional aid efforts totalling over US$2.6m. PM's decision to end its controversial regional ASEAN Art Awards programme was explained in terms of the tsunami having prompted the group's companies to re-align sponsorship priorities to aid victims. Alongside positive media coverage and broad reputational advantages, donations elsewhere in the region suggest more direct strategic objectives. Recipients may become valuable allies, and around half of PM's annual "charitable" donations in Thailand were made to tobacco-related organisations. These included the Thai Tobacco Growers Association which subsequently called for an end to Thailand's and increased foreign investment, a longstanding PM objective.

Conclusions: Corporate philanthropy in key emerging markets can serve important global functions, and its particular importance for TTCs is evident from analysis of donations across Asia. Philanthropy should be viewed as intrinsic to broader corporate social responsibility strategic initiatives, and hence even donations to important social causes should be viewed as antithetical to public health objectives.

  Cessation: Availability and strategies Top

Adjustment for selection bias due to missing data in smoking cessation trials

Yash Jalundhwala, James W. Shaw, Myra Muramoto

Department of Pharmacy Administration, University of Illinois At Chicago, United States of America

E-mail: [email protected]

Objectives: Smoking cessation trials may suffer from significant biases due to subject withdrawal. A study was conducted to identify the determinants of withdrawal and evaluate the performance of methods to account for potential biases due to subject attrition.

Methods: Data were taken from a study of over-the-counter (OTC) vs. prescription-only (PO) nicotine inhalers for smoking cessation. 520 adult smokers were assigned to purchase nicotine inhalers with or without a prescription.

Data were collected at baseline and 2, 6, 26, and 52 weeks thereafter. Point-prevalent (PP) abstinence was modeled using probit regression with one of four approaches to account for missing data: available-case (AC) analysis, intent-to-treat (ITT) analysis, adjustment for sample selection (SS), and multiple imputation (MI).

Results: The estimated difference in the probability of PP abstinence between the PO and OTC [referent] groups was 0.27, 0.09, 0.23, and 0.14 using the AC, ITT, SS, and MI methods, respectively. Predictors of withdrawal identified using the SS approach included intervention ( P<0.001), time of follow-up ( P<0.001), intervention-by-time ( P=0.006), age ( P<0.001), race/ethnicity ( P=0.038), education ( P=0.006), baseline motivation to quit smoking ( P=0.004), daily cigarette consumption at baseline ( P=0.044), and number of cartons of inhalers purchased ( P<0.001).

Conclusions: SS methods provide little benefit over AC analysis. While ITT yields downward-biased estimates of intervention effect, MI appears to ameliorate this bias while avoiding the problems inherent with AC analysis. These findings have important implications for evaluating the results of smoking-cessation trials and guiding choices among interventions when implementing tobacco control programs.

High risk strategy in smoking cessation is feasible on a population-based level. The Inter 99 study

Charlotta Pisinger, Torben Jorgensen

Research Centre for Prevention And Health, Denmark

E-mail: [email protected]

Introduction: One strategy to achieving a high impact on public health has been large community-based smoking interventions, but several of these have shown disappointing results.

Methods: All 2,408 daily smokers included in a multi-factorial randomised population-based intervention study, Inter 99, Copenhagen, Denmark, were repeatedly offered individual face-to-face lifestyle consultation. All smokers were strongly encouraged to quit. Furthermore, smokers in the high intensity group were offered participation in smoking cessation groups. We measured self-reported and validated point abstinence at one, three and five-year follow-up and compared rates with a control group, using intention-to treat analyses. Logistic regression analyses were used to identify predictors of validated point abstinence at five-year follow-up.

Results: Compared to the control group it was twice as likely to be self-reported abstinent at five-year follow-up in the high intensity intervention group (OR: 2.19; 95%CI: 1.7-2.8; P < 0.001) and seventy percent more likely in the low intensity intervention group (OR: 1.71; 95%CI: 1.1-2.6; P = 0.016). The effect of the intervention was significant even when comparing validated abstinence in the intervention groups with self-reported abstinence in the control group (OR: 1.38; 95% CI: 1.1-1.8; P = 0.014). Male gender, vocational training, higher age at onset of smoking, high knowledge of harm of smoking and lower tobacco consumption predicted point abstinence at five-year follow-up.

Conclusion: This large unselected population-based study showed a significant effect on smoking cessation in the long term. The face-to-face setting, the repeated offer of assistance to quit and the multi-factorial approach may explain the success of the smoking cessation intervention.

Tobacco cessation in public health dental clinics: Outcome results of a clinical trial

Judith Gordon, Herb Severson, Judy Andrews, David Albert

Oregon Research Institute, United States of America

E-mail: [email protected]

Introduction: Public health dental clinic patients use tobacco at disproportionately high rates and this is a vulnerable population. The purpose of this study was to evaluate a tobacco cessation program delivered via public health dental practitioners.

Methods: 14 public dental clinics in three states (Mississippi, New York, and Oregon) were randomized to either a Delayed Training Control or Intervention Condition. Intervention Condition provided a brief cessation intervention based on the Clinical Practice Guideline, plus provision of free nicotine replacement therapy for patients setting a quit date. Follow-up assessments were conducted at 6 weeks, and 3 and 6 months post-enrollment.

Participants: All are at or below the federal poverty level. Approximately 20% of the participants reported being Hispanic/Latino; 40% African American; 38% White.

Results: At 6-week follow-up, respondents in the intervention condition were more likely to report quitting than those receiving usual care (10.8% vs. 4.6%, P<.001). Quit rates varied as a function of ethnicity, with African Americans in the intervention condition reporting the highest quit rates vs. those in the control condition (14.4% vs. 3.3%; P <.001). Detailed results by ethnicity and of the 3 and 6 month follow-up will be presented.

Discussion: The short-term results suggest that dental practitioners in public health settings can be effective in helping their patients to quit tobacco. In addition, preliminary 3 and 6-month data indicate that the effect of the intervention strengthens over time, providing further evidence to support the efficacy of dental office interventions for this underserved population of tobacco users.

FCTC Article 14 Implementation: Global assessment of programs to train tobacco treatment providers

Nancy Rigotti, Asaf Bitton, Ken Wassum, Ann Richards

Harvard Medical School, United States of America

E-mail: [email protected]

Background: Article 14 of the WHO Framework Convention on Tobacco Control (FCTC) directs countries to implement effective tobacco cessation treatment programs. This requires countries to train tobacco treatment providers.

Objectives: To identify tobacco training programs globally; to describe their teaching methods, funding, individuals trained; to compare their curricula with evidence-based tobacco treatment training standards developed by the Association for the Treatment of Tobacco Use and Dependence (ATTUD).

Methods: Using an advisory board of international tobacco control experts, we developed an online 37-item survey and administered it to contacts from a previous global survey of tobacco treatment guidelines. We sent surveys to 61 countries that represent all 6 WHO regions, further divided by human development index (HDI) levels.

Results: We received responses from 43/61 (70%) countries surveyed. Although 88% reported having tobacco treatment training programs, prevalence varied by HDI: 3/6 countries in the lowest HDI tertile, 8/11 in the middle tertile, and 26/26 in the highest tertile had programs. A median of 24 participants were trained annually (range, 0-2953). African programs trained fewer people than other regions. Most programs adhered to evidence-based guidelines (77%) and to most ATTUD competencies. Most trainers and most trainees were physicians. 67% of programs were funded by government grants. Funding was the biggest challenge reported.

Conclusions: Most upper-income countries reported having some tobacco treatment training program, primarily for physicians. Most programs adhered to evidence-based guidelines and ATTUD competencies. Training programs for non-physicians are needed, as is better program funding, particularly for middle- and lower-HDI countries.

Which works best? Group or pharmacy-based smoking cessation services

Linda Bauld, John Chesterman, Janet Ferguson, Ken Judge

University of Bath, United Kingdom

E-mail: [email protected]

The UK has a network of smoking cessation services free at the point of use. A number of different models of treatment have developed, offered in a range of locations. Limited evidence exists about which models achieve best outcomes, and for which smokers. Two of the most common are group-based services offering behavioural support plus pharmacotherapy, usually for 7 weeks, and pharmacy-based services which offer less intensive one to one support plus pharmacotherapy for 7 weeks or longer. This observational study compares these two models of treatment in Glasgow, Scotland's largest city and addresses: Short and longer term outcomes associated with each model of service. Factors (client and/or service characteristics) that influence outcomes. Relationship between costs and outcomes for the two models of service. Effectiveness of services in reaching and treating clients from disadvantaged parts of the city. Clients' views and their perspective on factors influencing cessation outcomes. Results At 4 weeks, CO validated outcomes were 18.6% for pharmacy-based services (27.8% when self-report cases included) and 35.5% for group services (41.3% with self-report cases). A wide range of client characteristics were associated with cessation outcomes, including age, gender, socio-economic status, level of addiction. Results from multi-variate analysis suggest that even when controlling for these characteristics, smokers were twice as likely to quit at four weeks (OR 1.92) if they used the group service compared with pharmacy-based support. The presentation will also outline relapse rates between 4 and 52 weeks and full results at one year.

FCTC Article 14 Implementation: An overview of surveillance efforts to define tobacco dependence treatment activities worldwide

Asaf Bitton, Nancy Rigotti

Harvard Medical School, United States of America

E-mail: [email protected]

Background: Article 14 of the WHO Framework Convention on Tobacco Control (FCTC) calls on countries to develop and disseminate guidelines based on scientific evidence and best practices, and to take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence.

Objectives: To provide an overview of tobacco dependence treatment guidelines, tobacco treatment services, and tobacco treatment training programs across the world, we will review the current status of data available on these topics. Our goal is to provide an up-to-date overview of tobacco dependence treatment issues in order to assist policymakers and governments in implementing Article 14.

Methods: A set of linked presentations with an introductory presentation to set the overview and landscape. Each of the 3 specific surveys have been submitted as separate abstracts. These report the results of surveys of countries on (1) their nature of any tobacco dependence treatment guidelines; (2) the type of tobacco dependence treatment available in the country; and (3) the existence and content of any training programs for tobacco treatment providers. In this proposed overview presentation, we will provide a summary of existing data collection efforts to define tobacco dependence treatment for the purposes of assist in implementing Article 14.

Conclusion: Preliminary efforts have been made that can serve as pilot data for future monitoring of tobacco treatment globally in order to realize the goals of Article 14.

Evaluating the efficacy of nicotine lozenges for smokeless tobacco cessation

Jon Ebbert, Herb Severson, Brian Danaher, Ivana Croghan

Oregon Research Institute, United States of America

E-mail: [email protected]

Background: Smokeless tobacco (ST) is known to increase the risk for cancer of the mouth and gum, larynx, and salivary gland. A need for efficacious interventions exists as ST users report the desire to quit. Preliminary studies suggest that nicotine lozenges are well-accepted by ST users and decrease tobacco cravings.

Objectives: To evaluate the efficacy of 12 weeks of 4-mg nicotine lozenges for increasing the prolonged and point prevalent all tobacco abstinence rates at 3 and 6 months compared to placebo lozenges in smokeless tobacco (ST) users when all users receive a behavioral treatment for tobacco dependence.

Methods: We conducted a double-blind placebo controlled, two-group phase III clinical trial with adult ST users in two sites (Oregon and Minnesota).

Results: We recruited 270 smokeless tobacco users of which 264 were male and 6 were female. The mean age of the sample was 36.5 (SD = 10.8), 96% Caucasian, 97% use snuff, and mean cans per week were 4.2 (SD = 2.6). The readiness to quit as measured on a 10 point scale was 8.8 (SD = 1.1). We are just breaking the blind for the study and will report full results for 3 and 6 month follow up with biochemical verification of self reported quitting. The initial results appear very positive and this will be the first trial reporting positive results for a nicotine replacement therapy for smokeless tobacco cessation.

Conclusions: Nicotine lozenges may be the first pharmacotherapy with proven efficacy for smokeless tobacco users.

  Economic impact and public attitude about smokefree spaces Top

Attitudes to and policy debates on smokefree cars in Europe, North America and Australasia

George Thomson, Nick Wilson

University of Otago, Wellington, Newzealand

E-mail: [email protected]

Background: Laws requiring smokefree cars when children are present have been adopted in a number of North American and Australian jurisdictions. This is likely to be an area for ongoing policy development, due to the very high levels of secondhand smoke that can occur in cars.

Objectives: To review the evidence of public and official attitudes, and to explore the policy debates on smokefree cars, in Europe, North America and Australasia.

Methods: Electronic searches were made for attitudinal data and compliance data, and for policy debates, from national, states and provincial jurisdictions, for the period 1990 to 2008.

Results: We identified over 15 published studies on attitudes and behavioural responses associated with smokefree cars. Where data are available, there appears to be majority public adoption of not smoking in cars when others are present. Currently, there are insufficient data on the acceptability and compliance with smokefree car laws, although there is high support in one setting (South Australia). The policy progress in the jurisdictions which have adopted smokefree car laws (n=8+) appears to not depend on an intermediate stage of government smokefree car media campaigns, but may relate to the existence of other smokefree indoor environments laws in the jurisdiction.

Conclusions: While smokefree car media campaigns are probably a helpful aid to facilitating smokefree car laws, previous indoor smokefree laws may be a more important driver of such change.

The economic impact of smoke-free legislation on sales turnover in restaurants and bars in Santa Fe Province, Argentina. 2008

Carlos Alberto Candioti, Oscar Alberto Costa, Verσnica Schoj

Smoke Free Environmental Alliance In Argentina (ALIAR), Argentina

E-mail: [email protected]

Background: Breathing secondhand-smoke causes morbidity and mortality. Smoke-free laws are the only remedy. Santa Fe province has enacted a law that prohibits smoking in all public places and workplaces, including restaurants and bars (July, 2005). Although there was scientific evidence from around the world (Scollo et al.) that proved that 100% smoke-free environments policies had not impacted negatively on sales at bars and restaurants, the hospitality industry opposed this legislation through legal and legislative methods.

Objectives: To measure the economical impact of 100% smoke-free environments legislation on bar and restaurant sales in Santa Fe Province, Argentina.

Methodology: Patrons' survey (subjective impact) and econometrical study (objective impact) on data provided by the API (Provincial Revenue Administration) to compare real sales in a time series (30 months before and 30 months after the law's entry into force).

Outcomes: The subjective study showed that almost 50% of bar patrons thought that sales would drop when the law was implemented. Currently, almost 1/3 considers that sales have actually dropped as a consequence of the smoke-free law (smoking patrons=36,9%; not smokers=25,5%; P=0,01; n=470). However, the objective study has proven that, far from the expected decrease, sales have risen significantly (16,96%) and that this increase is directly related to the "law implementation" variable.

Conclusions: There is scientific proof that 100% smoke-free environments policies do not have a negative economical impact. This study provides local evidence to use this affirmation for advocacy and enforcement of laws in a country that has not ratified the FCTC.

Community's perspective on the free-smoking restaurants in Ha Noi city of Vietnam

Quynh Anh Tran

Viet Nam Public Health Association, Vietnam

E-mail: [email protected]

Background: Although, tobacco control has been recently received special attention from the Vietnamese Government, policy on the smoke- free public place, especially on smoke - free restaurant, has not been complied in Vietnam. With the support from the SEATCA, the VPHA worked on this study aiming at the potential of a smoke- free restaurant policy in Viet Nam.

Objective: 1. To determine the needs and attitude toward free-smoking policy among restaurant owners and employees in Ha Noi; 2. To inform the policy-makers and tobacco-control activists in Viet Nam about the potential of the free- smoking restaurant model.

Method: This study applied the convenience sampling with 200 customers in 20 restaurants in Ha Noi City, Viet Nam. The owners and employees joined in-depth interviews, while customers administered the questionnaires.

Result: 71.7% customers felt uncomfortable with smoking while having meal. Many customers supported the idea of the smoking-free area in restaurants. The owners were welcome the smoking-free restaurant model. From their perspectives, it is a part of the modern trendy. It is obviously good for their health and their co-workers' health. The owners and employers strongly recommended that the policy should take into account the current limitation of restaurants in terms of size and scale.

Conclusion: A policy of smoke-free restaurant in Ha Noi is the expectation of restaurant customers, owners and employees. However, the policy should come up with the establishment of smoking-free area within each restaurant, which should have a space appropriate to the whole setting.

The economic impact of smoke-free laws on the sales of bars and restaurants in Argentina

Martin Gonzalez-Rozada, Mirta Molinari, Mario Virgolini

Universidad Torcuato Di Tella, Argentina

E-mail: [email protected]

The history of smoke-free legislation in developing countries is very recent. In South America by the end of 2006 only one country, Uruguay, and one city and three provinces of Argentina had applied smoke-free laws. Trying to pass such laws produced negative reactions, by the tobacco industry and by the owners of bars and restaurants, claiming potential economic losses induced by a decline in sales due to the smoke-free laws. The main objective of this paper is to analyze in a scientific way, the economic effects of the smoke-free laws on the sales of bars and restaurants in Argentina. We use a quasi-experimental design and the econometric estimation procedure of difference-in-difference to study if smoke-free laws affected the sales of bars and restaurants in the city of Buenos Aires and in the provinces of Cσrdoba, Santa Fe and Tucumαn. Contrary to allegations of the tobacco industry and the owners of bars and restaurants, the econometric evidence presented in this paper shows that these laws did not affected negatively the sales of bars and restaurants. Moreover, in the case of Buenos Aires, we showed that the smoke-free legislation induced an increase in the sales of bars and restaurants. These results are similar to the vast majority of the scientific evidence founded for developed countries. Government officials of those provinces that are trying to pass smoke-free laws can use this empirical evidence to promote the implementation of such laws and to protect the health of patrons and employees in bars and restaurants.

Secondhand smoke exposure, pet health, and pet owner attitudes

Amanda Holm, Sharon Milberger, Ronald Davis

Henry Ford Health System, United States of America

E-mail: [email protected]

Background: Dogs and cats whose owners smoke are known to be likelier to develop certain cancers. While some smokers quit or refraining from smoking indoors because they know secondhand smoke harms people, no studies have examined the effect of pet ownership as a motivation for behavior change.

Objectives: Investigate smoking behavior, home smoking policies, and attitudes toward behavior change among pet owners who smoke and/or live with smokers.

Methods: Online survey of U.S. pet owners.

Results: 3,293 pet owners participated (76% owned dogs, 53% cats, and 10% birds); 40% were ever-smokers, and 21% current smokers. About 70% of current smokers wanted to quit in the next six months. About 70% of participants, including smokers, forbade smoking anywhere in their homes. However, among non-smokers who live with smokers, only 58% forbade smoking in their homes. If told research showed secondhand smoke could harm pets, significant numbers of smokers and non-smokers would change their behaviors or forbid smoking in the home. Pets living in households with a smoker were 24% more likely to have a health problem ( P = 0.000). Cancer and skin problems were significantly associated with smoking households when all pets were considered together.

Conclusions: Knowledge of the health effects of secondhand smoke on household pets has the potential to motivate individuals to adopt smoke-free home policies and encourage smokers to quit. In addition, there is an association between pet health problems and smokers living in the household.

The attitude-bias on self-reported assessments of economic effects of smoke-free hospitality venues

Ingeborg Lund, K.E. Lund, J. Hetland, L. E. Aaroe

Norwegian Institute for Alcohol And Drug Research, Norway

E-maill: [email protected]

This paper examines the associations between pre-event attitudes to the Norwegian ban on smoking and post-event opinions on the economic effects of this ban as reported by service personnel. The data comes from a panel study among 907 people working in the hospitality industry collected in May 2004 and May 2005. Smoke-free hospitality venues were introduced June 1 st , 2004. The objective of the study was to detect how degree of pre-ban support influenced post-ban assessments on patronage, and to discuss whether self-reports are valid as measures of economic consequences. The results showed that hospitality-workers who initially had a positive view on the smoking ban also had significantly more positive assessments on patronage than those initially negative to the ban on smoking. This was evident under control for type of hospitality venue and reported smoking status for customers. Pre-ban attitudes influenced economic aspects as well as reports on milieu variables in pubs and restaurants. A separate analysis that included only smokers showed the same pattern, indicating that the participants' initial views on the smoke ban had affected their rating of the outcome of the law more than their smoking status had. The paper concludes with a discussion on how the influence from attitudes on the respondents answers clearly indicates that self-reports might be less valid than previously thought.

Perceptions regarding enforcement of the indoor smoking law among Brazilian owners and managers of entertainment establishments

Andrea Silveira, Isabel Scarinci

Pontificia Universidade Catolica Do Parana, Brazil

E-mail: [email protected]

Background: It is well known that second hand smoke is a major factor in tobacco control efforts. Even though the Brazilian federal government has passed a law to forbid smoking indoors in public places, not all establishments follow it.

Goal: The purpose of this study is to identify factors that may contribute to whether or not establishment' owners and managers support and enforce this law in their places.

Methods: This qualitative study consisted of 11 in-depth interviews with owners and/or managers of different types of entertainment establishments. Based on the results of the qualitative interviews, a quantitative questionnaire was developed to confirm the qualitative findings and administered to 60 owners and/or managers of different types of entertainment establishments.

Results: The quantitative findings revealed that 73.3% did not enforce the indoor smoking law, and there were no differences across type of entertainment establishment (e.g., restaurants, night clubs). The content analysis of the interviews allowed us to generate four factors that may be considered major barriers to the implementation and enforcement of the law, as to know: cultural and collective identity (individual/social group characteristics/beliefs and their reaction towards the tobacco issues), political appropriateness (the acknowledgment of the existent law, the political efficacy and the willingness to enforce the law), social relationships and expectation (the perceptions about the law and tobacco issues, besides enablers and nurtures were found to be strong influences), cultural and political empowerment (positive, negative and existential values, beliefs and practices about the law and secondhand smoke).

  Farming Top

Finding alternatives to tobacco agriculture - the case in Nyanza Province, Kenya, East Africa.

James Oduor

Social NEEDS Network, Kenya

E-mail: [email protected]

Background: The abstract paper is based on earlier researches carried out by SocialNEEDS Network an NGO based in Kisumu City, Nyanza Province, Kenya. The tobacco farmers according to the researches are vulnerable to different challenges that make them suffer. They wanted to venture into other crops and crops for biofuels is felt to be one of the alternatives.

Objectives: Finding alternatives to tobacco farming by: - 1. Introducing alternative crops to tobacco agriculture. 2. Establish the possibility of venturing into the biofuel industry.

Methods: 1. Carry out information research on biofuels, crops used, maturity of the crops and marketing opportunities. 2. Share with tobacco farmers the findings and get their responses. 3. Come up with a pilot project to measure the viability of the biofuel crops.

Results: Tobacco farmers diversifying to other cash crops and doing away with tobacco. Increased employment opportunities for communities that will be targeted especially the youth. Idle land will be put to good use through the production of crops for biofuel industry. Sustainable development will be initiated.

Conclusions: The community members are able to take a great responsibility for their destiny and control it for their own benefit. This should be only catalysed by giving them the right information that would make them face their challenges with an open mind.

Assessment of the environmental impact and farmers' perception on tobacco farming in Tanzania

Lutgard Kokulinda Kagaruki, Adelaide Bitulo

Tanzania Tobacco Control Forum, United Republic of Tanzania

E-mail: [email protected]

Cross sectional surveys were carried out in Ruvuma and Tabora Regions, to assess the environmental impact and farmers' perceptions on tobacco farming in Tanzania. Survey results indicated that, farmers observed the following hazards resulting from tobacco farming: decline in natural forests, decline in animal and plant species, drying up of water sources and wetlands, expansion of agricultural farms and, increase in soil erosion, at varying degrees. Transect walk surveys in selected areas of Ruvuma and Tabora indicated an obvious change in vegetation cover over the years of tobacco farming; from thick forests to shrubs and bushes. More than 86% of the farmers in Tabora Region indicated that revenue from tobacco contributed less than 50% on poverty alleviation. Sixty five percent of interviewed farmers in Tabora Region wanted to change from tobacco farming to alternative livelihoods, while the remaining (35%) wanted to continue with tobacco, simply because of the assured market of the leaf, compared to other crops. Following serious sensitisation carried out in Namtumbo District of Ruvuma Region, tobacco farming has decreased from 22,300, in 2006, to 6,333 acres in 2007. In one village, Mtonya, only 325 out of 1,450 previous tobacco farmers planted the crop in the 2008 season. These farmers have now adopted simsim, sunflower, groundnuts, maize and beans farming and, markets have been secured for their produce. All efforts need to be done, to assist resource-poor tobacco farmers to adopt alternative livelihoods, in order to improve their socio-economic status and, save the environment from further destruction.

The potential of adopting bamboo as an alternative crop to tobacco farming in South Nyanza region, Kenya

Jacob Kibwage Kibwage, Godfery Netondo, Alphone Odondo, Grace Moraa

Maseno University, Kenya

E-mail: [email protected]

Background: 80% of Kenya's tobacco production comes from South Nyanza region. Despite the global policies aimed at reducing world tobacco production and use, the Government's policies seem to encourage more tobacco production. This trend has led to devastating food insecurity, occupational and environmental hazards and forest degradation in the region.

Objective: To investigate through farm trials and market surveys the potential of adopting bamboo as an alternative crop or source of livelihood to tobacco farming in South Nyanza region, Kenya.

Methods: The study was carried out on 120 trial farms where 2451 bamboo seedlings were planted. The seedlings were planted under the same natural tobacco growing conditions. Half of the bamboo clumps were randomly selected for monitoring. Literature review, interviews and participant observation on tobacco and bamboo production were conducted.

Results: Bamboo does well in soil and agro-climatic conditions similar to those of tobacco and can fetch 4-5 times more in terms of incomes. Most of the bamboo products sold in the formal retail market in Kenya are imported. Bamboo production has the potential in reducing socio-economic, health and environmental problems associated with tobacco farming. Existing curing skills and structures used by tobacco farmers can effectively be utilized in bamboo processing.

Conclusions:. The shifting from tobacco to bamboo is possible because the majority of farmers are willing. However, they must be well trained on bamboo processing at the community level and the market should be well structured with more bamboo species introduced in the region because of their diversified uses.

How much subsidy does tobacco cultivation receive in india? Discussions on the divergent stand of the government as against its tobacco control

Vinod Annigeri, Nayanatara Nayak

Centre for Multi Disciplinary Development Research (CMDR), India

E-mail: [email protected]

Tobacco happens to be a puzzle for the economists because it brings benefits and negatives simultaneously to the individuals as well as to the society. Merit good argument of Public Economics has proved to be wrong in view of the subsidies that tobacco as a crop enjoys in the Indian economy. We undertook an empirical study during the year 2004 to quantify the subsidy to tobacco farming because such an information gap existed in India. Our study made a modest attempt to bring to limelight such an issue which would be an eye opener to the policy makers who promote tobacco on the one hand and cry to reduce tobacco consumption on the other. There are Direct, Indirect and Hidden subsidies to tobacco farming in the Indian context. The study selected the states of Gujarat, Karnataka and Andhra Pradesh which account for more than 90 per cent of tobacco production in the country. The amount of subsidy (all kinds of subsidies) enjoyed by tobacco per acre per crop season in these three states is indicated below: Karnataka - Rs. 266 Andhra Pradesh - Rs. 542 Gujrat - Rs. 541 Various schemes and programs, which contained subsidies towards tobacco, were documented as part of the study. Hidden subsidies flowing from the tobacco industry directly or through the Tobacco Board of India have also been accounted for in the study. The study also highlights the ways and means of controlling tobacco subsidies

Impacts of tobacco farming on livelihood and health of the farmers

Trang Nguyen Thi Thu, Minh Hoang Van, Giang Kim Bao

Hanoi Medical University, Vietnam

E-mail: [email protected]

Background: Even though the amount of research on tobacco in Vietnam has recently increased rapidly, there remains no research on the health impact of the tobacco industry on cultivators. Subjects: 1) provide a preliminary comparison between tobacco cultivation related revenue and expenditure in selected areas in rural Vietnam; 2) examine the relationship between tobacco cultivation and self-reported illness in the study population.

Methods: Two tobacco farming communes were selected for exposed subjects. We also chose two non-tobacco farming communes for comparison. In each commune, 120 households were sampled. The head of household was first interviewed about the family's livelihood, then all other family members (aged 15-69) were interviewed on the occurrence of illness during the last 6 months, using structured questionnaire.

Results: Where the expenditure figures do not include personnel costs, it appeared that the average tobacco farmer did benefit financially from tobacco cultivation. However, if a personal opportunity cost was added, this benefit was seen to be minimal. The occurrences of 9 out of the 16 health problems were statistically significant (tobacco growing farmers are higher than non-tobacco farmers) The regression model shows that people who grew tobacco, older people, the women, and the individuals with lower economic status were more likely to have increased frequencies of the identified health problems.

Conclusion: The findings from study provide valuable and timely evidence that can be used to increase public awareness as well as develop and implement appropriate responses to the harmful effects of tobacco growing.

The urgency to find alternative livelihoods: An anthropological case study of tobacco tenants in Malawi

Laura Graen

Blue 21 E.V. / Campaign Rauchzeichen!, Germany

E-mail: [email protected]

Background: Many tobacco growing developing countries that produce leaf for tobacco companies rely on exploited laborers, including children. Tobacco families who receive little or no money for their work continue to labor on farms. The case study of bonded labor in Malawi examines poverty and landlessness that keep tobacco families tied to tobacco. Malawi's economic dependence on tobacco and the influence of tobacco industry create urgency in the search for alternative crops and livelihoods.

Objectives: The study will determine the extent and nature of bonded labor on tobacco farms in Malawi and create a database of qualitative information from tenants that policymakers and researchers could use to develop effective policy recommendations and grassroots activities to find alternative crops and livelihoods for tobacco families.

Methods: The study uses ethnographic data from interviews with tobacco tenants, farm authorities, union leaders, and health advocates in Malawi. Other sources are peer-reviewed literature, newspaper articles, video documentaries, tobacco companies' publications such as websites and annual reports.

Results: Malawi's tobacco workers and their families exist in slave-like conditions and sell their labor on tobacco farms to access food and temporarily escape poverty. Global tobacco companies benefit from low cost child labor and bonded labor in Malawi.

Conclusions: Malawian tobacco tenants exist in a poverty cycle that forces their children to work instead of getting an education. Health advocates and policymakers are beginning to focus attention on bonded laborers on tobacco estates. The study promotes integration of their experiences in activities to implement the WHO FCTC.

Phasing out tobacco cultivation in Maryland: A case study

Chris Bostic

University of Maryland School of Law, United States of America

E-mail: [email protected]

The State of Maryland has successfully reduced its tobacco leaf production by 90% over the past decade through a government-subsidized phaseout program. Historically, tobacco has been the leading agricultural crop in the state, and many areas were completely dependent on the international leaf market. A small percentage of the funds from the Master Settlement Agreement were set aside by the legislature to aid farmers in transitioning away from tobacco growing. The program is completely voluntary, but the vast majority of tobacco farmers chose to take advantage. The presentation will be of a case study prepared by the University of Maryland School of Law.

  Inequalities and human rights I Top

The Scottish smoke-free Legislation - gains and losses in affluent and deprived communities

Deborah Ritchie, Claudia Martin, Amanda Amos

University of Edinburgh, United Kingdom

E-mail: [email protected]

Background: Scotland implemented comprehensive legislation banning smoking in public places in March 2006.

Objectives: This paper will describe key findings from a longitudinal qualitative study of four socio-economically contrasting communities in Scotland.

Methods: A longitudinal qualitative case-study in four localities which used a range of techniques, including repeat in-depth interviews, focus groups, semi-structured interviews and observations in selected public places across four waves before and after legislation. Participants comprised: a purposively recruited panel of 40 current and former smokers; 11 focus groups with non-smokers, smokers with dependent children and young people aged 18 -25; 14 interviews with community informants.

Results: There were changes in smoking patterns and behaviour in all four communities. These were most marked within the poorer communities where there was an overall reduction in tobacco consumption. Changes in smoking behaviour were associated with perceived health and financial gains (eg reduced exposure to secondhand smoke, lower smoking consumption), as well as social losses (eg increased stigma of being a more visible smoker, disruption to social networks).

Conclusions: Smoke-free legislation had a marked impact on smoking behaviour. It contributed to changes in both attitudes and norms around smoking and consumption, particularly in the less affluent communities. The findings highlight the importance of considering the consequences of both gains and losses in future tobacco control action.

Smoking inequalities in adults: Evidence for action in Chile

Marνa Paz Corvalαn, Paula Margozzini, Dean Schillinger

GLOBALink, Chile

E-mail: [email protected]

Background: Chile has a new tobacco control legislation. We will look how this law will affect smoking inequalities. We present the Chilean situation before the law as a baseline for future law's impact evaluation.

Objectives: To describe association between social variables and smoking, to define stage of Chilean cigarette epidemic before the law, 2003.

Methods: Analysis done using ENS2003. Used cross-sectional household survey conducted 2003using stratified multistage probability sample of civilian, non- institutionalized adults. Current smoking prevalence described by age, gender, educational attainment, rural status. Logistic models used to adjust for age, gender.

Results: 3,619 adults over 17 years old were interviewed; response rate was 63.5%, refusal rate 7.5%. Population prevalence rates, 95% confidence intervals: current smokers 42.4% (39.8-45.1), 48.3% (44.1 - 52.5) men and 36.8% (33.5 - 40.1) women. The highest prevalence was men under 25 years old: 61% (50,4 - 72,4). Adjusted prevalence odds : rural vs. urban OR=0.71 (0.54-0.95), less than 8 years vs. over 12 years education OR=0.67 (0.46-0.98). Educational inequalities were higher in women and the under 60 year old population.

Conclusions: Chile has the highest world smoking prevalence in women and significant social inequalities. Population over 12 years of education has higher prevalence. Chile in 2003 was instage 2 of the epidemic.While Chile's recent law provides a promise to curb the epidemic, without an increase tobacco taxes Chile may be missing to prevent a rise in smoking prevalence among those of lower socioeconomic status.

The poor/rich divide affects adolescent smoking in California, USA

Ritesh Mistry, William McCarthy

University of Califronia, Los Angeles, United States of America

E-mail: [email protected]

Background: Past research suggests that measures of area-level absolute income (e.g., median income, proportion of households below the poverty level, etc.) and relative income (i.e., income inequality) are influential to health. However, their role specifically on adolescent smoking is not well understood.

Objectives: To assess whether the degree of county-level income inequality (i.e. the income gap between the rich and poor) is associated with adolescent smoking.

Methods: Data were used from the California Independent Evaluation of Smoking Prevention Programs 2003-04 (N=20,573 students, M=261 schools). Experimental smoking defined as 30-day use and ever use less than 100 cigarettes. Current smoking defined as 30-day use. Daily smoking defined as smoking at least one cigarette everyday for past 30 days. Socioeconomic context measured at the county-level using 2000 US Census data on the Gini coefficient, a widely used income inequality measure, and percent population below the poverty level. Conditional multilevel regression used to estimate effect of socioeconomic context on smoking while controlling for county-level and student-level confounders.

Results: Students in counties within the highest quartile of income inequality were at higher risk of daily (OR= 1.33, 95% CI=1.04, 1.70) and current smoking (OR= 1.67, 95% CI=1.20, 2.32), but not experimental smoking (OR=0.93, 95% CI=0.73, 1.18), than those in the lowest quartile. Percentage below poverty was not associated with smoking risk.

Conclusions: Risk of addictive smoking increased with increasing income inequality. Tobacco prevention efforts may benefit from socioeconomic policy interventions, particularly those that work to distribute income more equitably.

Inequities in tobacco use: Preliminary findings of the WHO commission on the social determinants of health

Christopher Fitzpatrick, Anne-Marie Perucic

World Health Organization, Switzerland

E-mail: [email protected]

Background: Tobacco use meets all four criteria which define the WHO Commission on the Social Determinants of Health's Priority Public Health Conditions (PPHC): a large aggregate burden of disease; large disparities across and within populations; disproportionate effects on certain populations or groups within populations; a global epidemic.

Objectives: 1) Summarize evidence on the differential distribution of tobacco use and differential health and other consequences among different populations or groups; 2) Analyze causal pathways leading to inequalities in tobacco use and its health outcomes; and 3) Propose possible entry points for reducing tobacco-related inequities.

Methods: A literature review is summarized using the PPHC Knowledge Network analytical framework for patterns of inequity and their upstream determinants. New statistics and regression results are presented, employing recent World Health Survey results and data from the WHO Report on the Global Tobacco Epidemic 2008.

Results: The patterns of inequity are variable across the sample of 50 low- and middle-income countries surveyed, but in the plurality of countries, the prevalence and intensity of tobacco use is highest among the poorest income quintiles. There is reason to believe that progress in tobacco control is disproportionately distributed, with the richest enjoying the most efficacious implementation of tobacco control interventions.

Conclusions: To achieve coverage of the most disadvantaged populations, in particular those who use or are exposed to tobacco use in informal settings, a new paradigm of enforcement may be required, alongside both population and individual interventions that are more pro-poor.

Tobacco use and poverty in India

Rijo John, Wendy Max, Hai-Yen Sung

University of California San Francisco, United States of America

E-mail: [email protected]

Various studies have documented the high prevalence of tobacco consumption among the poor. It is known that the prevalence of tobacco consumption is higher among the poor in India too. However, no study has quantified the level of poverty among tobacco users versus the rest of the population in India. This paper attempts to quantify the level of poverty among tobacco using households versus other households in India and explore the relationship between tobacco use and poverty. The result of this study will have public health policy implications especially in adopting taxation as a means of tobacco use regulation. Standard FGT (Foster, Greer, and Thorbecke) class of poverty measures are used to estimate the poverty among tobacco using households and the rest. The data are taken from two rounds of a nationally representative household sample survey (The 55 th (1999-2000) and 61 st (2004-2005) rounds). The estimates of poverty are based on the official poverty lines by the Planning Commission, Govt. of India. A logistic regression model is used to estimate the relationship between tobacco use and poverty. It is used to predict the probability of a tobacco consuming household falling below poverty line in India. Results from the preliminary analysis reveal that the level of poverty is 7% higher among tobacco using households than other households in rural India and 5% higher in urban India. The depth and severity of poverty as measured by Poverty Gap Index and Squared Poverty Gap respectively are also higher among the tobacco using households.

Tackling inequalities in tobacco use: Conclusions for policies from the commission on the social determinants of health

Anne-Marie Perucic, Christopher Fitzpatrick

World Health Organization, Switzerland

E-mail: [email protected]

Background: Tobacco use and its consequences are perceived as a global epidemic. However, there is a differential distribution of consumption and health impact among different populations and/or groups. In order to understand this phenomenon, the association between tobacco use and the social determinants of health need to be explored.

Objectives: Summarize the evidence of the differential distribution of tobacco use and its consequences and, based on the determinants highlighted, develop entry points for addressing these inequalities and inequities.

Methods: The analysis was based on the WHO Commission on the Social Determinants of Health's Priority Public Health Conditions (PPHC) Knowledge Network analytical framework. Following the framework, the proposed interventions were developed based on their impact on availability, acceptability and accessibility of tobacco products. The interventions also addressed the upstream (societal level) and downstream (individual level) determinants of tobacco use.

Results: The WHO Framework Convention on Tobacco Control (WHO FCTC) is a strong entry point for the implementation of the different interventions defined. However, the interventions remain under-implemented at country level, thereby reaching only part of the population and facilitating inequities in tobacco use and its impact.

Conclusions: The implementation of the WHO FCTC provisions needs to be done through the 'equity lens'. This implies tailoring the interventions so as to reach the most disadvantaged groups of the society.

  Legal/litigation/regulation I Top

Willful misconduct: How the United States government avoided paying disability benefits to veterans with tobacco-related diseases

Naphtali Offen, Elizabeth A. Smith, Ruth E. Malone

University of California, San Francisco, United States of America

E-mail: [email protected]

Background: In 1997, the U.S. Department of Veterans Affairs (VA) ruled that military veterans who smoked in service and subsequently developed tobacco-related disease could receive disability compensation. Government legislation overturned that decision.

Objectives: To examine U.S. government arguments used to justify passage of this legislation, and to compare them to government arguments about tobacco advanced in other arenas.

Methods: Review and analysis of publicly available tobacco industry documents, newspaper databases, legal archives and other sources.

Results: The U.S. government feared the financial burden of supporting veterans with tobacco-related diseases. In opposing the VA's ruling, the government argued that a veteran's choice to smoke was 'willful misconduct' and thus ineligible for compensation. The military's direct encouragement of smoking through provision of free or cheap cigarettes and privileges for smokers was ignored. However, in contemporaneous lawsuits to recover government costs for treating smokers with tobacco-related illnesses, the government rejected tobacco industry assertions that individuals freely choose to smoke, instead arguing that deceptive industry promotional practices had addicted millions. Veterans and their allies accused the government of hypocrisy. Repeated Congressional attempts to reinstate the veterans' benefit have failed.

Conclusion: This case study analyzes one government's attempt to externalize the costs of smoking. Like the tobacco industry, to serve its financial interests the U.S. government both promoted tobacco use and blamed smokers for the consequences. Government hypocrisy and complicity in promoting tobacco use should be exposed and linked to the high costs of smoking and the cost-effectiveness of tobacco control.

Including tobacco hazard and occupational risk factors into the national guideline for occupational health surveillance in China

Chao Qiang Jiang, Tai Hing Lam

Guangzhou Occupational Disease Prevention and Treatment Center, China

E-mail: [email protected]

Aim: To promote the knowledge and awareness about the harmful effects of smoking, and the application of occupational hazard control regulations and measures for tobacco control in the workplace, we listed tobacco hazards into The Technical Specifications for Occupational Health Surveillance (OHS), the Occupational Health Standards of China.

Methods: We organized a task force for Technical Specifications for OHS and used research findings in China to show that smoking is at least as important as occupational hazards in damaging the health of the workers. We advocated for the inclusion of smoking and passive smoking as the essential personal information for OHS, and that tobacco control should be a focus in the control of health hazards in the workplace.

Results: Based on our previous cohort studies of 160,000 workers exposed to smoking and occupational hazards in Guangzhou and Harrington's study on lung cancer from smoking or asbestos exposure, smoking greatly increased the mortality and risk for lung cancer. After three years of hard work, debates, persuasion and 6 revisions, our proposals were included in The Technical Specifications for OHS. Smoking was accepted to be as important as the occupational exposure history. The drafted standards were approved by the National Ministry of Health and put into practice on October 1, 2007. This shows, control of smoking in the workplace is a main focus.

Conclusions: For the first time in the history of occupational health in China, tobacco control is now a major focus in the workplace and is enforced by law nationally.

FDA regulation of tobacco and risk beliefs about tobacco products

Annette Kaufman, Mark Parascandola, Maansi Bansal-Travers, K. Michael Cummings

U.S. National Cancer Institute, United States of America

E-mail: [email protected]

Background: In the United States, tobacco products are currently not regulated by the Food and Drug Administration (FDA). However, it is not known how well informed consumers are about the lack of tobacco product regulation. Additionally, consumers' beliefs about government regulation of tobacco products may be related to their beliefs about tobacco product risks. Given the priority of regulation as set forth by the Framework Convention on Tobacco Control, it is important to understand consumers' awareness of tobacco product regulation and the health risks of tobacco products.

Objectives: The purpose of the current study is to examine how smokers' beliefs about FDA evaluation of cigarettes may be related to beliefs about the risks of smoking.

Methods: A nationally representative, random-digit-dialed telephone survey was conducted resulting in data for 1,046 adult current cigarette smokers assessing perceptions of the health risks of cigarette smoking, beliefs about FDA evaluation, demographics and smoking characteristics.

Results: Approximately 54% incorrectly reported that FDA currently evaluates cigarettes or that they did not know. Compared to individuals who correctly identified that FDA does not regulate cigarettes, these individuals believe the risks of smoking are lower. FDA evaluation beliefs are significantly related to beliefs about personal lung cancer risk ( P<.05) such that those who report the FDA does not regulate cigarettes perceive higher comparative lung cancer risk.

Conclusions: These results indicate that smokers who are poorly informed about FDA regulation of tobacco products are more likely to believe there are fewer risks associated with smoking.

The role of using an evidence-base health authority to move forward tobacco control legislation

Marino Francispillai, Karen Smith

Alberta Cancer Board, Canada

E-mail: [email protected]

Background: Tobacco reduction is key to the Alberta Cancer Board's (ACB) goals of reducing projected cancer incidence and mortality by 2025. ACB has researched and developed an evidence-based innovative system which in conjunction with new tobacco control legislation will increase the accessibility and efficiency to help Albertans quit smoking.

Objectives: To use the research rigor of a health authority to pursue options other than lobbying to help secure tobacco control legislation.

Methods: To guide tobacco control strategies, the ACB undertook a Situational Analysis of tobacco control and tobacco use in Alberta. This 'Snapshot' was used to provide briefings to our partners on the Campaign for a Smoke-Free Alberta (CSFA) coalition, and subsequently distributed broadly amongst politicians, health boards, labour and business groups and other key stakeholders. It is now being used to inform legislation and to guide tobacco control programming throughout the province.

Results: As an evidence-based health authority and key member of CSFA, ACB played an instrumental role in the passing of the Tobacco Reduction Act, one of the strongest tobacco control laws in Canada. By providing research and evidence-based documents (such as: demonstrating projected cancer incidences with and without tobacco control legislation; providing original data on tobacco-attributed hospitalization cost, etc.), ACB worked within its boundaries and used its strength of being a research-based health authority to influence policy change.

Conclusions: The involvement of a government health authority, such as ACB, can play a significant role in enhancing tobacco control efforts by their ability to provide un-biased evidence-based facts.

Moratorium on new tobacco products: Rational and criteria to withstand challenges

Flory Doucas, Neil Collishaw, Cynthia Callard, Heidi Rathjen

Physicians for a Smoke-Free Canada, Canada

E-mail: [email protected]

The tobacco industry exploits loopholes in current laws and regulations by introducing new products and modifies existing products. New products and changes made to existing products and brands reposition tobacco products as contemporary, acceptable and, too often, as improved. As more jurisdictions ban certain package characteristics or products, authorities should also consider moratoriums on all new products. According to industry documents, technological innovations, product changes and improvements or changes to imagery contribute in transforming existing products into new products. Aside from the actual changes, product innovation is by itself a form of marketing and therefore harmful to public health. A ban on all new products may well favour the products of domestic and foreign manufacturers who are already present on the market. Other countries and other manufacturers could threaten to challenge a moratorium through international trade agreements on the grounds of blocked access to such markets. Manufacturers may also threaten to challenge moratoriums on new products on the grounds of breaches to freedom of expression rights and trademark guarantees. However, supported by the overarching goals of the FCTC, Canadian authorities can construct moratoriums to comply with international trade agreements and other legal impediments. There have been moratoriums on other products and services to protect public health in various jurisdictions which have either withstood trade challenges or never been challenged at all. Governments should consider implementing bans on all new products as a mean to impede tobacco industry product development and marketing aimed at circumventing existing regulations.

Phasing out tobacco

Neil Collishaw, Cynthia Callard

Physicians for A Smoke-Free Canada, Canada

E-mail: [email protected]

Background: Current regulation of tobacco companies restricts advertising, requires warnings on packages and offers other measures that discourage demand for tobacco products. Virtually none of our current control measures attack the problem of tobacco use directly by requiring tobacco companies (who, after all, are largely responsible for creating the tobacco epidemic) to reduce their sales to the point of near extinction.

Objectives: This paper will present one or more ways that this could be done through new legislation and regulation, with a view to creating a planned phase-out of tobacco products over a period of two decades.

Methods: The phase-out will be planned so that tobacco companies can continue to meet their fiduciary duties to their shareholders over most of the phase-out period. This would be accomplished by reversing the incentives for profit-making. Selling more cigarettes would negate profits; profit-making opportunities would henceforth come from selling fewer cigarettes.

Results: Adopting a plan to phase out tobacco, along the lines suggested here, could result in some significant supply-side controls on tobacco.

Conclusions: Adoption of such a plan also has the potential to significantly alter the ways tobacco companies do business in the direction of doing much, much more to achieve the public health goal of progressively phasing out tobacco use.

  Legislation and policy Top

Indonesian tobacco control legislation: Why we haven't succeeded?

Rohani Budi Prihatin

Center for Research and Information Services, Indonesia

E-mail: [email protected]

Objectives: The purpose of this paper is to provide an overview of some challenges faced by the Member of Parliament in drafting the Bill on Controlling the Impact of Tobacco Product on Health.

Materials and Methods: This study uses depth interview with Members of Parliament of the Republic of Indonesia, especially Members who initiates the above-mentioned Bill.

Results: 1. Members of Parliament who initiate this Bill are facing numerous difficulties in drafting the Bill on Controlling the Impact of Tobacco Product on Health. 2. Those difficulty and problems is in the struggle to gain support from other Members of the House. 3. The tobacco business often promote and advertise tobacco products at the House complex and its weaken the fundamental nature in drafting the Bill. 4. The Government, in this case the Ministry of Health, and also tobacco business are indifferent about this Bill.

Conclusion: All those challenges faced by the initiator of the Bill on Controlling the Impact of Tobacco Product has cause the Bill to be delayed on its enactment.

Bloomberg in Pakistan and Egypt, way forward

Farrukh Qureshi, Fatimah El Ewa

World Health Organization EMRO, Egypt

E-mail: [email protected]

The Bloomberg philanthropy; provided an opportunity for many countries to plan activities for which funds were never previously available. At the same time, one of the main outcomes of Bloomberg philanthropy was the release of the WHO Report on the Global Tobacco Epidemic 2008 with a new set of recommendations by WHO to its Member States for effective tobacco control policies. The contribution of the Bloomberg Philanthropies is recognized to be one of the most important donations ever for tobacco control, not only at international level but also at regional and national levels. The two priority countries in the EMR region are Pakistan and Egypt, many things has changed at country level due to this initiative, within the priority areas of the Bloomberg there is a need for a wider vision to move forward and accomplish what is expected. The year 2008 will be a real challenge for the countries that are the main focus of the initiative. Evaluating the main outcomes of implementing this initiative at country level will be the focus of this presentation in the main areas of the Bloomberg, ban on advertising, change of image, health warnings and tobacco free public places. Even after the two years grant to the priority countries the grants components of the Bloomberg will still be on going, yet more activities to take place giving the chance for a continuation and sustainability of many elements that were supported by the Bloomberg.

National surveillance of tobacco control measures: Sri Lanka

Olcott Gunasekera

Sri Lanka National Federation On Smoking Or Health, Sri Lanka

E-mail: [email protected]

After an eight year gestation period finally legislation was passed in August 2006 to create a legal framework for control of tobacco use. Civil society organisations played a key role in shaping the required legislation. Under its provisions a National Authority on Tobacco and Alcohol (NATA) was established in January 2007. Because of the pressure of the industry to soften legislation and its implementation, there was an urgent need to set up a mechanism for national surveillance of tobacco control activities. The outcome was the formation of a National Surveillance Committee under the umbrella of the Sri Lanka National Federation of NGOs against Drug Abuse. The Committee meets monthly to review developments and decide on immediate measures to be taken. A network of monitors was created and a questionnaire was prepared for reporting from the field. Every six months a Review meeting is held for which members of the Authority are invited. Two such meetings ('Six months after NATA', 'Twelve Months after NATA') were held. Media too were invited. Some of the major issues that were brought up concerned a) office facilities for NATA; b) need for greater public awareness of legal provisions of NATA Act; c) need for clear instructions to authorised persons under the Act; d) inadequacies of current legislation to become fully FCTC compliant e) failure to meet the FCTC deadline on package warnings. Lesson learnt - "Constant Vigilance of Civil Society is required even after passing of legislation".

Gender indicators for tobacco control policies in Chile

Lezak Shallat, Sonia Cavarrubias

Fundacion EPES, Chile

E-mail: [email protected]

Toward the Construction of Gender Indicators for Tobacco Control Policies in Chile Chile has the highest rate of smoking by women and girls in the Americas. Its 2006 tobacco law limits cigarette sales, advertising and public smoking, but does not address women explicitly. In contrast, mandates to incorporate gender policies into health and social programs abound. The country's formidable women's movement has developed many strategies and tools for advancing gender equity in health, but has been blind to the epidemic of women's smoking. This presentation will present the findings of a feasibility study conducted by the grassroots organization Fundacion EPES (Popular Education in Health). The study asked what gender indicators for tobacco control in Chile would look like: what areas would they address? what information exists and what is missing? What can tools like time use and quality of life studies contribute to make more visible the stress, peer-pressure and other gender-related factors that encourage smoking by Chilean women? Gender indicators could provide Chile's Health Ministry with a much-needed tool to shore up its work with women and youths and are useful to civil society for tracking government performance. They could also advance FCTC goals of promoting gender considerations. This feasibility study systematizes material collected in 2007 national meeting on gender and tobacco control conducted by EPES; interviews with UN and PAHO gender specialists, international experiences, and literature. The project is being conducted in 2008.

California's secondhand smoke database: A tool for policy making

Narinder Dhaliwal, Dian Kiser, Theresa Boschert

California's Clean Air Project, United States of America

E-mail: [email protected]

There are 61 public health department jurisdictions incorporating over 480 cities in California. These local and statewide tobacco control programs educate and encourage local/regional government entities in adopting and implement strong secondhand smoke policies. In an effort to enable these health jurisdictions to determine who has already implemented policies and ordinances and to assist in educating the local government entities, a secondhand smoke policy database was created by California's Clean Air Project-CCAP. The CCAP SHS Policy Database provides access to local, county and statewide laws, ordinances and resolutions, both mandatory and voluntary policies that have passed at the local levels and address exposure to secondhand smoke (SHS). Information can be accessed by geographic location, topic, keyword search or even date of adoption. The database provides a brief summary of the code text and municipal and/or county code titles and section numbers for each entry, along with the year of adoption. Whenever possible, direct links to city (municipal) and county websites are provided. The database is updated monthly. During the first year of the existence of the database, the site received over 300,000 visits by health advocates, policymakers and members of the public. The oral database presentation will provide attendees with a comprehensive understanding of how a centralized, user-friendly, free searchable database for secondhand smoke policies can benefit them and assist with educating the government entities with whom they work. The CCAP California Secondhand Smoke Policy Database can be accessed at

The Dutch national tobacco control programme 2006-2010

Stefan Wigger, Grieto Zeeman, Rob Kuiten

Dutch Cancer Society, Netherlands

E-mail: [email protected]

In 2006 the Dutch Cancer Society, Netherlands Heart Foundation, Dutch Asthma Fund, the Ministry of Health and STIVORO presented the National Tobacco Control Programme 2006-2010. The goal of this Programme is to reduce the smokers prevalence towards 20% in 2010 (2006: 28%). The National Tobacco Control Programme contains all possible (evidence-based) interventions in tobacco control. Every year an action plan is written by the task force. A set of criteria guides the task force to determine which interventions should be part of this Action Plan. We only incorporate interventions in the action plan which have enough support in the political and (health) professional arena. Besides the task force, the three funds and STIVORO formed a platform for a lobby and advocacy. This platform aims to influence political decision makers and other stakeholders on several issues in tobacco control. The three health funds and STIVORO undertook several lobby-activities concerning a smoke free hospitality industry and a tax increase (2007). For 2008 we are lobbying for reïmbursement for professional help and support when smokers want to quit. Action Plan 2008: - July 1: implementation smoke free hospitality industry and tax increase (€ 0,55); - Media campaign to support implementation of smoking ban in hospitality sector; - Large media campaign to motivate large smokers to quit smoking; - Implementation (pilot) project 'reimbursement support when quitting smoking'. In the presentation the complicating process of developing annual action plans will be described. Results of the interventions executed in 2007 and 2008 will also be presented.

Tobacco policy: Beyond gold to a multi-governance platinum standard

Jennifer Duncan, Marino Francispillai

Alberta Cancer Board, Canada

E-mail: [email protected]

Background: The "Gold" standard is widely used to advance smoke-free policy, however, standards for other tobacco polices have not been developed. Tobacco policy change often prompts cessation efforts. The Platinum Standard for Tobacco Control provides the structure and context for many levels of governance to reduce tobacco use through policy supported by other tobacco control resources.

Objectives: To establish platinum standards for a broad range of tobacco control policies across multiple levels of government and to establish appropriate levels of cessation support.

Methods: Existing and proposed tobacco policies and cessation strategies were used to prepare a draft framework. Provincial, national and international policy and cessation experts reviewed the framework and provided expertise to define the Platinum Standard for Tobacco Control.

Results: Building upon the foundation of the Framework Convention on Tobacco Control the Platinum Standard delineates aspirational policies to reduce tobacco use through extending smoke-free spaces to select outdoor areas, regulations for tobacco product content, packaging and labeling, and advertising restrictions. Policies to guide prevention interventions as well as offer cessation support are included. Policies to divest industry holdings, to refuse industry donations and research funding and to require full disclosure of industry promotional activities and industry lobbying are recommended. The Platinum Standard will include implementation strategies to be used by provincial (state) and municipal governments, health and research institutions, educational institutions and (other) employers.

Conclusions: The Platinum Standard outlines numerous tobacco policies and supportive programs to be implemented at varying levels of governance to reduce tobacco use.

  Measuring exposure to second hand smoke Top

ETS exposure during waterpipe smoking versus cigarettes smoking

Mostafa Mohamed, Aisha Aboul Foutouh, Mohamed Moamen

Dept of Community Medicine, Egypt

E-mail: [email protected]

Background: PM 2.5 is one such ETS airborne marker which represents the concentration of particulate matter in the air less than 2.5 microns in diameter. PM2.5 measurements have been shown to correlate well with levels of ETS from cigarette smoking.

Objectives: The purpose of our study was to measure PM2.5 levels as a marker of indoor air quality in a sample of hospitality workplaces in Egypt characterized by waterpipe smoking.

Methods: A convenience sample of 35 hospitality settings (15 waterpipe cafι cafes, 15 tents and 5 restaurants) was selected in Cairo and Giza governorates in Egypt and PM2.5 concentration levels were assessed. A data collection sheet was used to record the number of smokers in the place, and the smoking pattern.

Results: In general, most of waterpipe cafes (11 cafes) were open air placed at a street bank with undefined size, while the few others (4) were closed. On the other hand all tents and restaurants were closed places. The average PM2.5 levels in open air waterpipe cafes was 478 (SD=225) μg/m3 ranging from 100 to 1313. However, the average PM2.5 level in closed tents was significantly much higher, 1411 (SD=1011) μg/m3 ranging from 111 to 5200 μg/m3. PM2.5 levels were much higher inside closed settings that were offering waterpipes. The average PM2.5 level was significantly much higher in cafes and tents with waterpipes smoking than that in other sampled places where only cigarette smoking was found.

Exposure to environmental tobacco smoke assessed by salivary cotinine in hospitality workers in serbia

Srmena Krstev, Djordje Stojiljkovic, Milica Varagic

Serbian Institute of Occupational Health, Serbia

E-mail: [email protected]

Background: In Serbia smoking is not legally banned in hospitality premises and is widespread.

Objectives: With this study we wanted to estimate the salivary cotinine, a metabolite of nicotine in hospitality workers - non-smokers.

Methods: Two groups of non-smoking hospitality workers were selected (total of 94): exposed group in restaurants and cafes where smoking was permitted (N=45) and non-exposed where smoking was banned (N=49). Saliva samples were collected using salivettes prior to and after their working shift, in winter and summer seasons.

Results: Using paired sample T-test, increased levels of salivary cotinine were observed during the shift in both types of restaurants and cafes and in both seasons. However, in winter, both levels of cotinine and the increase were more pronounced, being among non-exposed workers 4.22 ng/ml prior to work, and 6.17 ng/ml at the end of work ( P=0.078), and among exposed hospitality workers 7.19 ng/ml, and 8.49 ng/ml, respectively ( P=0.033).

Conclusions: Our study found higher post-shift cotinine levels, more pronounced in winter and in premises where smoking is permitted. However, pre-shift levels are considerably high, and only 21.3% of all participants had no traces of cotinine in their body at pre-shift samples. It could be due to the widespread exposure to SHS, first, at work in the crew rooms where smoking is allowed and, second, at home, where 50.5% of subjects live with a smoker, and where 81.7% allow smoking at home. Our results confirmed that exposure to SHS is one of the major occupational risks of hospitality workers.

Secondhand smoke in office workplaces using indicator benzo(a)pyrene in air and 1-hydroxypirene urine

Sonny Warouw, Tati Suryati

Ministry of Health Republic Indonesia, Indonesia

E-mail: [email protected]

Second Hand Smoke is the main cause of Indoor air pollution, especially in the building that smoking is allowed. Tobacco smoke associated with acute and chronic health effects. Among the substances in tobacco smoke which have drawn special attention is Polycyclic Aromatic Hydrocarbons (PAHs). PAHs is a group of chemical carcinogens. Benzo(a)Pyrene (BaP) usually used as a reference substance of it. The International Agency for Research on Cancer (IARC) classified BaP as "probable human carcinogen (Group 2A). A cross-sectional study was conducted among 48 government office workers from 5 sub district office of South Jakarta, Indonesia. The level of personal dust (TSP) and BaP were determined during working. Urinary biomarker 1-OHP from respondents was taken at the end of works. The aim of the study were to see the association between smoking and non smoking with concentration level of BENZO(a)PYRENE in air, and 1-OHP urine. The result showed that the average (mean) of BaP was 0.5921 μg/m3 (SD=6309). The urinary concentration 1-OHP was 700.69 ng/gr creatinine (SD=512.98). The average of BaP in nonsmoking was 0.33 μg/m3 and in smoking was 0.81 μg/m3. The average 1-OHP in nonsmoking was 925.03 ng/gr creatine and in smoking was 2303.89 ng/gr creat.

Conclusion: Secondhand smoke effecting level of BaP in air and concentration 1-OHP in nonsmoking respondents. The average BaP concentration was Medium level of dangerous, some respondent were in high level of dangerous (cancer risk). It is recommended to develop 100% smoke free in the office workplace using indicator BaP and 1-OHP urine.

Tobacco-smoke derived particulate air pollution in indoor places in Uruguay, May 2006.

Adriana Menιndez, Mark J. Travers, Andrew Hyland, Michael Cummings

Sindicato Mιdico Del Uruguay, Uruguay

E-mail: [email protected]

Background: Degree NΊ 268/05 signed in September 2005 became Uruguay in the 5 th smoke free country in the world since March 1 st 2006.

Objective: To assess indoor air quality in establishments with and without indoor smoking.

Methods: Air quality was tested in restaurants, bars, transportation, casinos and other venues, in Canelones, Maldonado, and Montevideo. A TSI SidePak AM510 Personal Aerosol Monitor was used to sample and record the levels of fine particles (PM2.5) in the air. Particles of this size are released in significant amounts from burning cigarettes, are easily inhaled deep into the lungs, and are associated with pulmonary and cardiovascular disease and death.

Results: Levels of indoor air pollution ranged from 7 μg/ m 3 to 1,235 μg/ m 3 . 4 of the venues sampled were smoke-free, and the average level of PM2.5 in these venues was 7μg/ m 3 . Smoking was observed in 27 of the venues sampled, and the average level of PM2.5 in these venues was 314μg/ m3. The level of indoor air pollution was 98% lower in venues that were smoke-free compared to venues where smoking was observed ( P<0.001). Lowest levels of indoor air pollution were found in restaurants (78 μg/ m 3 ) and highest levels were found in those venues in the "other" category (a casino and retail outlets) (320 μg/ m 3 ).

Conclusions: Indoor air was significantly less polluted in those venues where smoking was prohibited and didn't occur, than in those places where smoking was present.

Measuring Secondhand Smoke Exposure in the Home and Workplace

Wendy Max, Hai-Yen Sung, Yanling Shi

University of California, San Francisco, United States of America

E-mail: [email protected]

Background: Exposure to secondhand smoke (SHS) can have important impacts on health similar to active smoking. Though workplace smoking restrictions have become more and more common in the U.S., many workers are still exposed to SHS at work. People also continue to be exposed to SHS at home.

Objectives: This study compares self-reported and serum cotinine measures of exposure to SHS for never-smoking children, adolescents, and adults. Estimates are compared for blacks, Mexican Americans, and whites.

Methods: Data from the National Health and Nutrition Examination Survey for 1999-2004 were analyzed. This survey includes both self-reported exposure and serum cotinine measures. Home exposure is indicated if someone smokes regularly in the home. Workplace exposure is indicated if workers respond that they can smell other people's smoke at their desk. A person with a serum cotinine level >= .05 ng/mL was categorized as SHS exposed.

Results: Self-reported exposure rates are highest for children, followed by adolescents and adults. Blacks had the highest self-reported rates at home and at work and the highest cotinine levels among adults. Mexican Americans had the lowest exposure rates and the lowest cotinine levels among those exposed at home or work and in all age groups. The home is now a more likely place of exposure than the workplace for most people. Conclusions. Using serum cotinine to measure exposure yields much higher prevalence rates than self-reports. Either way exposure is measured, rates remain high despite many tobacco control efforts.

Validity of a questionnaire of exposure to secondhand smoke in relation to salivary cotinine

Esteve Fernandez, Marcela Fu, Jose Maria Martinez-Sanchez, Josι A. Pascual

Catalan Institute of Oncology, Spain

E-mail: [email protected]

Background: Few studies have examined the validity against biomarkers of self-reported exposure to secondhand smoke gathered from questionnaires.

Objectives: To examine the sensitivity and specificity of a simple self-reported questionnaire on secondhand smoke among non-smokers against salivary cotinine.

Methods: Cross-sectional study of a representative sample in Barcelona, Spain (n=1245) during 2004-2005. We obtained information on secondhand smoke exposure by questionnaire and salivary cotinine concentrations. The present analysis includes 775 adult (16 years) non-smokers. We computed geometric means (GM) and 95% confidence intervals (CI) of salivary cotinine concentrations according to the settings of exposure (home, work/study center, leisure, and public/private transport). We computed sensitivity and specificity from dichotomous variables of exclusive exposure (ie, exposed only at home) and join exposure (0-4 settings). We used salivary cotinine concentrations as the gold standard (<1: non-exposed, >1: exposed).

Results: The GM of salivary cotinine (in ng/ml) was 1.47 (95%CI 1.26-1.71) among non-exposed subjects, 1.60 (1.22-2.10) when exposed only at home, 1.17 (0.64-2.14) when exposed only at work/study center, 1.40 (1.21-1.62) when exposed only during leisure, and 1.89 (0.91-3.95) when exposed only in transports. Sensitivity and specificity was 25.7% and 76.5% at home; 6.0% and 90.7% at work/study center; 50.0% and 46.7% in leisure; and 7.6% and 94.0% in transports. Sensitivity for exposure in any setting was 76.4% and specificity for exposure in 4 settings was 84.8%.

Conclusion: The questionnaire shows a medium ability to classify true exposed subjects correctly in exclusive settings and properly identifies the true non-exposed subjects when join exposure is considered.

How monitoring air quality can help to implement smoke free laws.

Paul Hooper, Hilary Wareing, Nina Gotz

Department of Health In The West Midlands, United Kingdom

E-mail: [email protected]

In July 2007 England implemented a comprehensive smoke free law. Air quality and other monitoring associated with the law would be undertaken by the government but reporting of findings would take some time. With funding from Cancer Research UK, the Tobacco Control Collaborating Centre organised a series of visits to premises that would be affected by the new law to determine pre and post conditions and to report quickly to maximise publicity. Field workers were trained in six regions and equipment supplied for air quality monitoring and Cotinine tests. Pre- and post-law questionnaires were designed for staff, owners of businesses and customers. Over 50 places were visited (including pubs, clubs and betting shops) before and after the law came into effect, over 450 questionnaires completed and air quality tests carried out to strict protocols. The methodology had also received ethics approval. Results were analysed and initially published in a media-friendly way. They showed improved attitudes of owners and staff towards the new law; improved air quality and a reduction in Cotinine levels in non-smoking staff. Media coverage included national and regional television and radio, national and regional newspapers and trade press. The results of the monitoring underlined the need for the smoke free legislation. The publicising of the results helped to imbed the new law and give public health professionals strong arguments. This paper illustrates that quality does not have to be sacrificed for speed of reporting and robust testing procedures can be applied to activities aimed at media coverage.

  Smokefree local experiences Top

Household smoking rules in Armenia

Narine Movsisyan, Karine Sahakyan, Varduhi Petrosyan

Center for Health Services Research And Development, American University of Arme, Armenia

E-mail: [email protected]

Background: Women and children are particularly vulnerable to secondhand smoke (SHS) exposure in homes as a result of high smoking rates among Armenian men (61.5%).

Objectives: This study explored household smoking rules in Armenian homes using data from a population-based survey conducted in May-June 2007 in three provinces of Armenia, including the capital city.

Methods: The study utilized a multi-stage cluster sampling method. Data on smoking related knowledge, attitude and practices were collected from 18-60 year old 360 men and 360 women in selected households by trained interviewers. Descriptive statistics and Chi-square test for differences between proportions were used in the study.

Results: The overwhelming majority (82.2%) of households had at least one smoker, with mean number of 1.23 (sd=0.89) smokers per household. About 70.0% of survey respondents acknowledged absence of any smoking restrictions in their households. Smoking was allowed in some rooms in 11.3% and banned in 19.5% of the surveyed households, including 9.2% of homes with exceptions made for guests. Respondents with university education and ex-smokers were more likely to have smoking restriction and bans in homes ( P<0.0001). Having a child in the household was not linked to stricter smoking rules.

Conclusions: Urgent interventions are needed to reduce SHS exposure in Armenian homes through voluntary adoption of smoke-free household rules. We suggest that monitoring and measurement of personal SHS exposure and indoor air pollution could be an effective tool for public education and promotion of smoke free homes in Armenia.

New approaches to tobacco-free practice: Bridging the global divide

Tatyana El-Kour MS RD, Hashim El-Zein El-Mousaad

World Health Organization, Jordan

E-mail: [email protected]

Jordan is undergoing a rapid epidemiologic transition in healthy lifestyle. Smoking is one of the most important threats to individual and community health. Tobacco control policies are needed to promote smoke-free environment through the life course and to reduce tobacco-related chronic diseases. The population is expected to more than double over the next ten years with smoking-related diseases, including cancer, chronic bronchitis, pulmonary emphysema, and coronary heart diseases as leading causes of deaths in Jordan. The financial and social costs associated with the increasing number of population and with management and treatment of tobacco-related diseases and disabilities will present a major challenge for both the government and individual families. In this paper, we explore the strengths and gaps and identify lessons learned based on analysis of the current tobacco trends and major strategic directions of the national tobacco policy. We conclude that multiple strategies and plans for tobacco control practices are available and there is a clear weak intra and inter-sectoral coordination in health promotion programs targeting tobacco use. Targeted community-based initiatives offer practical approaches to smoke-free patterns and have the potential to reverse the national tobacco epidemic and reduce the risk of major chronic diseases while promoting the national adoption of tobacco-free programs with effective communication, education, prevention, and intervention regimens. Widening the community and gender base is a challenging task and warrants a broader understanding of the determinants and consequences of tobacco epidemiology trends.

Prevention of secondhand smoke: Efficacy of the cigarette and other tobacco products act, 2003 case studies of three public transport organizations in Karnataka (India)

Nayanatara Nayak, Vinod Annigeri

Centre for Multi Disciplinary Development Research (CMDR), India

E-mail: [email protected]

The paper is based on an empirical study carried out in the year 2007 covering 2600 commuters interviewed in the premises of three public transport corporations in Karnatka state in India. The objective was to validate the efficacy of the Act, 2003 enacted by the Government of India to prevent secondhand smoking in public places. The three public transport systems exhibit different levels of tolerance to smoking and sale of tobacco products in their premises. The survey results indicate that implementation of the ban does not impose any additional cost on transport organisations and there is reduction in secondhand smoking in premises where there is strict imposition of the ban. The resistance to smoking came from the public rather than authorities. Unfortunately there is lack of awareness among regulatory authorities in small towns on the provisions and rules of the Act. Public are also confused as they lack information where to smoke, amount of fine to be paid, whom to pay and, where to pay. We usually think flaccid on many of the laws because the implementation is always weak may be on account of corruption, practical problems, lack of awareness among public and lack of understanding of the law by the implementing authority itself. The situation is not very much different with the Act, 2003 with exception to BMTC, which is one of the cases studied. But, positive response from the media, public and NGOs is encouraging and can be mobilized for putting a full stop on secondhand smoking.

Smoke free path

Narender Sharma

Himachal Pradesh Voluntary Health Organization (HPVHA), India

E-mail: [email protected]

Background: HPVHA is working with American Cancer Society from October 2007 onwards in making Shimla a Smoke Free City. While proceeding for the sensitization of the Law Enforcers it is a common finding that those incharge of the related responsibilities are found ignorant of it. The implementation of the Law hence takes a back seat as the initial steps involve bringing officials face to face with the Law books.

Methods: A need assesment study was conducted to understand the already exizting status of the law and awareness levels among community members.The study highlighted two major facts: 1 .Almost dormant state of the Law and 2. Buying and selling of tobacco being undertaken as a harmless social norm. Implementationof the Tobacco Law has required us to follow a double edged methtodology of approaching and sensitizing the concerned government officals (who are the law enforcers) and creating mass awarness through media for raising the conscious levels of the people (who are the ultimate bearers of the said law).

Result and Conclusion: The media conferneces organized have been fruitfull in sensitizing the media and community and introducing the gravity of the issue to all. HPVHA has initiated the process of implementing tobacco control program and are hopeful of bringing the desired results by the end of this year and also being able to present a bigger picture of the our efforts in controlling the tobacco menance during the 14 th World Conference on Tobacco or Health in Mumbai.

Smoke free Chandigarh: A case study

Hemant Goswami

Burning Brain Society, India

E-mail: [email protected]

Background: The Indian tobacco control legislation came into effect in 2004. This legislation among other things mandates smoke-free public places, hotels and requires each public place to affix appropriate warning boards. Despite the legislation, none of the states in India had enforced the law till 2006 when innovative approach resulted in complete compliance of the law and produced Chandigarh (Population 1.04 Million - Area 114 Sq. Km) as the first smoke-free State in India.

Objectives: To understand how the correct mix of various ingredients and components of tobacco control activism can result in positive results. To assess how Chandigarh became the first smoke-free state of India.

Methods: The smoke-free Chandigarh process was assessed through various documents, correspondence, legal papers, pictures and media reports. It was found that innovative and new methods were tested to facilitate smoke-free campaign. Besides the regular educational activities to generate public support; Burning Brain Society used the power of independent judiciary, other legislations like Right to Information Act and liaisoning with the bureaucracy and the media to achieve success.

Results: Innovation in strategic war against tobacco resulted in Smoke-Free Chandigarh. The compliance with smoke-free legislation reached over 85 percent within six months of the initiative. Nearly 1800 warning boards as prescribed under the Indian tobacco law were installed within six months and hundred percent hotels and educational institutes became smoke free.

Conclusions: Judicious mix of various form of activism can bring out good results. The results depend on a strategic combination of various activities.

Impact of ban of smoking in first smoke free city of Chandigarh in India

Vikas Bhatia, Sonia Puri, Amritpal Kaur, Vijayawnt Mayank

Government Medical College And Hospital, India

E-mail: [email protected]om

Background: Despite "The Cigarettes and other Tobacco Products Act, 2003" in India, modern day epidemic continues. Chandigarh is the first city in India to enact and implement total imposition of ban on smoking in 2007.

Aim: To assess the impact of ban among youths and adults in Chandigarh.

Methodology: Nearly one year of ban by Chandigarh Administrarion, India a study was conducted by interviewing 209 youths and adults smokers in March-May,2008. Eighteen vendors selling cigarettes and tobacco products were also interviewed.

Results: The age-wise distribution of the subjects was 46.9% in 18-25, 22% in 26-35, 14.3% in 35-45 and 16.7% in 45+ yrs ge-group. 70.3% of participants and 72.2% of vendors were aware about ban yet they were selling. Though, 55.5% vendors admitted decline in the sale. Source of information about the ban was predominantly friends (67.9), newspaper (22%), Radio/TV/Internet (22%) and family (6.2%). Major factors for smoking were peer pressure (64.6%), look cool and have fun (24.4%), relive stress (7.6%), influenced by actors (11.5%) and TV (5.3%). 47.4% suffered from various respiratory infections, recently. Following imposition of ban, 86.1% didnot find any difficulty in procuring cigarettes, however, 20.6% of the friends of the respondents and 19.6% themselves reduced frequency of smoking.

Conclusion: Despite ban of smoking, it has shown limited impact on smoking habit. Enforcement of law needs strict compliance as cigarettes and tobacco products are easily available in the city. Behaviour Change communication strategy and quit smoking efforts need to be focused as well.

Secondhand smoke exposure among patrons in a pub in Thailand

Naowarut Charoenca, Nipapun Kungskulniti, Punyarat Lapvongwatana, Stephen Hamann

Mahidol University, Faculty of Public Health, Thailand

E-mail: [email protected]

The purpose of this study was to assess levels of urine cotinine from pub patrons exposed to common, high levels of secondhand smoke (SHS). Ten nonsmokers consented to submit urine samples after visiting a pub in Chiang Mai, Thailand on 2 consecutive nights for four hours on each night. Urine samples collected from patrons were analyzed for cotinine using gas chromatography/mass spectroscopy. A TSI Sidepak AM510 Aerosol Monitor was used to estimate exposure to tobacco smoke-derived particles of less than 2.5 microns (PM2.5). Exposures of 304 and 327 micrograms per cubic meter of SHS-PM2.5 were recorded on the first and second nights. The mean urinary cotinine increased from 0.75 nanograms per milliliter (ng/ml) of urine at baseline, to 1.29 ng/ml on day 1, and 3.75 ng/ml on day 2. Paired-samples T tests reveal the increases from day 0 to day 2 and from day 1 to day 2 are statistically significant ( P<0.01 for both). The analysis was also done using log-transformed values and using non-parametric methods and results were the same. On average, cotinine levels of patrons at least doubled after each night's exposure to high levels of smoke-derived particles from heavy smoking in this pub. These findings show that even occasional high exposures to SHS result in increased levels of cotinine, an indicator of toxic and carcinogenic smoke constituents.

  Smokefree policies evaluation Top

Evaluation of policy on smoking restriction in healthcare institutions of Georgia

Kakha Gvinianidze, Suzaynn Schick, Thomas Novotny, Katharine Hammond

Institute of Public Health, Georgia

E-mail: [email protected]

Background: In 2003, the Georgian Parliament restricted smoking in all healthcare facilities. This pilot study was intended to assess the degree of noncompliance with the law and to identify potential strategies for increasing compliance.

Objectives: Observation of smoking restriction policies Measurement of level of tobacco smoke in buildings Qualitative research on attitudes, knowledge, and practices

Methods: For observational study researchers without preliminary warning, observed and recorded violations of smoking rules according questionnaire in randomly selected institutions. Tobacco smoke was measured by passive sampling of nicotine and active sampling of particles by TSI AM-510 photometer. For qualitative research used in-depth interviews with representatives of administrative branch, doctors and nurses.

Results: In 78.1% of the observed institutions, smoking restrictions were violated. Fifty of the 51 samplers placed in the isntitutions registered concentrations of nicotine above the level of detection. Of these, 52% showed concentrations below 1 m/m 3 nicotine, 27% showed concentrations between 1 and 5 m/m 3 and 20% were above 5 m/m 3 . By results of the qualitative study Georgian medical community lacks information about tobacco control; they are more concerned about other social problems. At that healthcare facilities are characterized by low level of management and tobacco control policy enforcement mainly depends on the personal characteristics of managers.

Conclusion: Effective tobacco control legislation will address the observed barriers by requiring that all healthcare facilities be entirely smoke free, by instituting surveillance and enforcement measures and by providing funding for tobacco control education among Georgian medical personnel.

Long-term impact of the non-smoking Spanish law on the levels of secondhand smoke

Maria Jose, Lopez Manel, Nebot Carles, Ariza Spanish Smoking Law Evaluation Group

Public Health Agency of Barcelona, Spain

E-mail: [email protected]

Objectives: A non-smoking law came into force in Spain in January 2006. The objective of this study is to assess the impact of this law on exposure to secondhand smoke (SHS) two years after the implementation of the law.

Methods: Before and after evaluation study with repeated measures. Vapour-phase nicotine was measured as an airborne SHS marker. The settings studied were offices, university premises, and hospitality venues from eight different regions of Spain. Nicotine measurements were taken at baseline (three months before the law) and 6, 12 and 24 months after the law.

Results: 336 paired samples taken before and two years after the law have been included in this study. The preliminary results show that the median nicotine concentration decreased by 80.0% in offices from Public Administration, 66.6% in universities, and 85.0% in private sector ( P<0.05). Regarding the hospitality sector, the nicotine concentration in restaurants that went smoke-free decreased by 95.9% ( P<0.05). However, in those venues where smoking is still allowed no significant differences were found. Furthermore, the median nicotine concentrations found in discos and pubs two years after the law are still extremely high (27.8 mg/ m 3 ).

Conclusions: Overall, this study shows the long-term positive impact of the law in reducing SHS in indoor workplaces and hospitality venues that became smoke-free. However, two years after the law, most hospitality workers continue to be exposed to very high levels of SHS. A total ban including all hospitality venues is required in Spain.

The impact of implementation of smokefree legislation in England on location and duration of self-reported exposure to others' smoke in children and adults

Jennifer Mindell, Heather Wardle, Soazig Nicholson

University College London, United Kingdom

E-mail: [email protected]

Background: England became one of the largest countries to implement comprehensive smokefree legislation on 1 st July 2007. Many workplaces and some public places introduced smokefree policies before the legislation was implemented.

Method: The Health Survey for England is an annual nationally representative cross-sectional health examination survey. In 2006, 14,142 adults aged 16+ and 7,257 children were interviewed; equivalent figures in 2007 were approximately 7,500 adults and 7,500 children. In addition to socio-demographic data at the individual and household level, questions were asked in both years on children's exposure to smoking by a carer and on the location and duration of teenagers' and adults' exposure to others' tobacco smoke. Analyses, adjusting for the stratified, clustered, two-stage sampling design, will compare location and duration of reported exposure to tobacco smoke in 2006 and the first and second halves of 2007.

Findings: The 2007 data will be available to the authors later in 2008. The initial major findings will be available by the end of the year.

Approaches to evaluating smoke-free policies

Stephen Babb

CDC Office On Smoking And Health, United States of America

E-mail: [email protected]

Background: When smoke-free laws are enacted, tobacco control programs are typically expected to assess the effects of these laws. Often little lead time is available before the law takes effects to plan the evaluation and collect baseline data.

Objectives: To provide an overview of available approaches to evaluate the effects of smoke-free policies.

Methods: We reviewed the studies of smoke-free policies discussed in the 2006 Surgeon General's Report on secondhand smoke, more recent published studies, and the experiences of U.S. state tobacco control programs and other countries.

Results: We identified five broad types of studies that can be used to assess the impact of smoke-free laws. These studies assess five outcomes: (1) public attitudes towards and support for the laws; (2) compliance with the laws; (3) air quality in hospitality venues (e.g., restaurants, bars, casinos); (4) health indicators among nonsmoking employees of hospitality venues; and (5)economic impact on hospitality venues. We also identified four criteria that can be used to determine which of these studies are suitable to conduct in a specific site: (1) the stage the site has reached in the policy process; (2) the issues that are the focus of debate and of policymakers' attention; (3) the provisions of the smoke-free law, in particular any exemptions it contains; and (4) the resources available to conduct the evaluation, including funding, personnel, and expertise.

Conclusions: A variety of approaches are available for assessing the effects of smoke-free laws. Evaluators can select optimal approaches based on a simple assessment.

Global voices: Working for a smoke free world

Ami Valdemoro, Antonella Cardone, Cassandra Welch

Global Smokefree Partnership, United States of America

E-mail: [email protected]

Background: This session will cover the GSP Global Voices 2008 report, including: 1) a map presenting the progress towards smokefree worldwide; 2) a brief summary of the arguments used to plead the case for smokefree policies, 3) an outline of tobacco industry tactics in opposition to smokefree policies; 4) seven core principles for how to promote effective smokefree policies; and 5) an overview highlighting those countries currently taking action

Objectives: To make the case for Smokefree policies worldwide. By presenting and examining the findings of this global status report on smokefree policies, presenters will address the following questions: What do we mean by smokefree policies? How do smokefree policies protect worker health? How are countries taking action? What is the FCTC? What are countries obliged to do?

Results: Nine countries have adopted 100% smokefree laws - Bermuda, Iran, Ireland, New Zealand, Northern Ireland, Scotland, Uruguay, Wales, and England. Subnational jurisdictions in the USA, Canada, Australia, and Argentina have adopted similar laws. As of July 1, 2007, more than 200 million people are protected from the dangers of secondhand smoke. The success of existing smokefree places confirms that the momentum towards comprehensive smokefree laws is now unstoppable.

Conclusions: Evidence from the implementation of comprehensive smokefree laws shows that these policies improve worker health, are cost effective, and popular. In addition, new smokefree policy initiatives worldwide demonstrate that governments around the world are continuing to become engaged in supporting smokefree policies

Complex tobacco control strategy evaluation Mumbai 1: Innovations from the smoke-free ontario strategy

Robert Schwartz, John Garcia, Shawn O'Connor, Nadia Minian

Ontario Tobacco Research Unit, University of Toronto, Canada

E-mail: [email protected]

Rationale: Evaluation of complex strategies poses difficult challenges of attribution. There is general agreement that combining complimentary interventions in comprehensive strategies leads to synergies in advancing the achievement of population level outcomes.

Objectives: The objective of this study is to develop and implement an innovative approach to assessing the impacts of multiple interventions implemented across numerous organizations in various settings.

Methods: Review and synthesis of existing literature have been used to identify evidence-based paths to achieving strategy objectives and evidence-based estimation of nature, direction and levels of expected contribution of the various interventions to progress in each path. Results from distinct evaluation studies and data from a performance measurement system were used in estimating the actual contribution of each intervention to each path.

Results: The assessment is providing a clear picture of gaps in the mix of interventions currently in place. The evaluation is demonstrating that some highly recommended efficacious interventions are having less impact than expected due to low reach and to lower levels of fidelity and effectiveness than suggested by previous studies. At the same time, the evaluation is showing that impacts through some of the major paths have been substantial.

Conclusions: Building on previous work, we have developed a new approach that facilitates strategy planning, evaluation planning and answering central evaluation questions about the overall effectiveness of strategies.

Evaluation of a comprehensive smoke-free policy in Mexico city

James Thrasher, Rosaura Pιrez, Ana Dorantes, Edna Arillo

University of South Carolina, United States of America

E-mail: [email protected]

Background: In April 2009, Mexico City became the first city in Mexico to enact 100% smoke-free legislation in all enclosed workplaces, including restaurants and bars.

Objectives: Assess changes in knowledge, attitudes and behaviors related to success of comprehensive smoke-free policy in Mexico City.

Methods: Data will be drawn from three population-based representative surveys of adults who live in Mexico City: before enactment of the law (n=800); three months post law (n=1000); and seven months post law (n=1000).

Results: Data from the pre-legislation survey indicate that the Mexico City was relatively primed for the smoke-free law: knowledge of secondhand smoke dangers and beliefs about rights to breathe smoke-free air was high (approximately 90% on most indicators). Although 90% of the population was aware of the law, most believed that smoking would still be allowed in separately ventilated spaced. Support for 100% smoke-free policies was strong, although lower for restaurants (80%) and bars (60%) than for other places. Among those who went to restaurants or bars in the last month (, 56% saw someone smoking the last time they went to a restaurant and 80% saw someone smoke the last time they went to a bar. Most people (60%) believed that compliance would be difficult to achieve. Trends in these and other relevant data will be tracked across the three surveys.

Conclusions: The Mexico City population appeared primed for comprehensive smoke-free legislation. Results from post-implementation surveys will clarify the success of this policy and media efforts to support it.

  Tobacco industry monitoring II Top

Using repatriated profits to fund global tobacco control

Cynthia Callard, Neil Collishaw

Physicians for A Smoke-Free Canada, Canada

E-mail: [email protected]

Funding provided for global efforts to control tobacco use is small, especially in comparison with the volume of the global tobacco market. The Framework Convention for Tobacco Control could mandate increased spending on global efforts, but has so far resisted this approaches and has chosen to rely on voluntary assessed contributions to raise its US$ 8 million budget. Other approaches are available, including levies on transnational transfers of tobacco industry profits. This method would increase available funding, make the 'polluter pay' and also address the regressive impact of smokers in developing countries indirectly paying taxes to developed country governments as a result of profit taxes on multinational tobacco companies. BAT is only one of several multinational tobacco companies which repatriate profits from developing countries, and is an illustrative example of this potential funding source. The government of the United Kingdom received about US $1.5 billion as corporation tax on BAT's repatriated profits in 2007, and is expected to continue to receive similar amounts. Much of these tax revenues originate in developing countries: tax on BAT's repatriated profits from Africa and the Middle East was about US$227 million in 2007. This amount alone is about 30 times the budget of the FCTC secretariat and almost twice the size of the Bloomberg initiative. This paper draws on taxation policies in other areas to suggest options for stable and equitable funding for tobacco control efforts, as well as exploring the regressive nature of corporate taxes on repatriated tobacco profits.

Global tobacco industry activities against tobacco excise tax

Hadii Mamudu, Martin Otanez, Stanton Glantz

Center for Tobacco Control Research And Education, University of California At S, United States of America

E-mail: [email protected]

Background: Taxation is the most important fiscal policy for tobacco control because of the strong inverses relation between price and tobacco use. Excise tax increases affect the tobacco industry ability to maximize profit and recruit new smokers. The World Bank and the World Health Organization (WHO) have promoted tobacco excise tax since the 1990s, and it became Article 6 of the 2003 WHO Framework Convention on Tobacco Control (FCTC).

Objectives: We examine the global activities of the tobacco industry against excise tax from the early 1990s when the World Bank decided not support tobacco projects.

Methods: We analyze previously secret tobacco industry documents and World Bank and WHO archival documents.

Results: Since at least the early 1990s the World Bank and WHO have promoted tobacco excise tax as a price-measure to curb tobacco use. In contrast, the tobacco companies worked individually, collaboratively, and through National Manufacturers' Association to 1) lobby national governments and international organizations against excise tax increases, 2) restructure tax systems to help maintain their market shares, 3) undermine tax systems through smuggling and evasion, and 4) worked with academics and think tanks to demonstrate the negative economic consequences of excise tax and portray it as regressive tax.

Conclusions: Understanding historically global activities of tobacco companies against excise tax will help policymakers and governments to thwart the tobacco industry influence in promulgation of effective excise tax policy and implement Article 6 of the FCTC.

Norwegian public funds invested in the tobacco industry

Sverre Berg Lutnaes

Norwegian Cancer Society, Norway

E-mail: [email protected]

Background: The Norwegian Government Pension Fund - Global is a Sovereign Investment Fund (SWF) where surplus revenue from the Norwegian petroleum industry is put. Although not receiving its finances from pensioners, it is considered to be the world's second largest pension fund with a total value of 263,3 billion EUR. According its annual report, the Norwegian Government Pension Fund had invested 1.73 billion EUR in tobacco stocks and bonds pr. 31.12.2007.

Objectives: The presentation will look at how the Norwegian Cancer Society, as part of the Norwegian anti-tobacco lobby, has made advocacy efforts at banning the tobacco investments from the Fund.

Methods: To the possible extent, the presentation will discuss what arguments have turned out to have most effect on stakeholders. Examples of arguments include tobacco's effect on poverty in developing countries and how investments counteract the intention of article 5.3. of the WHO FCTC.

Results: Audience will be provided with a backdrop to carry out similar actions in other countries. Even though the presentation will look at how advocacy has been aimed at politicians and the Ministry of Finance in Norway, the argumentation set up could also be used for addressing private investors.

Conclusions: In order to have investors ban investments in the tobacco industry one needs a comprehensive set of arguments. The Norwegian experience shows that giving focus to arguments concerning the health consequences of tobacco use might not be sufficient.

A gentleman's disagreement: Cooperation versus competition among transnational tobacco companies

Nathaniel Wander, Jeff Collin

University of Edinburgh, United Kingdom

E-mail: [email protected]

Background: It has been useful to tobacco control to observe that transnational tobacco companies (TTCs) act as a cartel to normalize substance abuse, create customers, and subvert health regulation. However, labels like 'Big Tobacco' that emphasize cooperation may result in insufficient attention being paid to within-industry competition.

Objectives: To understand potential public health consequences of within-industry competition.

Methods: From industry documents, we constructed a case study of a policy disagreement among TTCs, and interpreted the dispute via analysis of differences in corporate histories, structures and regulatory environments.

Results: In 1991, Philip Morris (PM) proposed to provide package health warning labels in all its markets, but encountered vehement opposition from competitors BAT, Imperial, Gallaher, Rothmans, Reemtsma and R.J. Reynolds International. Contesting new labelling provisions and fearing further demands for European Community-wide regulation, these companies were reluctant to volunteer concessions or promote uniformity. Facing greater domestic competition and more complex relationships with overseas subsidiaries than the vertically-integrated, home market-dominant PM, none was willing to act in advance of the others Unaffected by the shareholder activism that PM hoped to assuage through its 'voluntary' policy, none saw benefit in a strategy designed to protect a competitor.

Conclusions: Analysis of strategic competition across TTCs can advance understanding of conditions under which corporations will cooperate or compete to shape regulation. Understanding within-industry policy disagreements, such as between 'national practice' and global 'reasonable regulation,' assumes particular significance in the context of varying national and corporate responses to the WHO Framework Convention on Tobacco Control.

Tobacco industry denormalization: The Keystone of effective tobacco control

Melodie Tilson, Lorraine Fry

Non-Smokers' Rights Association, Canada

E-mail: [email protected]

Background: Research demonstrates that Tobacco Industry Denormalization (TID) is a core component of effective comprehensive tobacco control strategies. While in many ways Canada is a world leader in tobacco control, our track record on TID has been mixed.

Objectives: To develop a strong case that having the public, health organizations, and government decision-makers understand the tobacco industry's role in creating and perpetuating the tobacco epidemic is essential to creating a social climate favourable to stringent regulation of industry practices and products.

Methods: Public opinion surveys on attitudes toward the tobacco industry will be analyzed. National, provincial, and local tobacco control initiatives focusing on the industry's behaviour will be reviewed and assessed in the context of current industry efforts in Canada to 'normalize' themselves and their products.

Results: Evidence of the impact of TID interventions will be summarized. Effective TID initiatives in Canada will be showcased, as will the consequences of failing to focus sufficient attention on TID, that is, tobacco company successes in influencing the public policy debate and controlling the agenda on issues such as harm reduction and contraband tobacco.

Conclusions: The experience in Canada supports the evidence from California and elsewhere that effective TID blunts the influence of the tobacco industry. Recent developments in Canada prove that the corollary is also true: without ongoing, effective TID, there is a substantial risk that tobacco companies and their allies will influence the public policy debate and thereby weaken tobacco control.

Understanding the tobacco industry to plan for the future of tobacco control

Anna Gilmore, Jeff Collin, Sally Cartwright, Gary Fooks

University of Bath, United Kingdom

E-mail: [email protected]

Background: BAT trades in 180 countries and sells two-thirds of its cigarettes outside the west. Yet the apparent threat of the FCTC has yet to dent its share price, underlying the need to understand how knowledge of the industry can inform tobacco control policy.

Objectives: To understand how BAT sees the future in order to learn lessons for tobacco control.

Methods: Analysis of BAT documents, annual reports and the company website, industry analyst and media reports. Analysis of BAT's strengths, weaknesses, opportunities and threats.

Results: Global volume growth is stagnating and will be increasingly reliant on population growth and rising incomes. Competition for shares of this now largely static pool will therefore intensify and efficiency savings will be key to delivering shareholder value. Focus on key markets (with the balance between size and profitability central), segments (lights, menthol), brands (global drive brands) and consumers (the young and women in emerging markets) is central. "Pull" strategies focus increasingly on relationships with the retailer and consumer, innovative products and packaging and new marketing techniques, while distribution (often overlooked by tobacco control) remains critical. The success of BAT's corporate social responsibility (CSR) programme is increasingly enabling it to shape the regulatory environment.

Conclusions: Opportunities for tobacco control are greater than in the past. The tobacco control community should harness techniques used by the industry and implement measures it fears to maximise effectiveness of tobacco control strategies. It must also urgently address the CSR agenda to prevent the industry gaining further advantage.

Why tobacco industry denormalization is critical to the reversal of the tobacco epidemic

Gar Mahood

Non-Smokers' Rights Association, Canada

E-maill: [email protected]

Background: The acceptance by legislators and the public that the tobacco industry is a normal, legitimate industry doing what normal businesses do has protected manufacturers from the severe measures that normally accompany the development of an epidemic. If the industry normalization process is not reversed, and the industry is not stripped of this normalcy, the significant reforms needed to address the epidemic may not occur.

Objectives: To show why Tobacco Industry Denormalization (TID) should be a core component of any tobacco control programme and why "denormalization" should be restricted to a focus on corporate rather than individual behaviour.

Methods: Governments and health charities have placed the responsibility for the tobacco epidemic on individual behaviour ("stop smoking") while ignoring the business forces driving the epidemic. The presenter will explain why this almost exclusive "blame-the-victim" approach to reducing tobacco markets must end and why TID strategies must be introduced to tobacco control initiatives

Results: TID was a core component of Canada's National Strategy until the government, perhaps faced with industry threats, backed away from TID. Despite government resistance, TID is rapidly being embraced by health interests.

Conclusions: The manufacturers recognize the threat that TID represents to the "business-as-usual" approach in their response to the epidemic they cause. The presenter will show that there are no valid blocks to this strategy. TID does nothing more than tell the truth about tobacco industry behaviour. TID will break down the resistance to needed reforms.

  Youth-focus policies and programs Top

Tobacco policies, normative influences and adolescents' smoking intentions: A mediation analysis

Abraham Brown, Crawford Moodie, Gerard Hastings

University of Stirling, United Kingdom

E-mail: [email protected]

Prevention programs and policies designed to deliver normative information, primarily to 'denormalise' socially significant behaviours, have found that normative influences have a strong impact on health behaviours such as smoking and alcohol use and also intentions to engage in these behaviours. Adolescents construct and modify their smoking norms either directly, or indirectly, through information from people they interact with, media campaigns and regulations. Norms often spur and guide behaviour in a direct and meaningful manner, and the mechanisms underlying normative influence exist in a variety of social contexts that people encounter daily. Tobacco denormalisation draws from this conceptualisation and seeks to reduce tobacco use by providing accurate information to correct misperceptions of smoking prevalence and approval by significant others, create unfavourable tobacco industry's perceptions, and consequently establish conservative group norms. This study examines tobacco policy influence on adolescents' smoking intentions, via their normative beliefs. Structural equation modelling was employed to assess data from wave four (n=1159) of the Youth Tobacco Policy Study, which examines the impact of the Tobacco Advertising and Promotion Act on adolescents' tobacco marketing awareness and smoking behaviours. Results suggest that anti-smoking messages affected adolescents' smoking intentions through the mediated effect of perceived prevalence and sibling approval of smoking. Smoking intentions were reduced by perceptions of smoking restrictions, through the independent effect of perceived prevalence and sibling approval. Both anti-smoking messages and smoking restrictions were directly related to intentions. The findings address the need for action on tobacco policies that incorporate normative messages to denormalise smoking.

The effects of a three-year smoking prevention program in secondary schools in Finland

Marjaana Pennanen, Ari Haukkala, Erkki Vartiainen

National Public Health Institute, Finland, Finland

E-mail: [email protected]

Background: This study evaluates the effects of a three-year smoking prevention program in secondary schools in Helsinki. The study is part of European Smoking prevention Framework Approach (ESFA), in which Denmark, Finland, the Netherlands, Portugal, Spain and the UK took part.

Methods: In Finland 27 secondary schools participated in the program (n=1821). Schools were randomized to treatment (13) and control groups (14). The program lasted for three years, starting in 1998 when participants began their 7 th grade. The program included 14 lessons of information about smoking and refusal skills training. During the three years smoking prevention was also integrated in regular subjects. The community-element included parents, parish confirmation camps and dentists. Treatment schools received the prevention program and control schools standard health education curriculum.

Results: At the baseline participants average age was 13.8. Among baseline never smokers (60.8%) the program had a significant effect on onset of weekly smoking in the treatment group [OR=0.63 (0.45-0.90), P=0.009] compared to control group. Students that performed poorly at school smoked regularly six times more than those who achieved the best grade average at the age of 15.

Conclusion: This study shows that school and community based smoking prevention program can prevent onset of smoking among all adolescents, including high-risk students.

The power of policy: Critical mass and tipping points for reducing youth smoking on Guam

Annette David, Grace Lapid-Rosadino, Paul Nededog

Health Partners, L.L.C., United States of America

E-mail: [email protected]

Background: Youth smoking on Guam, a US Territory in the Western Pacific, was among the highest in the region in the '90s. Island leadership adopted key policy initiatives---restricting youth tobacco access, raising tobacco taxes and establishing smoke-free public places---in 1999, 2003 and 2005.

Objectives: Examine the association between youth smoking prevalence and tobacco control policy initiatives.

Methods: Smoking prevalence among youth were derived from the Youth Risk Behavior Surveys, 1995 to 2007. The temporal association between tobacco control policies and youth smoking was examined.

Results: In 1995, smoking prevalence among Guam high school students was over 40%, climbing to 44.7% in 1997. The first decrease occurred in 1999, when youth tobacco access prohibition was enacted. Smoking prevalence remained unchanged in 2001, but dropped in 2003, when tobacco taxes were raised from $0.07/pack to $1.00/pack. Smoking among Middle School students, first tracked in 1999, increased in 2001 and 2003. The first significant decrease occurred in 2005, when the smoke-free law came into effect. In 2007, both HS and MS smoking rates dropped further, in the absence of additional policy initiatives.

Conclusions: While each tobacco control policy initiative was associated with temporal decreases in youth smoking, sustained declines occurred only after the addition of a smoke-free policy in a community where youth tobacco access prohibition and tobacco tax increase pre-existed. The data suggests that combined policies are necessary for sustained declines in youth smoking, and that smoke-free policies can serve as the "tipping point" for continued behaviour change.

Comprehensive children's tobacco control: The American Academy of pediatrics (AAP) Julius B. Richmond center of excellence (Richmond Center)

Dana Best, Mark Gottlieb, Karen Wilson, Jonathan Klein

The Smoke Free Project, United States of America

E-mail: [email protected]

Background: The AAP Richmond Center, established in 2006 with support from the Flight Attendant Medical Research Institute, is dedicated to eliminating children's exposure to tobacco and secondhand smoke.

Objectives:To describe our methods for changing the practice of child health care in clinical and community health settings through rapid translation of research into policy and practice.

Methods: The Richmond Center is a "virtual center," linking physicians, lawyers, social scientists, epidemiologists, public health experts and staff at the AAP and 9 academic centers. Communication is via email, an interactive website (, conference calls, and occasional meetings. Projects and activities address associations between tobacco and health, building careers in children's tobacco control, dissemination of best clinical practices in tobacco control, legal and regulatory policy advocacy, and counseling and systems change effectiveness studies.

Results: Achievement to date include many publications, a comprehensive tobacco policy for AAP, clinician and tobacco champion trainings, additional grants accrued towards children's tobacco control activities, new investigators, and development of sustained collaborations with other FAMRI-funded centers and other tobacco control and primary care organizations.

Conclusions: Comprehensive children's tobacco control is underway through the Richmond Center. This "virtual" structure has increased collaboration between key pediatric communities, leading to significant progress in engaging child health advocates in tobacco control in a short period of time. This model may be useful for other national and international efforts seeking to increase tobacco prevention and control capacity targeting children's health.

Introducing project activity: Advancing tobacco cessation in young persons belonging to low socio-economic groups in India

Monika Arora, K. Srinath Reddy, Melissa Stigler, Cheryl Perry

HRIDAY (Health Related Information Dissemination Amongst Youth), India

E-mail: [email protected]

Background: Tobacco is an emerging, significant, and growing threat to youth health in India. Disadvantaged youth from low socioeconomic communities are particularly vulnerable to the dangers of tobacco.

Objectives: To (a) investigate the determinants of tobacco use and tobacco cessation among disadvantaged youth living in slums in Delhi; (b) pilot test a comprehensive, community-based tobacco control intervention in slum communities in Delhi as part of a demonstration project; and (c) introduce Project ACTIVITY, a group-randomized intervention trial that extends this demonstration study to test the efficacy of a comprehensive approach to tobacco control for disadvantaged youth living in Delhi.

Methods: Five focus group discussions with 37 boys and girls aged 10- 19 years were undertaken in two slum communities in Delhi in 2005. Subsequently, a comprehensive community- based tobacco cessation intervention was developed and pilot tested in one intervention and one control slum community in Delhi in 2006-7.

Results: Results from the focus groups suggest that access, affordability, role models and peer pressure are important determinants of tobacco use and/or cessation. Findings from the demonstration study were positive. Intervention youth exhibited a higher quit rate (ƒ΄:14.8%, 95% CI (-1.3, 30.9), P=0.07) and a lower rate of experimentation than the control community (ƒ΄1.3%, 95% CI: (-0.3,-2.3), P=0.007) over time.

Conclusions: Comprehensive, community-based interventions may be effective in controlling tobacco use among slum dwelling youth. Results of demonstration project will be extended and tested in a larger, group randomized trial (Project ACTIVITY), the design of which will be discussed in this presentation.

Preventing tobacco use among youth in India: How did project MYTRI reduce tobacco use?

Melissa Stigler, Derek Smolenski, Monika Arora, Cheryl Perry

University of Texas school of Public Health, United States of America

E-mail: [email protected]

Project MYTRI (Mobilising Youth for Tobacco-Related Initiatives in India) was a large, group-randomized trial of a school-based, multi-component intervention designed to reduce multiple forms of tobacco use among students in grades 6 through 9 in India. Thirty-two schools in Delhi and Chennai were recruited, matched, and randomized to receive the intervention (n=16) or serve as a delayed program control (n=16). The intervention was a two year program and included classroom curricula, school-wide media, parent involvement, and peer-led health activism. Students (n=14,063) were surveyed before, during, and after the program was implemented. Mixed-effects models for repeated measures data were used to assess changes in tobacco use and related psychosocial risk factors across time. Results suggest that MYTRI was able to successfully reduce cigarette ( P < 0.05) and bidi smoking ( P < 0.01). Positive changes in multiple psychosocial risk factors for tobacco use were also observed ( P < 0.05). Mediation analyses are now being conducted to examine the mechanisms by which MYTRI achieved its effects. Analyses of the first year of the program suggest that increases in knowledge about the adverse health consequences of tobacco ( P < 0.05); positive changes in social norms around tobacco use ( P <0.05); and reductions in reasons to use tobacco ( P < 0.05) were responsible for alleviating tobacco use among youth. Mediation analyses of both years of this two year intervention are underway and will be useful in identifying program elements that were effective -- and ineffective, which has important implications for the design of tobacco prevention interventions for youthin developing nations like India.

Progress on tobacco free school policy: Preventing use and providing protection

Jane Pritzl

United States of America

E-mail: [email protected]

Background: Tobacco free school policies protect children from exposure to second hand smoke and from observation of tobacco use while at school and school events. They help establish a norm of non-use for all forms of tobacco. The US has long had state and federal efforts in place to encourage the adoption of tobacco free school policies and Healthy People 2010 includes an objective to increase tobacco-free environments to 100 percent.

Objectives: Provide common definition of tobacco free school policy Describe various initiatives and progress made

Methods: A variety of strategies have been used to assess progress in the adoption of tobacco-free school policies, including government and state surveys, policy reviews by NGOs, state-by-state interviews with key informants, and collection of policies and materials. The most current information available from these efforts has been assembled to provide insight into what progress has been made and how it is being achieved.

Results: Tobacco free school policies have increased since 2000. Indicators of change vary by the reporting organization and how a "tobacco - free school" is defined. States differ regarding the level of activity on this objective, the agency or organization that initiates it (Departments of Health, Education, foundations or NGOs) and strategies used.

Conclusion: Combining regulatory and voluntary, federal, and state strategies, significant progress has been made in the U.S. However, The Healthy People 2010 objective for tobacco free schools is not likely to be met. Observations may guide others.

  Assessing the needs of the global tobacco control community Top

Assessing the needs of the global tobacco control community

Frances Stillman

Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public H, United States of America

E-mail: [email protected]

The Global Tobacco Research Network conducted the 1 st Global Needs Assessment for the 13th WCOTH in Washington, DC in 2006. At that time, over 2000 people participated. Results identified a need for mentoring and building networks to improve research and practice. Since that time, the landscape for tobacco control has changed and there has been more funding for programs and improved capacity. This presentation will discuss the reasons for conducting the Global Needs Assessment and will highlight the responses from researchers, clinicians and advocates. In addition, this presentation will discuss new approaches to public health networking and how this information will be used to help improve networking and communication in tobacco control.

Panel: Network development for global tobacco control

Frances Stillman

Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public H, United States of America

E-mail: [email protected]

The panel will discuss the need to improve collaboration and communication for Tobacco Control. The large and diverse tobacco control research community is composed of individuals and institutions that have a broad range of expertise (e.g., public health, epidemiology, behavioral science, communications, economics, political science, international law, and advocacy). Mechanisms are needed to enhance the ability of this group to work with each other to improve research and influence the larger policy and social environment.

Results from the 2 nd Global needs assessment

Elizabeth Donaldson

Johns Hopkins Bloomberg School of Public Health, United States of America

E-mail: [email protected]

This presentation will provide the results from the Assesment. The assessment has specific questions to identify the needs of researchers, advocates and clinicians. There are now two time periods that have been assessed so a determination of how the needs have changed since the 1 st assessment, which was done for the 13th WCOTH, will be provided. The information from the Assessment is useful to determine the current situation for tobacco control and highlights what individuals feel they need to accomplish their jobs.

Conducting the 2 nd global needs assessment

Atanaska Dineva

Johns Hopkins Bloomberg School of Public Health, United States of America

E-mail: [email protected]

This presentation will discuss the questionnaire and the methodology used to collect the data for the 2 nd Global Needs Assessment. The Assessment was conducted via the web with persons who had pre-registered to attend the 14 th WCOTH in Mumbai. Questions include the amount of time they spend on tobacco control, how they acquire information, and what are their specific requirements to perform their particular role in tobacco control. The Assessment also encouraged participants to provided more in-depth comments to highlight their current situation and better express their individual needs.

  Cessation: Population-based Top

Apprenticeship site-based smoking cessation intervention for blue-collar workers in the United States

Cassandra Okechukwu, Nancy Krieger, Glorian Sorensen, Elizabeth Barbeau

University of California, San Francisco/Berkeley, United States of America

E-mail: [email protected]

Objectives: National data from the U.S. show that occupations with smoking rates above 30% were all blue-collar, with construction workers having the highest prevalence at 38.8%. Blue-collar workers smoke more cigarettes daily and are less likely to successfully quit smoking. This study presents results of and lessons learned from a smoking cessation intervention for blue-collar apprentices entering construction/building trades in Boston, MA (USA).

Methods: Through a partnership with a trade union that trains apprentices, we implemented a group randomized controlled smoking cessation intervention among apprentices at ten sites (n=1213). Data were collected pre-intervention and at one month and six months post intervention periods. We estimated odds of smoking using SAS GLIMMIX and controlling for clustering by worksite and used multiple imputation to account for missing demographic information.

Result: Overall, 41% were smokers and 56.6% reported serious smoking cessation attempt within the last year. The intervention group had higher quit rates (26% vs. 16.8%; P=0.014) one month after the intervention. However, six months post-intervention, the difference in quit rate was no longer significant, but intervention group members were more likely than controls to smoke at least half a pack less (OR=3.13; 95% CI 1.55 to 6.31). There was no difference between the intervention and control groups in co-worker support for not smoking, smoking decisional balance, and cancer risk perception after the intervention.

Conclusion: The study demonstrates the feasibility of delivering an intervention through apprenticeship programs. It also underscores the need to improve the maintenance of smoking cessation among blue-collar workers.

Does motivational interviewing affect treatment outcome in tobacco quitline setting

Asgeir R. Helgason, Lars Forsberg

Karolinska Institute, Sweden

E-mail: [email protected]

Aim: To assess if adding Motivational Interviewing to the treatment protocol at the Swedish National Tobacco Quitline may enhance treatment outcome measured as "six months continuous abstinence" 12-months after first contact with the quitline.

Methods: Half of the quitline counselors were trained in MI using MITI-scores to monitor training and treatment fidelity. The other half of the counselors continued to work with the standard treatment protocol receiving extra boosters of lectures and supervision in Cognitive Behavior Therapy during the study period. Patients calling the quitline during the study period were randomly assigned to one of the two groups. The counselors in both groups were instructed to audiotape their treatment sessions at given intervals. The sessions were scored at the Motivational Interviewing Coding Laboratory at the Karolinska Institute in Stockholm using the MITI-scale. In the analysis the MI counselors were divided into two groups based on their MITI score on empathy, MI-spirit and MI-adherent statements.

Results: Data on six months continuous abstinence was retrieved from 590 patients at 12-months follow-up. Of patients receiving treatment from counselors trained in MI with acceptable MITI scores on at least two out of the three MITI variables (168/241), 31% reported abstinence. Of patients treated by counselors trained in MI not achieving these criteria (73/241), 25% reported abstinence. Of patients treated by counselors not trained in MI (83/349) 24% reported abstinence.

Conclusion: The data is presently being analyzed. There is a strong indication that high quality MI may increase treatment outcome in quitline setting.

Smoking cessation among italian adults: Attempts, intentions, and use of pharmacotherapy

Amy Ferketich, Silvano Gallus, Carlo La Vecchia

The Ohio State University College of Public Health, United States of America

E-mail: [email protected]

Over the past few decades in Italy, the prevalence of smoking has been steadily decreasing among males and stable among females. Smoking reached its lowest level of 23.5% (27.9% among males and 19.3% among females) in 2007. However, little is known about the individuals who continue to smoke in terms of their previous quit attempts or future intentions. The objectives of this study were to examine previous cessation attempts, future intentions to quit, and use of pharmacotherapy during a quit attempt among Italian adult smokers. The data for this study were collected as part of six Italian tobacco surveys conducted between the years 2002 and 2007 on a total of 4,927 smokers aged 18 years who were randomly selected to be representative of the population. The prevalence of ever having made a quit attempt was 38% and varied significantly with age, sex, education, and smoking intensity. Only 9.6% of smokers had an intention to quit in the next 6 months and only smoking intensity was related to intention to quit. Similarly, few smokers have used pharmacotherapy during any previous quit attempt: 9.4% overall and use varied positively with smoking intensity. These results suggest that, compared to smokers in the U.S., fewer Italian smokers have ever made an attempt at cessation, have an intention to quit in the near future, and have tried pharmacotherapy during a quit attempt. During the presentation, the potential reasons for the differences between Italy and the U.S. (as well as other European nations) will be discussed.

Changes in smoking status over one-year in a population-based cohort of smokers

Susan Bondy, J Charles Victor, Lori Diemert, K Stephen Brown

Public Health Sciences, University of Toronto, Canada

E-mail: [email protected]

Background: Few studies have examined the stability and variability in smoking behaviour over time, outside of intervention settings.

Objectives: This report describes the stability and predictors of change in smoking status among recent smokers over one year using a three-state Markov model.

Methods: From a panel study of smokers in The Ontario Tobacco Survey, we studied 1630 individuals who had smoked within 6 months of recruitment (July 2005 to December 2006) and completed biennial follow-up data for one year. At each interview, respondents were classified as daily smokers, non-daily smokers or recent quitters (not smoked within 30 days). Multichotomous regression models are used to examine the likelihood of reported changes in smoking behaviour.

Results: 72% of our sample maintained their smoking status for a year; another 8% changed smoking status with every interview. Daily smoker was the most stable category with 80% remaining such over one year. Roughly half of non-daily smokers remained such six months later, with roughly equal numbers shifting to daily smoking or cessation. Characteristics of people moving from daily to non-daily smoking were the same as those quitting altogether (e.g., intentions to quit and lower dependence), although younger respondents were more likely to shift to non-daily smoking as opposed to quitting. Shorter time since last cigarette was associated with relapse to non-daily smoking. Recent quitters using pharmacological aids had a high risk of returning to daily smoking.

Conclusion: Understanding the natural course of smoking behaviour change is important to inform and evaluate policies and cessation programming.

  Cessation: Reimbursement/worksite Top

Benefits and concerns of national smoking cessation programs-does reimbursement increase smoking cessation rates?

Antigona Carmen Trofor, Valentina Esanu, Mihaela Sandu, Traian Mihaescu

Clinic of Pulmonary Diseases Iasi, Romania

E-mail: [email protected]

Background: In 2007, Romanian Health Ministry developed "Stop smoking"3 months pilot program, designed to reimburse smoking cessation activity, a green-line phone and cost of therapy.

Aim: To evaluate impact of first reimbursing smoking cessation program run in our center. To identify gaps and values of the program, based on first 3 months expertise.

Materials and Methods: Patients were scheduled to initial visit by the phone, sent by G.P.-s, or following media information. Selection of subjects in the program was based on staff and medication resources and waiting-list Smoking abstinence assessed by carbon monoxide measurement in exhaled air and urinary cotinine tests, was main objective of the study.Secondly, impact of the gratuity of the program on patient's motivation to quit smoking and to their rate of attendance in follow-up visits was estimated.

Results: 100 initial consults were appointed, among which 46 were eligible to receive therapy (24 bupropion group, 14.varenicline group and 8 nicotine patches group). Treatment was completed by 54.3% of subjects, with 8.7* lost of follow-up and 15.2% side-effects requesting to abandon therapy. Overall success rate was 34.7%.

Conclusions: Reimbursement of therapy and payment of personnel for smoking cessation activity has increased individual compliance to quitting smoking and doctor's motivation to involve in this field, but future funding strategies impose to better cover population's education for a smoke free life, increasing network of smoking cessation centers all over the country and increased funds for pharmacological therapy delivery.

Experiences of a workplace tobacco cessation programme, in Mumbai, India

Pimple Sharmila, Shastri Surendra

Tata Memorial Center, India

E-mail: [email protected]

Background: The workplace is a potential setting through which large groups of people can be reached to encourage tobacco cessation. Tobacco cessation capacity is in its infancy in India, with no infrastructure to promote cessation among tobacco users.

Objectives: The aim of the study was to assess the effectiveness of behavioral tobacco cessation intervention, at the workplace.

Methods: The behavioral therapy intervention was implemented in two phases. The first phase involved an elaborate education programme on tobacco use prevention, followed by group and individual structured behavioral counseling for tobacco cessation. The second phase after three months involved repeat individual and group counseling for reinforcement of tobacco cessation advise. The main outcome measure was self reported tobacco abstinence assessed at the end of six months.

Results: Out of 231 workers were using tobacco in some form.181 (78.4%) were using smokeless tobacco and 21.6% (50) were using the smoked form. Compliance of the participants for outcome assessment was 59.7% at the end of six months. Out of the 138 workers assessed, 44 (19%) reported no change in the tobacco use status, 62 (26.8%) reported abstinence for complete six months and 2 (0.9%) had restarted use after a brief abstinence.

Conclusion: The study showed that the behavioral workplace tobacco cessation intervention is effective and is a simple, cost effective, feasible and sustainable intervention which can be integrated with routine health examinations to achieve long term tobacco cessation.

Tailoring worksite smoking cessation programs

Sharifa Stewart, Stephanie Paredes, Susan Grace, Scott McIntosh

University of Rochester, United States of America

E-mail: [email protected]

Background: Employers increasingly offer worksite wellness programs, resulting in healthier employees, greater retention than competitors, and more productivity. Programs often focus on diet and physical activity, but less often on smoking cessation programs.

Objectives: The objective was to assess employees' attitudes toward smoking cessation programs in comparison to programs addressing weight management. Ongoing programs can use findings to accommodate each site's specific needs and requests by offering a 'menu of services'.

Methods: A university partnership with a managed health care plan partnered for a self-reported survey comparison of employee attitudes at multiple work sites in a large metropolitan area in upstate New York. Data were collapsed and compared by frequencies between categories.

Results: Smoking cessation ranked low in importance in contrast to nutrition and weight management, which ranked highest at all sites.Employees may not be considering the long term effects of tobacco, and may be more concerned with body image. Data help identify the proportion of employees that may be in need of interventions specific to smoking. Other results indicated that half of smokers attempted to quit, but majority had no professional help. Half of smokers stated that their physician had not advised them to quit.

Conclusions: Employees tend to favor nutrition and weight management more than smoking cessation. Employers must adopt programs that educates about the dangers of smoking. It is important for employers to purchase insurance packages for their employees that reward efforts to quit smoking. Funded by NY State DOH Contract (McIntosh, PI).

A Multi-Hospital smoke free campus initiative

David Feldmann, Gabrielle Kapsak, Deborah Ossip-Klein, Scott McIntosh

University of Rochester, United States of America

E-mail: [email protected]

Background: In the U.S., over 1,200 hospitals, healthcare systems, and clinics have adopted smoke free campus policies. Allowing smoking on a medical campus is inconsistent with the mission of improving community health. A planful coordinated process is needed to ensure successful policy implementation.

Objectives: The University of Rochester Medical Center, along with several other area hospitals, simultaneously implemented smoke free initiatives in November, 2006. The coordinated initiative required each system to plan for policy changes, employees and clinician training, and the provision of cessation services.

Methods: In order to inform each of these system-wide aspects, accurate information was needed on current tobacco use, preferences for treatment options, and opinions about the policy. A multi-system surveillance initiative was implemented with a brief survey (online and hard-copy) for all employees of each system.

Results: Common strategies in the implementation were observed: Meetings, Individual timelines, Community wide implementation, Subcommittees, Inpatient Procedures, Visitors & Outpatients, Clinician Training, New pathways in Electronic Medical Records, Pharmacotherapy, Signage, Security, and Policy changes. Survey allowed individuals to voice concerns, ideas, objections, and support of the initiative, and captured data on which smoking cessation resources were requested.

Conclusions: Subcommittees help design specific strategies. Common timeframes and policy implementation dates are helpful. Survey helped understand smokers' needs. Common learning curve increased cohesion, commitment and idea sharing. A 1-year timeline is appropriate for overcoming fears, biases, and barriers which can enable support from leadership as well as employees. Funded by NY State DOH Contract (McIntosh, PI).

  Contraband and counterfeit Top

Illicit tobacco trade in the Mercosur countries

Alejandro Ramos, Roberto Iglesias, Mario Virgollini, Mirta Molinari

Research Centre of The Tobacco Epidemics (CIET) Uruguay, Uruguay

E-mail: [email protected]

An intelligence gathering and study on the illegal tobacco trade in the MERCOSUR countries (Brazil, Argentina, Paraguay and Uruguay) coordinated by Alejandro Ramos of CIET, Uruguay, funded by the Bloomberg Initiative, has been completed by May 2008 and produced several documents and a concept paper. The intelligence gathering involved information on systems of transportation, points of entry to each country, etc., and involved primary sources such as interviewing of operators, police and border controls besides reviewing secondary sources Principal conclusions: The illegal market in the region presents some differential characteristics from other parts of the world.

1) The illegal trade on cigarettes is based on factories producing in the Paraguayan territory, have substituted the former legal export and illegal reentry of cigarettes manufactured in Brazil typical of the nineties. 2) The volume of the Paraguayan cigarette export industrial capacity was estimated to be around 73 billion cigarettes in 2006, an amount half of the cigarette consumption of Brazil. 2) Long borders, lax control policies and corruption involving the trade of different products, not only cigarettes, characterizes the illegal trade in the MERCOSUR region. 3) Tobacco illegal trade involves cheap brands made for illegal regional and foreign markets. Counterfeiting of major international cigarette brands exists but not a main business. 4) At present multinational tobacco companies do not operate in this market and rather suffer many costs from this trade. 5) Penalties for tobacco smuggling involve mostly the seizing of merchandise and sometimes the vehicles, very rarely prison terms for smugglers.

Contraband and counterfeit tobacco - exploring an economic disincentive to the denormalization of tobacco

Rob Hornsby

Northumbria University, United Kingdom

E-mail: [email protected]

Background: Contraband and counterfeit tobacco represents a major stumbling block to efforts to control tobacco use through taxation and other legislative means. Cigarette smuggling is estimated to lose the UK Treasury over ͳ3 billion per year. Knowledge about the organization of the trade in smuggled and counterfeit tobacco is limited and patchy. Previous research has indicated that in some deprived communities in the north east of England, smokers use little else and contraband suppliers are regarded as 'Robin Hood' characters, providing a vital service to socio-economically hard-pressed communities.

Objectives: To understand better the operation of the smuggled and counterfeit tobacco market through analysing its organization, its key characteristics, the composition of local criminal firms, and the distribution/supply routes into indigenous local markets.

Methods: Analysis of existing datasets and the study of contemporary materials to build up a set of case studies illustrating common patterns.

Results: Some information on cigarette bootlegging by entrepreneurial criminals has already been published (Hornsby and Hobbs 2007). This study presents the analysis of accumulated data on upper level contraband ('container traffic') and the tobacco manufacturers' complicity in feeding the market with contraband tobacco.

Conclusions: In examining the rapidly changing modus operandi of the contrabandiers and the profound implications of this illicit trade for public health, the problem of smuggled and counterfeit tobacco moves beyond mere criminal justice studies and is placed squarely in the emergent field of criminality as social harm.

Purchase of contraband cigarettes on first nations reserves in Ontario, Canada

Roberta Ferrence, Rita Luk, Joanna, Cohen, Susan Bondy, Stephen Brown, John Garcia, Paul McDonald, Robert Schwartz

Ontario Tobacco Research Unit, Canada

E-mail: [email protected]

Background: Effective taxation policies provide the greatest impact on tobacco consumption and the related health burden. However, the availability of untaxed or partially taxed cigarettes seriously undermines these policies.

Objectives: We estimate the prevalence of purchasing illegal contraband cigarettes on First Nations reserves in Ontario and identify correlates of purchasing behaviours, assess the share of contraband of total cigarette consumption and quantify the impact on taxation revenue. We also discuss implications for control of contraband globally.

Methods: Data were collected from the Ontario Tobacco Survey, a regionally-stratified representative population survey designed to over-sample smokers. The present study focused on 1,391 adult smokers interviewed 2005 to 2006. Prevalence of purchasing cigarettes on reserves was assessed with descriptive statistics. A two-part model was used to analyze correlates of purchasing behaviors: logistic regression for participation in recent purchasing of cigarettes on reserves and ordinary least squares regression for quantity of purchases.

Results: Among current smokers, 37% reported ever purchasing cigarettes on reserves, 26% reported recent purchasing and 12% reported usually purchasing. Smoking characteristics were associated with purchasing cigarettes on reserves and with amount of purchase, but socio-demographic characteristics were mainly associated with purchase on reserves. Contraband cigarettes purchased on reserves resulted in tax losses of $122.2 million CAD, and contraband accounted for 14% of reported total cigarette consumption.

Conclusions: These findings have implications well beyond Ontario. Governments should strengthen their contraband prevention measures, as recommended by the FCTC, to ensure that tobacco taxation achieves its intended health benefits and protects existing tax revenues.

Anti-contraband measures: Evidence for better practice

Robert Schwartz, Jeff Sweeting

Ontario Tobacco Research Unit, University of Toronto, Canada

E-mail: [email protected]

Background: This "knowledge synthesis" looks to explore and evaluate "anti-contraband" tobacco policies, through a study that is global in scope. The policies analyzed are licensing, tax markings/stamps, "tracking and tracing," record keeping and control measures, enhanced enforcement, export taxation, tax harmonization, and tax agreements/compacts, as well as Memoranda of Understandings with the industry, and public awareness campaigns.

Objectives: This project combines both academic and policymaker research and perspectives, to assess which measures have been most successful at addressing contraband tobacco, and how the illicit trade frequently adapts to policy implementations, requiring iterative strategies by policymakers.

Methods: Existing academic research on this topic is complemented with case studies involving over 40 key-informant interviews with policymakers and other experts, in several jurisdictions, to understand what policy measures have worked most successfully under given conditions. Findings are validated and vetted with expert focus panels in four jurisdictions.

Results: An important contribution of this is the recognition of the diversity of "contraband" itself, ranging from illicit growing and distribution, to unlicensed manufacturing, as well as organized tobacco smuggling and counterfeiting. The study finds that several policy measures are needed to effectively curb contraband activity.

Conclusion: This synthesis provides a comprehensive analysis of anti-contraband measures, and provides significant insight into the efficacy of various approaches, and the environments which support specific policy interventions.

  Countering target marketing Top

Indigenous peoples: Altria apology to Maori people (A world first)

Shane Kawenata Bradbrook

Te Reo Marama, Newzealand

E-mail: [email protected]

Altria (Phillip Morris) has only apologised to one organisation and group of people in the world regarding the marketing and selling of a tobacco product. In 2006 the Chair of Altria apologised for their exploitation of Maori (the Indigenous People of New Zealand) for selling a tobacco brand called 'Maori Mix' in Israel. The product, when discovered, was removed from the market immediately. Subsequently a challenge to Altria at the Annual General Meeting resulted in three unprecedented apologies for this exploitation of an ethic group. The story of the challenge, the media exposure and apology will be discussed with possible future application for other advocacy avenues.

Killer Quotes! Using tobacco industry documents to create an interactive campaign

Catalyst Andy Berndt

United States of America

E-mail: [email protected]

"We have a critical resource in the fight against the tobacco industry - its own words! Catalyst has put a new spin on the tobacco industry documents, and we want to share this exciting campaign with our colleagues around the world. We have just concluded our Killer Quotes Tour, a statewide educational and recruitment initiative focusing on industry quotes. Youth leaders did their own document research, identified powerful quotes, and helped to develop a text messaging campaign and community events where teens across the state screen printed their own killer quotes posters, learned more about the tobacco industry, and signed up to get involved in Catalyst. This workshop will be an opportunity to share our strategies and methods, from creation to conclusion. The campaign materials are available for free on our website and we'll provide a copy of this presentation. We are in the process of evaluating the campaign based on the number of new members it generates. Upon completing the workshop, participants will: Understand the campaign and feel comfortable replicating core components to complement youth action in their communities. Identify opportunities to use tobacco documents as a resource to support work with youth. Catalyst focuses on strategic youth advocacy to support social environment change around tobacco issues. Catalyst employs CDC best practices for state and community interventions, working to build capacity for social norm change at the community and state level. If accepted, please group on a panel with youth abstracts from April Kusper and/or Anna White. "

REAL girl talk campaign: Counter-marketing for the tobacco industry's focus on teenage girls

Nicole Sutton, Jennifer Pescador, Melissa Chong, Cheryl Albright

Cancer Research Center of Hawaii - University of Hawaii, United States of America

E-mail: [email protected]

In 2007 RJ Reynolds Tobacco Company launched a new cigarette directed at girls and young women: Camel No. 9. The product is advertised in fashion magazines and in local communities through special promotional activities including in-store promotion. Develop a youth-driven, teen focused, advocacy-based counter-marketing initiative to expose Camel No. 9. Girls aged 13-20yrs from REAL, Hawaii's Youth Movement Exposing the Tobacco Industry, a statewide youth-led program, were recruited to review tactics used by the tobacco industry since the 1920's to target women. Information from the review was used to devise a special girl-focused initiative for Hawaii. The REAL Girl Talk campaign invited girls to parties where a 15 minute presentation, Lady Killer, about the history and current tobacco marketing strategies directed at girls and young women was shared. Youth participants were offered the opportunity to take action on the spot by asking women's magazine editors to permanently discontinue tobacco advertising in the publications. Counter-marketing gear items were distributed including REAL branded lip gloss, compact mirrors, and cosmetic brush kits. Participants were offered additional opportunities to receive training and support to host their own REAL Girl Talk parties for their own friends. Counter-marketing by adolescents can be done on limited resources. Keys to the success of such initiatives include 1) engaging teens in the development of the counter-marketing message; 2) creating peer to peer message delivery; 3) facilitating a swift response to tobacco industry campaigns; and 4) development of an approach where teenage girls can take action on the spot.

US advocates responses to camel no. 9 and the farm

April Kusper

Campaign for Tobacco-Free Kids, United States of America

E-mail: [email protected]

Over the past year, the tobacco company, Reynolds American (RJR), has launched numerous outrageous campaigns enraging advocates across the United States. The first was for a new product, Camel No. 9. These cigarettes come in a shiny black box with flowery hot pink or teal borders. The slogan is 'Light and luscious." 'Loathsome and lethal' would be more accurate as this product is just the latest tactic by Big Tobacco to attract new female smokers. This presentation will show how advocates across the US fought back by asking magazines to stop running Camel No. 9 advertisements, holding counter events and collaborating with members of Congress. In November 2007, RJR, ran an ad in Rolling Stone Magazine's Fortieth Anniversary issue introducing Camel's "The Farm", a philanthropic campaign to support indie rock bands. The ad featured a two-page spread stating that Camel is "Committed to supporting and promoting independent record labels." Those two pages opened up to an insert titled "Indie Rock Universe" that was essentially a four-page cartoon promoting a whole range of bands clearly violating the Master Settlement Agreement (MSA) between the states and the major U.S. Tobacco Companies. Come learn how the public health community responded with outrage and why several state Attorneys General sued RJR for their blatant disregard of the provisions of the MSA.

  Counter-marketing Top

Gone viral? heard the buzz? A guide for tobacco control practitioners and researchers on how web 2.0 can subvert advertising restrictions and spread health information.

Becky Freeman, Simon Chapman

University of Sydney, Australia

E-mail: [email protected]

All nations that have ratified the FCTC must ban the advertising of tobacco products. The growth in Internet-based marketing techniques may be subverting these advertising regulations. Explosive rises in use of social networking and user generated content websites is further fueling product promotion through electronic media. In contrast, there is a very limited body of health research on these "new media" advertising methods. This paper provides an overview of these advertising methods and details examples relevant to tobacco control. There is a vast untapped potential for health practitioners and researchers to exploit these same media for health promotion.

Inventing the wheel: Towards an integrated hub and spoke model for stop smoking interventions

Andy Graham

Department of Health, England, United Kingdom

E-mail: [email protected]

Background: England's Tobacco Control National Support Team provides tailored support to areas facing challenges in Tobacco Control. This includes working with Stop Smoking Services to support smokers to quit. While these are the most comprehensive services in the world, many face challenges dealing with the reality of organisational change, a developing competitive market and demanding targets.

Objectives: To identify a framework for those services facing challenges to review and redevelop working practices ensuring fitness for purpose, taking account of the finite nature of the resources available, and using these to maximum effect.

Methods: A group of cessation experts was convened and worked to develop a framework for integrated support which was evidence based and realistic for those in the field. This was based on the specialist stop smoking team working in a strategic way to develop and facilitate the deployment of an integrated support package involving the full range of partners.

Results: A workshop based on this approach was developed to facilitate the process of change for Services that required assistance in re-designing their provision. Where this framework for comprehensive and integrated stop smoking support has been implemented performance has improved and local targets have been met.

Onclusions: An effective approach was developed, using key expertise and the evidence base, which ensures an integrated approach to provision of stop smoking support. This allows effective use of existing resources and a level of performance that meets local targets. It provides a consistent and equitable level of service for the local community.

Three anti-tobacco advertisements produced using computer graphics techniques

Victor Sojo, Julian Rojas-Millan

Universidad Central De Venezuela, Venezuela (Bolivarian Republic of)

E-mail: [email protected]

Two 27 second advertisements have been produced by students of the Universidad Central de Venezuela using advanced computer graphics techniques for high impact. Making use of a recent Venezuelan regulation, these advertisements will be compulsorily displayed free of charges on local television networks across the Country, possibly including a TV station which is seen in most countries of South America. The first of the advertisements pictures a cigarette over a black background. The cigarette starts expanding, bending and twisting around itself until it turns into an extremely intricate knot; the knot then shows in a humanized behaviour a will to break free, struggling with itself, as a text appears stating: "nicotine is highly addictive, if you haven't started smoking, don't do it". The second advertisement also starts with a cigarette, this time filling most of the screen, the tip ignited. There is a sound of inhaling, the cinders in the tip are intensified, then turned into ashes which grow towards the cigarette-end; as the cigarette turns into ashes, it bends flaccidly downwards. Each time the off-sound inhales, the cigarette (turning further into ash) bends further and more flaccidly in a comical way. A text fades in: "Tobacco causes impotence… really…". The copyrights of the advertisements will be donated to the Pan-American Health Organization/World Health Organization, for free distribution to all member countries; since there is no voice over in any of the advertisements, versions in other languages can be easily produced by only changing the layover texts.

Developing a measure of exposure to tobacco related media and messages

Donna Vallone, K. Vishwanath, Laura Beebe, Elisio Perez-Stable

American Legacy Foundation, United States of America


Background: The impact of communications in both promoting AND dissuading tobacco use is based on a series of concatenating assumptions including that the audience member has (a) come in contact with the message AND the medium in which the message has been placed, (b) attended to it, and (c) reacted to the message leading to change in knowledge, opinion, attitudes and behaviors. Measurement to validate these assumptions, however, has been weak and need more systematic work.

Objectives: Drawing on work in communication research, we will describe a systematic process through which we developed a Tobacco-related Media and Message Exposure (TeRMM) Index that attempts to capture people's exposure to messages that encourage and discourage tobacco use and the channels through which the exposure has taken place.

Methods: Using a three-phased approach, in Phase 1, we conducted 14 focus groups with almost 50 people from diverse racial, ethnic and socioeconomic backgrounds. In phase two, we developed a questionnaire using the focus groups transcripts and have subjected it to cognitive testing.

Results: In Phase 3, the index will be used in a national survey on cessation to assess its psychometric properties, validity and reliability.

Conclusions: This presentation will outline a scientific process of developing an assessment to tobacco message exposure, the TeRMM Index that does not currently exist in the field. The index will help the tobacco control community in not only assessing what information the audience is exposed to on tobacco but also how to design future messages on tobacco control.

  Smoking and pregnancy Top

Detection of smoking in pregnant women. Validation of a brief tool

Miriam Rozenek, Laura Pezzano, Sandra Braun, Mariela Alderete

Hospital Italiano De Buenos Aires, Argentina

E-mail: [email protected]; [email protected]

Background: Smoking is one of the most modifiable risk factors in pregnancy. Approximately 18% of pregnant women smoke (self-reported), but this population tends to deny their smoking status much more than others (45%). The use of tailored questionnaires with closed options increases the acceptance of smoking in pregnant women up to 40%. They are still not available in our language.

Objectives: To validate a questionnaire in Spanish, in order to create an effective tool to detect tabaquism in pregnant women.

Methodology: We used a questionnaire with five closed options recommended by the US Health Service Guide. The validation process included a linguistic and a psycometric phase. The reliability of the tool (reproductibility and stability) was estimated, with kappa coefficient and chi square test. CO in exhaled air (used as gold standard) was measured and compared to the results of the questionnaire.

Outcomes: High levels of concordancy and reproductibility (Kappa coefficient=1) and stability (x2= 60; P<0.0001) were reached. Compared to CO in exhaled air, the questionnaire had low sensitivity and high specificity (96%).

Conclusion: Since validation was conducted following each of the described steps, the local version obtained is applicable to the Spanish language in general. It is now time to apply the tool and to observe whether it is useful to initiate a cessation program to help pregnant smokers quit in our country. This protocol was supported by a grant from the National Ministry of Health, through a National Contest, (Carrillo Oρativia 2007).

A patient-centred smoking cessation intervention: Barriers and promoting factors to smoking cessation as perceived by pregnant women

Zaino Petersen, Maria Emmelin, Maria Nilsson, Kathy Everett

South Agfrican Medical Research Council, South Africa

E-mail: [email protected]

Background: A recent study by the Medical Research Council (MRC) found that 43% of disadvantaged pregnant women smoke during. This led to the MRC developing a client-centred smoking cessation intervention at public sector antenatal clinics. The components of the intervention included; 1) Training of midwives in brief motivational interviewing 2) training of lay peer educators in brief motivational interviewing and 3) developing culturally appropriate material to motivate women to quit and to assist them in their behaviour change.

Aim: The aim of this study is twofold: 1) To describe the cognitive, emotional and behavioural responses of pregnant women towards a smoking cessation intervention and 2) to explore pregnant women's attitudes to- and perceptions of a client-centred intervention, and its role in changing smoking behaviour

Methods: In-depth interviews with 12 women and 8 focus groups were conducted with women attending antenatal clinics in Cape Town and who were exposed to the intervention. Women were purposively sampled based on age, smoking status and duration of pregnancy. In-depth interviews were analysed using content analysis and the focus groups were analysed using the Grounded Theory approach.

Results: The preliminary results show that women prefer the intervention components over normal clinic procedures. Women who quit after exposure to the intervention attribute their behaviour change firstly to the peer educator, followed by the culturally appropriate material and lastly to counselling from the midwife. More analysis is being done to look at women's perception of the client-centred approach and its role in behaviour change.

Maternal smoking during pregnancy: Associations with physical control and coordination among offspring

Matz Larsson, Scott M. Montgomery

The Respiratory Clinic, Sweden

E-mail: [email protected]

Background: Animal studies suggest that maternal exposure to inhaled tobacco products during pregnancy may adversely influence foetal neurological development. A small study suggested effects may be greatest for the non-dominant side.

Methods: The National Child Development Study is following the lives of all those born in Great Britain between the 3 rd and 9 th of March 1958. This analysis used information on 13,207 subjects collected at birth and age 11 years. Smoking during pregnancy was recorded prospectively at birth. Physical control and coordination were tested by a school doctor at age 11 years: time taken to pick up 20 matches (PUM), left and right hand, and copying designs (CD). Test scores were dependent variables in linear regression analysis, with adjustment for sex, birth weight, gestational age, breast-feeding, social class, parental education, mother's age and pubertal development (age 11 years).

Results: Maternal smoking of over 10 cigarettes per day during pregnancy was associated with poorer performance among offspring, indicated by a longer duration for PUM or a lower CD score. Adjusted regression coefficients (95% confidence interval and P value): PUM left hand 1.271 (0.55, 1.99; P=0.001); PUM right hand 0.745 (0.02, 1.47 P=0.045); CD -0.116 (-0.02, -1.47 P=0.045).

Conclusions: Even after extensive adjustment (probably over-adjustment), smoking during pregnancy is associated with functional deficits in offspring, particularly in the non-dominant side. This is consistent with earlier research suggesting maternal smoking can result in a subtle impairment of neurological development among offspring.

Exposure to environmental tobacco smoke during pregnancy and reproductive outcomes: A population based cohort study in Mumbai-India

Sreevidya Subramoney, Prakash Gupta

Nordic School of Public Health, Sweden

E-mail: [email protected]

Background: The detrimental effects of active smoking upon pregnancy are well documented. A decrease in birthweight and an increase in preterm delivery has been documented in newborns whose mothers were exposed to ETS during pregnancy. The impact of ETS exposure on pregnancy loss is less studied.

Objective: To study the effect of environmental tobacco smoke exposure during pregnancy on low birthweight, preterm delivery and stillbirth.

Methods: A population-based prospective cohort study of 1217 pregnant women using a house-to-house approach. 96% were followed up after delivery. ETS exposure at home or at work, in the vicinity of the pregnant woman was sought. 856 women, who were neither smokers nor smokeless tobacco users and did not report any perinatal complications, were included in the analysis.

Results: The mean birthweight was lesser for the ETS exposed women and the difference although not significant, persisted after adjustment for age of mother, educational, employment and socioeconomic status, and preterm birth by multiple regression analysis (41 g). The adjusted odds ratio for low birthweight was 1.6, (95% CI, 1.0; 2.5), and for stillbirth was 3.8 (95% CI, 1.1; 12.5) Preterm delivery was not associated with ETS exposure (AOR=0.7, 95% CI, 0.4; 1.2).

Conclusions: The results were consistent with the hypothesis that the exposure to environmental tobacco smoke during pregnancy increaseas the risk of low birthweight (not statistically significant) and of stillbirth (significant). Counseling to prevent exposure to environmental tobacco smoke during pregnancy needs to be urgently instituted in the Indian health care system.

  Tobacco control law implementation Top

Strengthening tobacco control law implementation, lessons from Bangladesh

Sheikh Rafiqul, Islam

Law And Soceity Trust Bangladesh (LSTB), Bangladesh

E-mail: [email protected]

It is not enough to pass a law, it is also important to ensure strong implementation. Implementation can be strengthened both through proper drafting of the law, to ensure that roles and responsibilities for enforcement are clear, and following the law, by involving a wide range of players in monitoring and support to government for proper enforcement. Specific actions taken to strengthen implementation in Bangladesh include designing newspaper ads for government on the banning of smoking in public places, helping to organize mobile courts to remove illegal signboards, and providing models of the creation of smoking zones to ensure that main buildings are smoke-free. NGOs and others can play a vital role in law monitoring, for instance by checking cigarette packets for proper warnings, taking note of the location of ads and providing photographic evidence, checking on smoke-free, and so on. Regularly providing such information to local officials and other interested parties, including journalists, and following up to ensure action, can all help ensure strong and effective implementation. Approaching the implementation question as an area where further NGO involvement is needed, rather than simply a weakness of government, which needs to be criticized, would do much to advance the tobacco control agenda.

Current, former and never smokers in Poland: 30 years of observation

Krzysztof Przewozniak, Witold Zatonski

WHO Collaborating Centre, Cancer Center and Institute of Oncology, POLAND

E-mail: [email protected]

Background: Recent epidemiological estimates show that annually about 70,000 adult Poles die from smoking-related diseases, including 43,000 who die prematurely. The magnitude and patterns of smoking-attributable mortality changed substantially in the past twenty years.

Objectives: To recognize long-term changes in smoking behaviors in Poland in order to prepare new tobacco control strategy.

Methods: Nation-wide randomized surveys on smoking behaviors in adult Polish population.

Results: In 1974, 62% of men and 19% of women smoked daily. In 1982, where cigarettes were rationed and all adults received special coupons for cigarettes, smoking rates reached the highest level ever observed in Poland (80% of middle-aged men and 50% of women smoked daily). At that time, percent of former smokers was relatively low, both for men (15%) and women (6%). Furthermore, there was also big difference in prevalence of never smoking between men (15%) and women (70%). Tobacco market shortages and enforcing the comprehensive tobacco control policies and programs led to substantial reduction of smoking prevalence in Poland. In men, decline in smoking rates concerned all social strata and was much bigger than in women. Most recent survey shows that 34% of men are daily smokers, 19% ex-smokers, and 45% never smokers. In women, these rates are 23%, 10% and 64%, respectively. In women, smoking rates have fallen only in the young, especially high-educated women, however, this decline was first frozen and recently tends to be reversed.

Conclusions: Recent changes in smoking behaviors and patterns require revised tobacco control strategy and policy in Poland.

Implementation of the tobacco control law in India: A case study

Priyanka Dahiya, Cecily Ray, Abha Tewari, Monika Arora

Hriday, India

E-mail: [email protected]

A study was conducted in India to assess the current status of enforcement of the Cigarettes and Other Tobacco Products Act (COTPA), 2003. Although COTPA has been in India since 2004, there is an evident need to have effective enforcement that enhances the tobacco control situation. The researchers aimed to understand ground reality of enforcement and to identify strengths and barriers in implementation of the tobacco control laws in India. An analytical qualitative field study was carried out in 16 States and Union Territories to assess the status of enforcement, which had either notified officers under COTPA or their own tobacco control laws. The law enforcers were interviewed to determine the level of information available with them and level of enforcement in those States using a semi-structured interview schedule related to COTPA. Even though, the tobacco control law has not been implemented successfully in India, there are examples of effective implementation in States where there was NGO-Government collaboration. It also became clear that it is not only the enforcement officials who lack information about the law; there are many other challenges e.g., lack of inter-governmental coordination, lack of human and financial resources etc. which act as barriers in the effective enforcement of the law. Through this study it became evident that effective enforcement can be achieved by enabling the notified officials who are responsible to undertake this job. It would include police officers; medical officers; drug and food inspectors; principals/persons in-charge of educational institutions; and owners/persons in-charge of public places.

25 years of tobacco control in Asia-Pacific: What has made the difference?

Harley Stanton

Asia Pacific Association for The Control of Tobacco, Australia

E-mail: [email protected]

Asia-Pacific has been the focus of much effort by tobacco companies to market product over the last 25 years. For the past decade tobacco control has grown in strength within this region and some significant reductions in prevalence have taken place.

Objectives: The presentation will: 1. Review the changes in prevalence that has occurred in some of the key countries including China, Japan, Korea and Thailand as well as available data from some of the smaller countries including the Pacific islands; 2. Outline the strategies or factors that have led to these changes; and 3. Propose directions for future tobacco control efforts.

Methods: This presentation will review available trend data, policy and strategies implemented during the period for review and outline the results of differing approaches at the regional, national, local government and community level.

Results: The presentation will place particular emphasis on the need for a combination of strategies that build comprehensive tobacco control. Examples of good practice will be drawn from countries that have achieved the most significant advances in tobacco control and resulted in the largest annual reductions in prevalence in the history of tobacco use.

Conclusions: The most effective reduction in tobacco use occurs when comprehensive national and local policy and strategy combine to reinforce the objectives of tobacco control.

  Tobacco control policy impact and public perception III Top

The role of religion and religious leadership in influencing quitting behaviour among Buddhist Thai and Muslim Malaysian adult smokers

Hua-Hie Yong, Ron Borland, Stephen Hamann, Rahmat Awang

Thai Health Promotion Foundation, Thailand

E-mail: [email protected]

Background: In recent years, attempts have been made to incorporate religion in tobacco control efforts especially in countries where religion is central to the lives of people like Malaysia and Thailand. To ensure effectiveness, there is a need to understand what religious factors are important in influencing quitting among adult smokers.

Objectives: To examine prospectively the association between religious attitudes and religious leadership towards smoking, and quitting activity among Thai Buddhists and Malaysian Muslims.

Methods: Data used were 693 Muslim Malaysian and 1,539 Buddhist Thai adult smokers who completed both waves 1 (early 2005) and 2 (late 2006) of the International Tobacco Control Southeast Asia Survey (ITC-SEA). Respondents were asked about the role of religion and religious leadership on smoking at Wave 1 and quitting activity at Wave 2.

Results: For the Malaysian Muslims, baseline perception of their religion discouraging smoking and motivating advice from religious leaders were both significantly associated with increased likelihood of subsequent quitting (both making an attempt and succeeding). However, these religious factors have no clear net effects for Thai Buddhists. In both groups, those who reported being more religious were more likely to have quit by wave 2.

Conclusions: Religious attitudes and institutional forces appear to be important drivers of quitting for Malaysian Muslims but are unclear for Thai Buddhists. More research is needed to see if these effects are due to the way religion influences behaviour or other differences between the two groups.

Did smoker behaviors or exposures change in response to the Canadian cigarette ignition propensity regulation? [Firesafer3]

Richard O'Conno, David Hammond, Gary Giovino

Roswell Park Cancer Institute, United States of America

E-mial: [email protected]

Objectives: Fires caused by smoking materials are the leading cause of fire-related death in Canada. In October 2005, Canada became the first country to mandate reduced ignition propensity (RIP) cigarettes nationwide. Opponents have argued that the law might encourage careless smoking, and that RIP cigarettes are more toxic to smokers.

Methods: A random digit dialed telephone survey of 435 Ontario smokers was conducted in 2005 and then again in 2006 to explore changes in beliefs and behaviors in response to the law. A contemporaneous study collected smoking behavior and exposure data on 42 Ontario smokers before and after the introduction of Canada's LIP law. Participants smoked their usual cigarette brands through a CReSSmicro device for a 24-hour period, provided an exhaled breath carbon monoxide (CO) sample, and completed a brief questionnaire at baseline and follow-up.

Results: We found post-law that more smokers reported cigarettes going out often (3.7% vs 14.7%, P<.001), and noticing changes in taste (15.7% vs 26.1%, P<.001). We saw no evidence of increased risk taking in terms of leaving lit cigarettes unattended (26.4% vs. 22.4%, P=.12) or smoking in bed (14.7% vs. 14.6%, P=.52). The in-depth behavior and exposure study found no significant changes in CO boost (4.3ppm vs. 4.4ppm, P=.80), smoke volume (608.0mL vs 641.1mL, P=.09), or puff count (10.7 vs 10.5, P=.30) between baseline and follow-up.

Conclusions: Data indicate that Ontario smokers noticed changes to their cigarettes, but did not increase their fire-risk behaviors, change how they smoked, or increase their exposures from their cigarettes.

The experience of Uruguay in smoking cessation. First evaluation

Eduardo Bianco, Tania Palacio, Ana Cenandez, Elba Estevez

Framework Convention Alliance, Uruguay

E-mail: [email protected]

In 2004, the National Resources Found (FNR), a national partial health secure, started a smoking cessation program aimed to reduce CV complications in patients receiving cardiac invasive treatments. In 2005, this program spread to the general population and reached most of country cities. More than 100 programs were developed and supported with NRT and bupropion for free. The objective was to determine the Smoking Cessation rates and the maximum time of abstinence and proportion of patients who required drug treatment. This a reviewing study to evaluate an intervention program for tobacco cessation of a cohort of 5194 smokers admitted between January 2, 2004 and March 31, 2006. For qualitative variables were used test chi 2; for the analysis of abstinence as age and time as abstinence program provenance was used analysis of variance, after checking the conditions of application (Test of homogeneity of variance). 5194 smokers joined the FNR SCP. For this study were included 4500 cases. The average age was 45.7 years. Regarding 1121 followed up less than one year, 478 (42.4%) achieved abstinence. Regarding 904 followed up more than a year, 490 (54.2%) achieved abstinence at any time, and 223 (24.7%) were abstinent one year later.

Conclusion: It has done a study on a population of Uruguay who has participated in various programmes for Cessation of Smoking, this study is the largest run at country level. The results can be categorized as good. Anyway, we must note the methodological limitations that this research had.

Effectiveness of different styles of corrective statements advertisements

Michael Cummings, Christopher Banthin, Maansi Bansal-Travers

Roswell Park Cancer Institute, United States of America

E-mail: [email protected]

Background: This paper will present the results of an experimental study designed to compare the effectiveness of five different styles of corrective statements on different tobacco related topics such as addiction, low tar cigarettes and health effects. The dissemination of corrective statements was one of several remedies recommended by the Judge in the Department of Justice lawsuit. However, the exact wording and style of the corrective statements were not specified, so we undertook a study to test among various styles recommended to the court would be most effective.

Methods: This paper will report the results of an ongoing study that will include data on 240 adult smokers. Study subjects will be asked to view and rate five different styles of corrective statements; three of which were text based statements recommended to the court by different parties in the case (Plaintiffs, Defendants, and Interveners), and two experimental statements which utilize different pictorial styles (emotive and neutral).

Results: The different styles of corrective statements will be rated on different dimensions included comprehension, attentiveness, and recall of the message assess one week after exposure. We will also present data on a small sub-study evaluating subject's attention to the different corrective statement styles using eye-tracking to assess what subjects attend to when they are exposed to the ad.

Conclusions: The findings from this research should provide the court with evidence about which corrective statement styles are likely to be most effective.

  Youth and tobacco Top

Family and social environment role in youth exposure to tobacco

Marta Irena Porebiak

Cancer Centre - Institute And Warsaw University, Poland

E-mail: [email protected]

Family and social environment may impact on youngsters' smoking behavior, according to von Bertalanffy's system theory. Close persons can facilitate or inhibit teenagers' experiments with tobacco use. The aim of study was to examine if experiments with tobacco and youth regular smoking can be explained by smoking behavior of their close relatives and social environment members. The group of sixty three Polish seventeen year old high school students took part in this study. Modified Mostwin's Family Area Map was used to examine occurrence of smoking related behaviors in youngsters' environment. An additional indicator of exposure to tobacco was created. The results show that the tobacco exposure is significantly higher in the group of youngsters who actually smoke than in those who haven't been ever smoking. However there were no significant differences at all subscales between those seventeen year olds who have tried to smoke and those who have never used tobacco. Thesis about the impact of the environment on youths' tobacco use can be sustained. Smoke free environment is a quite good protection against youngsters smoking. Presence of smoking close family members and friends may lead to one's tobacco tasting. However it does not necessarily implicate regular smoking. There are many facilitators of smoking behavior among teenagers. Regular smoking always starts as apparent harmless experiments with tobacco. It can run by the identification or contra-identification way to regular tobacco use. It sustains the von Bertalanffy's thesis of equipotential and equifinal paths of behavior disorders, such us tobacco use.

Prevalence and correlates of smoking among undergraduates in Sri Lanka

Bilesha Perera, Chandramali Jayawardana, Ramani Perera

Department of Community Medicine, Sri Lanka

E-mail: [email protected]

Background: The tobacco industry's strategy is to create a positive image of smoking in educated youth first, and then to diffuse that image among other youth groups. Tobacco prevention programs are simply not available in the university system in Sri Lanka.

Objectives: To investigate prevalence and correlates of smoking in undergraduates in Sri Lanka.

Methods: A cross-sectional survey (n= 1269) was conducted using an anonymous, self-report questionnaire. Knowledge of and attitudes towards smoking were tested using MANOVA.

Results: Men (17.1%) were more likely than women (2.1%) to be yearly smokers ( P<.01). The prevalence of yearly smoking is higher among undergraduates who were from poor income families compared to that of others (10.4% vs. 6.8%, P<.05). The ages between 13 -17 years were found to be the most vulnerable years for this study population to initiate smoking. When the respondents were asked to rate their perceived stress of daily life, 11.2% of smokers compared to only 5.2% of non-smokers reported that their daily life is "very stressful." Even though junior females scored a higher mean value compared to junior males, this gender difference of the mean values of knowledge seem to have diminished when it comes to senior level. Females and senior undergraduates seemed to have healthy attitudes towards smoking compared to their counterparts.

Conclusions: Smoking is a significant health issue in this educated young people in Sri Lanka. Comprehensive tobacco prevention programs targeted at this influential youth population are needed to defeat tobacco company's marketing strategies.

A global youth tobacco study among 8 th , 9 th and 10 th grade students in Myanmar, 2007

Aung Tun, Nyo Nyo Kyaing

Department of Health, School And Youth Health Program, Myanmar

E-mail: [email protected]

Objectives: To describe the prevalence of cigarette and other tobacco use as well as information on five determinants of tobacco use of 8 th , 9 th and 10 th grade students in Myanmar: access/availability and price, environmental tobacco smoke, cessation, media and advertising, and school curriculum.

Methods: A multi-stage, school-based, two-cluster survey (n=3118, 8 th , 9 th and 10 th grade) was conducted in 50 basic education middle and high schools of Myanmar, using a pre-tested modified questionnaire based on the Global Youth Tobacco Survey questionnaire developed by CDC, USA. Myanmar conducted Global Youth Tobacco Surveys in 2001, 2004 and 2007.

Results: Between 2001 and 2007, a significant reduction in the proportion of students currently smoked cigarettes is observed (a fall from overall prevalence among 13-15 year olds of 10.2% to 4.9%) but reported use of other tobacco products had increased during the period from 5.7% to 14.1%. The ability to purchase cigarettes in a store had reduced significantly from 72.9% to 23.7%; percent who have been offered "free "cigarettes by a tobacco company had also reduced significantly from 17.1% to 8.7%. There is no change in percent of students receiving education on dangers of tobacco. The GYTS 2007 has shown that exposure to second-hand smoke still remains high both at home and in public places. Students are still exposed to cigarette advertisement. Enforcement of the national legislation on tobacco control needs to be strengthened, and the National Tobacco Control Program needs to be more comprehensive incorporating measures to reduce smokeless tobacco use and other non-cigarette tobacco products.

Factors associated with youth support of public smoking bans in developing countries worldwide: Results from the global youth tobacco survey

Howard Koh, Christine Judge, Robert Caughey, Charles W. Warren, Greg Connolly

United States of America

E-mail: [email protected]

Background: While public smoking bans are increasing in countries globally, this trend has been limited primarily to the developed world. Understanding youth attitudes toward such policies in developing countries may presage future trends in smoke-free initiatives.

Objectives: To understand factors associated with youth attitudes toward public smoking bans in developing countries.

Methods: We conducted bivariate analyses on combined data from youth aged 13-15 years (2000-2006) who responded to Global Youth Tobacco Survey administration in 114 developing countries. The question "Are you in favor of banning smoking in public places?" was the primary dependent variable. Independent variables pertained to tobacco use, secondhand smoke exposure, tobacco marketing, counter-marketing, knowledge of tobacco harm, and perceptions of smoking.

Results: Overall 77.3% of 352,652 youth favored public smoking bans. Survey responses most strongly associated with support of such policies were: knowledge of secondhand smoke harm (OR 2.49, CI 2.20 - 2.83), knowledge of smoking harm (OR 2.12, CI 1.83 - 2.46), non-smoking status (OR 2.06, CI 1.75 - 2.44), and counter-marketing (OR 2.02, CI 1.80 - 2.27). Responses in other dimensions were less strongly associated.

Conclusions: Youth support of public smoking bans appears to be strongly associated with knowledge and information about harmful effects of tobacco and current smoking status. Further research with multivariate analyses will clarify the relative importance of these and other factors in affecting attitudes toward policy proposals for the future.

  Mobilizing women's leadership to address tobacco use among girls and women Top

Women as workers: How the industry targets organized labor

Edith Balbach, Richard Campbell

Community Health Program, United States of America

E-mail: [email protected]

In the 1980's and 1990's, the U.S. tobacco industry, working through its Labor Management Committee, made substantial donations to the U.S. Coalition of Labor Union Women (CLUW) to secure its support for policies opposing tax increases and smokefree worksite regulations. CLUW's support framed these issues as 'anti-labor' and 'anti-working women,' while the industry was able to hide its role in this effort. Its financial support of CLUW also helped the industry to position itself as a friend of working class women, who have higher smoking rates than the general population. Unions are a trusted channel for reaching this population. This paper will build on this research to illustrate how the tobacco industry tried to implement this strategy on a more global level, using the tobacco documents made available through litigation in the United States. Some unions, such as the Tobacco Workers Union, clearly have a vested interest in supporting the tobacco industry. While their support can help to create a labor framing on industry issues, industry political strategies rely on working through other unions and labor organizations with less obvious connections to the industry. Understanding how coalitions are built with organizations working women trust is key for tobacco control advocates trying to reduce smoking prevalence among women and creating tobacco control programs and policies that will protect the health of working women.

Promoting tobacco control leadership among the women of civil society

Mira Aghi, Priyanka Dahiya

Advocacy Forum for Tobacco Control, India

E-mail: [email protected]

Promoting Tobacco Control Leadership among the Women of Civil Society For much too long, the tobacco industry has sold tobacco to women by exploiting their need for liberty, pleasure, and independence. The end result has been to the contrary-women have developed dependence and low self-image, in addition to facing disease and death. With the launch of health and well-being oriented policies in many countries including India, the time seems ripe now to undo this damage. These policies should also encourage women to assume leadership roles influencing young girls to develop life skills which will assist them to make healthy decisions and to negotiate with society for what is in their best interests. Staying away from tobacco is seen central to this leadership. Women who were typically seen as home-makers are collaborating with women who might be scientists, social workers, teachers, lawyers, nurses, and doctors to take on the responsibilities of their localities, neighborhoods, and districts and are beginning to assume roles of educating, mobilizing, and empowering young women like themselves to be more self aware, critical of consumerism, and analytical of promotions. Strategies of skill-development based on the needs of different women groups will be devised by a tested methodology of building it from the bottom up, by keeping all the constraints in mind, and by harnessing the resources in terms of time, talent, and varied expertise. The likely outcome will be the transformation of neighborhoods by empowered youth groups.

Inwat 1

Lorraine Greaves

International Network of Women Against Tobacco, Canada

E-mail: [email protected]

This session will focus on the challenges and opportunities for developing women's leadership in tobacco control. The key challenge facing INWAT and other organizations interested in improving women's health and women's status is to ensure that tobacco control activities include and mentor women leaders, work effectively with women's organizations, and seek to transform the status of women and girls in the context of reducing and preventing tobacco use by girls and women across the world. These goals are shared by INWAT and the World Health Organization. This session will feature presentations from across the globe, describe the gender-related issues in tobacco policy and the FCTC, highlight specific issues and challenges in working with women's labour groups, women's health organizations, governments, the tobacco control movement and civil society.

Promoting INWAT at the regional level

Mary Elizabeth Tamang, Francesca Russo, Annarosa Pettenς

Regione Veneto, Direzione Prevenzione, Italy

E-mail: [email protected]

Background: The International Network of Women Against Tobacco (INWAT) was founded in 1990 by women tobacco control leaders to address the complex issues of tobacco use among women and young girls. In 1997 representatives of 5 European countries got together to start the European Regional branch of INWAT.

Objectives: To create INWAT Europe to help raise awareness of women΄s tobacco use as a major problem throughout Europe and to urge the development of gender sensitivity in research and smoking programmes and of women-specific programmes and strategies.

Methods: Creation of a European INWAT Advisory Board. Participation in EU projects. Project development. Participation and organisation of sessions on women and tobacco in important European and World conferences. Networking.

Results: INWAT Europe has worked with the European Network on Smoking Prevention in developing and carrying out projects like on gender sensitive policy and research and the low income women. It has participated in Global INWAT and the World Conference on Tobacco or Health. In March 2005 in Barcelona and March 2008 in Stockholm INWAT-Europe held an expert seminar on women and second-hand smoke. INWAT Europe has worked to increase the numbers and support the work of women tobacco control leaders.

Conclusions: INWAT Europe is an example of how a handful of dedicated persons can create and sustain a network with almost no budget, and bring about changes in their region. Our future priority lies in supporting the development of women specific programmes and policies and in combating the tobacco epidemic among women.

Challenges in women smoking in central and eastern Europe

Magdalena Cedzynska, Krzysztof Przewozniak

Cancer Centre And Institute of Oncology, Poland

E-mail: [email protected]

Background: Epidemiological estimates show that annually about 169/100,000 population adult women from ten new EU members from Central and Eastern Europe (CEE) die from smoking-related diseases, including 78/100,000 who die prematurely (35-64 years). In contrast to men from CEE countries and women from some Western European countries, e.g. United Kingdom, female smoking-attributable mortality has been increasing in CEE region.

Objectives: To define challenges in women smoking patterns and trends in CEE countries.

Methods: Review of results from 1) the nation-wide surveys and census studies on smoking patterns conducted in adults (aged 20-64) in 27 EU countries and Russia (2002 and neighboring years), 2) national surveys on smoking trends in adults (15+) in selected CEE countries, 3) surveys of schoolchildren conducted in CEE countries within the GYTS and HBSC.

Results: In CEE region, there are some countries with very low women smoking rates (i.e. Lithuania - 13%) as compared with the EU average (27%) and another CEE countries with one of the highest rates in Europe (i.e. Bulgaria - 32%). Smoking prevalence in women in CEE region still increases or remains stable since the past two decades. Although smoking prevalence has fallen in some countries in the young high-educated women, this decline was lastly frozen. It is presumably due to rapid increase in smoking rates among girls caused by tobacco advertising addressed to women.

Conclusions: Changes in women smoking require a new tobacco control strategy that should more focus on girls, young adult and pregnant women, and their families.

Women and secondhand smoke in Europe

Amanda Amos, Sara Sanchez, Mariann Skar, Patti White

University of Edinburgh, United Kingdom

E-mail: [email protected]

Background: There are considerable differences in women's and men's domestic and occupational lives across Europe. Thus there are likely to be important gender differences in both exposure to second-hand smoke (SHS) in public and private places, and consequent health impacts. However, little attention has been given to this issue.

Objectives: To undertake a gender-based review of the evidence on SHS, including health effects, place and levels of exposure and the impact of interventions such as smoke-free legislation, in order to inform and progress effective gender-sensitive action on this issue in Europe.

Methods: Literature review, interviews with key informants from a range of countries in Europe, an INWAT-Europe expert seminar.

Results: Limited sex or gender disaggregated data are available on SHS in Europe. However, it is clear from available data that: SHS impacts on women's health, many women are still exposed to SHS in public places (including work) and in the home, and this varies considerably between countries. European women on average spend more time at home than men. Thus the home is a particularly important both for women's exposure to SHS and for women as a source of SHS exposure for children. Many women, particularly those living in disadvantaged circumstances, face barriers and challenges in trying to protect their children from SHS exposure in the home.

Conclusions: Recommendations are made for gender-based action at European, national and local levels. These include policy makers, health professionals, non-governmental organizations and research funding bodies.

Does the partial advertising ban have an impact on marketing strategies addressed to woman? A pre- and post-ban analysis

Martina Pφtschke-Langer, Nick Kai Schneider, Jessica Schόtz

German Cancer Research Center, Germany

E-mail: [email protected]

Background: Germany lacks behind on a complete ban on tobacco advertising, marketing and sponsoring. Thanks to an European Directive and after a clear decision of the European Court of Justice, Germany had to follow other European countries to implement at least a partial tobacco advertising ban in 2007.

Objective: From international observations it is widely accepted that only a complete advertising ban is effective. All previous partial bans didn΄t work because they offered tobacco industry the opportunity and means to shift focus to media not covered by the ban. Until now, there is no gender sensitive analysis on the consequences of advertising bans regarding print media addressed to women and men.

Methods: Based on qualitative methods developed at the University of California, San Francisco, and adapted to the German circumstances, key women magazines, lifestyle and young adults magazines published between 2005 and 2008 are analysis based on international evaluation standards. The study is being performed in 2008 and data will be available by early 2009.

Results: This pilot project will test the feasibility of the methodology and present first results on the pre' and postban marketing practices targetting women in Germany. Although the results are not predictable, a potential shift from direct advertising to indirect marketing might be unveiled.

Conclusions: There is hope that the study will generate the data needed to convince policy makers to introduce a comprehensive advertising ban, including sponsoring and indirect marketing.

  Capacity building and providing cessation interventions I Top

Promoting smoking cessation counseling practices among thai professional nurses

Sunida Preechawong, Krongjit Vathesatogkokit, Sangduean Suwanratsamee

Faculty of Nursing, Chulalongkorn University, Thailand

E-mail: [email protected]

Background: Throughout the world, since nurses work in a multitude of clinical settings, they have numerous opportunities to enhance their involvement in tobacco control. Empirical evidence has shown that smoking cessation advice provided by nurses significantly increases the abstinence rates. However, the involvement in tobacco cessation counseling of Thai nurses is limited due to several barriers, including lack of counseling skills and inadequate knowledge.

Purpose: This study examines the effectiveness of a self-efficacy intervention on Thai nurses' self-efficacy and smoking cessation counseling practices.

Methods: To implement the training intervention, the one-group pre-posttest quasi-experimental design was used. Ninety professional nurses were randomly recruited from three hospitals that involved in smoke-free hospital campaign. With the context of Bandura's self-efficacy theory, the participant nurses had five-hour training based on the 5A's for smoking cessation counseling program. Self-efficacy for tobacco cessation counseling and cessation-counseling practices were assessed at baseline, 3 and 6 months after training and were analyzed with repeated measures analysis of variance.

Results: The findings showed that the mean score of self-efficacy for tobacco cessation counseling was about the same from baseline to after 3 months of intervention ( P<.05), but significantly increased at 6 months. Moreover, the mean score of cessation-counseling practice significantly increased over time ( P<.05).

Conclusions: The findings suggest that a theory-based training in smoking cessation counseling can significantly increase nurses' confidence and provision of counseling. Future research should evaluate the long-term impact of such intervention on counseling behavior and patient outcomes.

Nurses' contrasting approaches in discussing smoking cessation with pregnant women

Katherine Murphy, Jeske Paijmans, Krisela Steyn

Medical Research Council, South Africa, South Africa

E-mail: [email protected]

Background: While 20% of South Africa women continue to smoke in pregnancy, the rate increases to 47% for a subgroup of disadvantaged women. Nurses are seen as a particularly appropriate group for the delivery of smoking cessation programmes as they generally regard health education as an important aspect of their work and spend more time with patients.

Objectives: This study aimed to investigate the extent to which nurses in public sector antenatal clinics are addressing this issue, as well as their approach to smoking cessation counselling and the responses of pregnant smokers.

Methods: This study used semi-structured, individual interviews with 34 nurses working in public sector antenatal clinics in five major,urban centres. Themes and categories were generated from the data using content analysis. Findings Despite a conviction that smoking in pregnancy was an important health problem, nurses did little to promote or support cessation. The prevailing approach was one of direct persuasion where the nurse assumed a dominant, advice-giving role. This often elicited a negative response from women, which left the nurses feeling frustrated and pessimistic that they could influence women's health behaviour. A minority of nurses adopted a more patient-centred approach. These nurses reported more positive attitudes towards cessation counselling and more confidence in their role as health educators.

Conclusion: If nurses are to play a constructive role in smoking cessation they need training in best practice smoking cessation methods and patient centred communication skills.

Investigating nurses' involvement in addressing patients' tobacco use

Annette Schultz, Shahadut Hossain, Joy Johnson

Psychosocial Onocology And Cancer Nursing Research Group, Canada

E-mail: [email protected]

Addressing patients' tobacco use ought to be a standard practice for nurses. Meta-analysis studies suggest brief interventions provided by nurses influence patients' decisions to stop smoking. While nurses believe there is an expectation that they address patients' tobacco use, there is a difference between what nurses' report ought to be and what is occurring in practice. Missed opportunities to address tobacco use are the reported practice norm. We lack an understanding of the factors that affect nurses' uptake of tobacco reduction activities. An organizational behavior perspective informed the development of a model that hypothesized relationships amongst plausible factors (individual characteristics, role attitudes, perceived barriers, and workplace climate) affecting nurses' engagement in tobacco reduction activities. The hypothesized model was tested using survey data collected as part of a larger mixed-methods study conducted at two Western Canadian hospitals (N= 214 nurses; 58% response). Structural equation modeling using the MPlus statistical program was used to test the proposed model. Nearly 60% of variation in the nurses' tobacco reduction practice was explained by the final model. The findings suggest role attitude, perceived resource availability, perceived co-worker's activities in addressing patients' tobacco use and perceived ability were important influencers effecting practice variation. Nurses' smoking status appears to indirectly influence practice through shaping role attitudes and perceived ability to address patients' tobacco use. Perceived availability of time and administrative expectations were not significant predictors of nurses' engagement in patients' tobacco use. In conclusion, diverse leverage points to enhance nurses' involvement in patients' tobacco use are identified.

Jordanian nurses and physicians learning needs for promoting smoking cessation

Kawkab Shishani, Erika Froelicher

Hashemite University, Canada

E-mail: [email protected]

Smoking has in addition to all other health problems devastating effects on the cardiovascular system in terms of myocardial Infarction, stroke, and peripheral vascular disease.

Objectives: The objectives were to estimate the: 1) frequency of smoking in nurses and physicians; 2) differences in frequency of smoking by gender; and 3) Jordanian nurses and physicians learning needs for smoking cessation counseling.

Methods: The design utilized was descriptive. Five hospitals were randomly selected, 261 nurses (65.3%) and physicians (34.7%) participated in this study from hospitals with a response rate of 65%.

Results: Prevalence of smoking among nurses and physicians was 41.5% (n=66) and 43.6% (n=38) respectively. A significant relationship was found between gender and smoking status OR= 5.45, (CI= 2.52, 11.74, P= 0.00). Considerable knowledge deficit exists among Jordanian nurses and physicians. Many health professionals did not recognize the addictive aspect of tobacco smoking, nor did they receive any formal training in smoking cessation approaches to use with patients. The encouraging finding was the recognition of the majority of nurses and physicians that University curricula must include information about smoking cessation.

Italian national programme of midwifes' counselling "SMOKE FREE MOMS"

Luca Sbrogiς, Elizabeth Tamang, Maria Teresa Villanova, Federica Michieletto

Az. ULSS9 Treviso, Canada

E-mail: [email protected]

Background: In Italy, one child over two has at least one parent who smokes, 70% of female smokers quit smoking during pregnancy; about 70% relapse after delivery; 20% of young female are smokers even at the beginning of pregnancy. In order to prevent ETS exposition of children, the Ministry of Health, the Italian League Against Cancer and the National Federation of the College of Midwives started "Smoke-free moms".

Objectives: The objective is favouring the intervention of midwives to support pregnant women to quit smoking and to follow them and their partners in the puerperal period in order to help those who quit remaining abstinent.

Methods: The national programme provides training to midwives in anti-tobacco counselling techniques, such as motivational cessation and follow-up, particularly during pregnancy and puerperium. The programme consists in tailored training, professional support, monitoring and effectiveness evaluation.

Results: A follow-up at two years after delivery conducted on 600 women in 2005-2007 proved that women and partners who received anti-smoking counselling have better percentage of abstinence compared to a control group.

Conclusion: The programme is well accepted by midwives and patients, feasible and sustainable. Brief counselling by midwives is possible in all settings, especially in out-hospital premises.

Developing nurses for a smokefree aoteaora/New Zealand: Results of a needs assessment and national survey of nurses' smoking history, knowledge and attitudes

Grace Wong, Hayden McRobbie, Faith Reed

Auckland University of Technology, Canada

E-mail: [email protected]

Background: Nurses play a key role in advising people to quit smoking and providing smoking cessation treatment. Smokefree nurse action groups promoting nurse involvement in tobacco control and supporting nurse led smoking cessation interventions exist in other countries. A similar group developed in the 1990s in Aotearoa/New Zealand is no longer active. We designed a needs assessment including a national survey of nurses' smoking history, knowledge and attitudes, prior to re-activating the New Zealand smokefree nurse action group.

Objectives: To evaluate the need for a New Zealand smokefree nurse action group

Methods: 1,000 nurses registered with the New Zealand Nursing Council were randomly selected and invited to complete an anonymous paper questionnaire assessing smoking history, attitudes, knowledge of the health risks of smoking and benefits of quitting, and knowledge of evidence based cessation interventions. Key informant interviews of key nurse and tobacco control workforce members, and a survey of practising nurses about the need for a smokefree nurse action group.

Results: Ninety percent of nurses felt it part of their responsibility to advise clients to stop smoking but over half of the respondents had not received training for effective evidence-based smoking cessation interventions. There was a wide misunderstanding that nicotine causes disease which may limit nurses' ability to intervene effectively. There was an excellent level of support for a smokefree nurse action group.

Conclusions: Barriers preventing effective smoking cessation interventions by nurses should be addressed. A nurse action group will contribute to removing these barriers.

Helping smokers quit: Evaluating a distance learning education program for nurses

Linda Sarna, Stella Bialous, Marjorie Wells

UCLA School of Nursing, Canada

E-mail: [email protected]

Background: Recommendations of the US Public Health Service Treating Tobacco Dependence Guideline are underutilized in clinical practice. Strategies are needed to ensure that clinicians provide evidence-based interventions.

Objectives: To assess the feasibility and effectiveness of Helping Smokers Quit (HSQ), a web-based educational program tailored for nurses, a toolkit of materials, web-resources, and support for nursing directors in improving self-reported nursing performance on smoking cessation interventions with hospitalized patients; to determine the maintenance of changes in performance (12-m post-intervention) and in hospital practices (24-m post-intervention) in intervention vs. control hospitals; and to determine the variables related to effectiveness.

Methods: An intervention-control (toolkit only), two-group, pre-post design, based upon the RE-AIM model, with 600 nurses in 30 hospitals in 3 states (15 intervention and 15 control hospitals). Webcast delivery of the RX for Change© curriculum. Data on nursing performance in smoking cessation will be collected pre/post intervention. Content analysis of types of assistance will assist in assessing feasibility. Regression models will evaluate effectiveness of HSQ, adoption/ maintenance of changes in nursing performance; multiple linear regressions will examine correlates of nurse performance.

Results: Initial findings of the project including sample characteristics and delivery of the intervention, and 6 months post intervention results will be presented.

Conclusions: This paper will share interim information about the effectiveness of a distance learning intervention to support the adoption of the Guideline into clinical practice as well as issues and barriers affecting implementation. Other opportunities for enhancing nursing involvement in cessation interventions will be discussed.

  Fctc Top

Analysis of print media coverage in regard to the FCTC in Argentina

Gabriela Alejandra Regueira, Carolina Perez, Veronica Sandler,

Cynthia Vilaplana

International Network of Women Against Tobacco, Argentina

E-mail: [email protected]

Background: The Argentinean President signed the FCTC in 2003. There was an intention of Congress to ratify it in 2005, but this did not happen due to the staunch opposition of the senators from the tobacco-growing provinces. Print media coverage of tobacco control is a tool deemed significant for the ratification of the FCTC. The manner in which the media takes a stand on a certain issue gives it priority on the public agenda and also helps define the way in which the public thinks about the issue.

Objectives: To analyze print media coverage of the FCTC by gathering information in the electronic and printed editions of ten local newspapers all over Argentina from 2003 to 2005.

Methods: Content analysis of newspaper articles.

Results: We obtain 1,327 articles on tobacco issues, 8.2% of them were focused on FCTC. The major number of articles reporting on FCTC were published in the provinces that produce tobacco (49.5%), compared with Buenos Aires city (30.3%) and the provinces that not produce tobacco. Coverage was also more frequent in 2005 (62.3%) than 2003 (37.7%). The most frequent type of article was news articles (83.5%). Most events covered were positive (55%) and negative (42.2%) for tobacco control. The point of view of opinion pieces was mainly positive (77.8%).

Conclusions: The information compiled will be useful for non-governmental organizations, social communicators and individuals in decision-making positions, in order to design a strategic communication plan that will pressure government levels, thereby accelerating the ratification process of the FCTC.

The FCTC: A catalyst for change in Mauritius

Deowan Mohee, Vassen Pauvaday

Ministry of health and quality of life, Mauritius

E-mail: [email protected]

Introduction: Tobacco use is a major public health problem in Mauritius. 35.5% of adult males and 15.0% of school youth are current smokers. 31.0% of school youth have ever tried smoking. The FCTC and Mauritius: The FCTC served as a catalyst for re-engineering the tobacco control program in Mauritius. It triggered the development of a 5-year National Action Plan on Tobacco Control and a new tobacco legislation. National Action Plan: It aims to prevent tobacco use, support quitting and promote a tobacco smoke-free environment. The major areas of tobacco control are addressed and strategies like multi-sectoral partnership, targeted interventions and social marketing are used. It advocates earmarking of taxes on tobacco for health promotion. The Action Plan has been appraised by the WHO and is serving as a model for some African countries. FCTC-compliant legislation: The new legislation required a wide consultative process. It is bringing sweeping changes to the tobacco landscape in Mauritius with eight rotating graphic warnings, control of second-hand smoke and sale to minors and complete ban on advertising, promotion and sponsorship. Mauritius is among the first countries in Africa to have an FCTC-compliant legislation.

Conclusion: The FCTC has set the stage for a comprehensive tobacco control program in Mauritius. Legislative, fiscal and organizational changes and political will are creating the supportive environment for reducing tobacco use and mitigating its impact on society.

Evaluation of public knowledge about Framework convention on tobacco control in Tehran during 2006

Hooman Sharifi, Gholamreza Heydari, Babak Sharif,

Kashani Zahra Hessami

Tobacco Prevention And Control Research Center, Iran(Islamic Republic of)

E-mail: [email protected]

Introduction: Framework Convention on Tobacco Control (FCTC) is the first legal mean in the world which is designed for promoting public health via a comprehensive campaign against tobacco smoking. This study has been done to evaluate the public knowledge about FCTC in Tehran the capital of Iran.

Material and Methods: A cross-sectional study has been done in the main public squares of Tehran during 2006-2007. It has been established via non-probability sampling by giving questionnaires which where designed and adapted according to WHO and IUATLD questionnaires. Totally 2053 persons were entered into the project.

Result: 47.2% of population had the experience of cigarette smoking (55.5% of males and 28.8% of females). Daily cigarette smoking prevalence was 22.7% (29.7% of males and 7% of females) ( P<0.001). 184 persons (9%) of participants had some information about FCTC, among which 35 persons (19%) or 1.7% of all participants completely knew some details of FCTC. The knowledge about FCTC among graduated people with a diploma or lower than that were 5.1%, among people with bachelor degree of science was 14.9% and among people with a higher degree than BA, was 33.3% ( P<0.001)

Conclusion: Smoking prevalence in this study is somehow more than similar studies. The public knowledge about FCTC is increasing by higher educational degree and this increasing is significant. The results show that the public knowledge about FCTC is very narrow and there is a clear need for implementing public information programs on FCTC.

Assessing the performance of the FCTC conference of the parties in promoting effective FCTC implementation

Jonathan Liberman, Madeleine Heyward

Framework Convention Alliance for Tobacco Control, Australia

E-mail: [email protected]

Background: The FCTC represents a remarkable achievement in global public health. Since entering into force in February 2005, it has already had an enormous impact. The FCTC describes itself as 'providing a framework for tobacco control measures'. As a 'framework convention', some elements of the FCTC are relatively generally expressed in the treaty itself, with the detail to be filled in through the development of guidelines on implementation and adoption of protocols by the Conference of the Parties (COP). The work of the COP is critical to effective implementation.

Objectives: To evaluate the action taken by the FCTC COP at its first three sessions, identifying successes, failures, challenges and lessons for its future work.

Methods: Examine the decisions taken at the first three sessions of the COP and evaluate their contribution to effective FCTC implementation.

Results: The first two sessions of the COP were successful. At its second session in June-July 2007, the COP adopted strong implementation guidelines on Article 8 (protection against secondhand smoke), decided to commence negotiation of a protocol on illicit trade, and to develop implementation guidelines on key FCTC Articles, including Articles 5.3 (tobacco industry interference), 11 (packaging and labelling) and 13 (tobacco advertising, promotion and sponsorship). The success of the third session of the COP, to be held in November 2008, will also be assessed.

Conclusions: To be identified after the third session of the COP.

Why securing article 5.3 is essential to effective FCTC implementation

Kathryn Mulvey

Corporate Accountability International, United States of America

E-mail: [email protected]

Background: There is powerful consensus among health advocates and public officials around the world that the tobacco industry should have no influence on public health policies. The World Health Organization Framework Convention on Tobacco Control (WHO FCTC), in Article 5.3, enshrines this concept in international law. However, Big Tobacco's interference in health policy remains one of the greatest threats to the treaty's implementation and enforcement.

Objectives: 1. Strengthen participants' understanding of tobacco industry tactics to subvert health policy, guidelines for implementation of FCTC Article 5.3, and the role of civil society in securing the treaty. 2. Discuss and develop strategies for advancing national laws and regulations based on Article 5.3 guidelines to prevent tobacco industry interference.

Methods: Share case studies of how Philip Morris International (PMI), British American Tobacco (BAT) and Japan Tobacco (JT) use their political and economic influence to weaken, delay and defeat tobacco control legislation around the world. Relate these case studies to participants' experiences at the national level and to FCTC Article 5.3 guidelines.

Results: Build capacity of participants to overcome tobacco industry interference and to advocate for strong laws and policies based on the FCTC. Ensuring implementation of Article 5.3 will facilitate other measures such as comprehensive bans on tobacco advertising, promotion and sponsorship, protection from exposure to tobacco smoke and effective warning labels

Conclusions: The integrity of the FCTC and the effectiveness of national tobacco control policies based on it hinge upon the measures taken at the national level to implement Article 5.3.

Evaluating the framework convention on tobacco control: Recent findings from the international tobacco control policy evaluation project (the ITC Project)

Geoffrey Fong, Michael Cummings, Ron Borland, Mary Thompson

University of Waterloo, Department of Psychology, Canada

E-mail: [email protected]

The Framework Convention on Tobacco Control (FCTC) holds great potential in reducing the threat of tobacco use throughout the world. But fulfilling the potential will depend on whether the policies actually implemented in the name of the FCTC are effective. There is thus an urgent need for evidence to support strong implementation of the FCTC, and evidence from rigorous evaluation of ongoing implementation of FCTC policies will help meet this need. The International Tobacco Control Policy Evaluation Project (the ITC Project) was created to conduct rigorous evaluation of FCTC policies-the only research effort that focuses on FCTC evaluation. To date, 15 countries, inhabited by over half of the world's smokers, are participating in the ITC Project: Canada, United States, United Kingdom, Australia, Ireland, Thailand, Malaysia, South Korea, China, New Zealand, Mexico, Uruguay, France, Germany, Netherlands, with ITC Surveys being developed in Bangladesh, Sudan, and India. In each country, prospective cohort surveys are being conducted among adult smokers, taking advantage of natural experiments created by some countries implementing FCTC policies. The ITC Survey questions are designed to be identical or functionally equivalent across countries, thus providing strong potential for cross-country comparisons. The survey includes measures of smoking behavior, psychosocial predictors of smoking/quitting, and multiple questions on the impact of each FCTC policy domain (e.g., warning labels, advertising/promotion, price/taxation, smoke-free). This presentation will describe the underlying model of the ITC Project and will present recent findings, focusing especially on findings in low- and middle-income countries.

A global SHS research program: Helping countries to comply with the framework convention on tobacco control

Andrew Hyland, Mark Travers, Cheryl Higbee, Michael Cummings

Roswell Park Cancer Institute, United States of America

E-mail: [email protected]

Goal: The foster a global secondhand smoke research network to fill important gaps relevant to decision makers as they consider implementing Article 8 of the FCTC.

Methods: A group of international SHS research experts helped identify the following questions as international priorities: 1) What is the relative contribution of SHS to indoor air pollution versus other sources of pollution?; 2) How knowledgeable are people about the dangers of SHS in different regions of the world?; and 3) What are the economic effects, if any, of smokefree regulations in developing or non-Western countries? Partnerships were developed to conduct studies in these areas in various regions of the world.

Results: Air quality studies in 32 countries shows pollution levels to be 10-fold greater in places where smoking is allowed compared to places that have 100% comprehensive smokefree policies. Surveys in Scotland and Ireland show that support for smokefree policies increased after they were implemented, and attitudinal data from 7 cities in China indicates moderate to high levels of support (>75%) for smokefree policies in many public venues. Economic studies are now underway in Uruguay, Argentina, Mexico City, and Beijing to assess how economic indicators may or may not have changed after smokefree policies were/are implemented in these jurisdictions.

Conclusions: The FCTC has spurred a considerable need for research and talented SHS research partners internationally. This research is helping to inform SHS policy debates as countries move toward complying with Article 8 of the FCTC.

  Health effects, screening, and biomarkers Top

Tobacco smoking and MRSA: The crossroad of epidemics

Sergejs Kuznecovs, Galina Kuznecova, Ivans Kuznecovs, Klara Jegina

Preventive Medicine Research Society, Latvia

E-mail: [email protected]

Objectives: Smoking tobacco is known to suppress the immune system and disturbe normal nasal flora. Hypothetically tobacco smoking could be associated with methicillin-resistant Staphylococcus aureus (MRSA) formation in the upper respiratory tract. The aim of the present investigation was to detect the amount of MRSA carriers among tobacco smokers.

Methods: Nasopharyngeal swabs MRSA and nasal tissue samples were taken from 2568 smokers and 3000 non-smokers enrolled for long-term study from 1998 through 2008. Person's smoking behaviour, age, gender, morbidity and use of antibiotics was recorded.

Results: MRSA nasal carriage was found in 1% of non-smokers (30/3000) and in 4% of tobacco smokers (103/2568) in 1998, in 1,5% of non- smokers and in 6% of smokers in 2000, 1,7% and 8,4% in 2001, 1,7% and 9,2% in 2002, 1,5% and 9% in 2003, and 1,2% and 10% patients in 2004. Male smokers ages 50-65 years ( P<0.001), antibiotic use ( P < 0.02), rate of hospitalization ( P = 0.005), and specific local IgE level ( P < 0.001) were significantly associated with MRSA colonization.

Conclusion: The nasal carriage of MRSA among tobacco smokers is high, undetectable, and growing. It is possible that tobacco smoking maybe the cause of nasal carriage of MRSA. From other risk factors for MRSA nasal carriage including antibiotics, rate of hospitalization, contact with health-care workers, previous MRSA infection, older age, diabetes and obesity, smoking is most significant because of its effect on immune system and contagious. There is a crossroad of smoking and MRSA epidemics and this trend is worrisome.

Smoking, cardiovascular stress-reactivity and sex differences in hypertension

Oxana Semyachkina-Glushkovskaya

Saratov State University, Russian Federation

E-mail: [email protected]

The associations between smoking, cardiovascular responses to mental arithmetic stress and hypertension were examined in 520 men and 495 women aged 30 to 40 years. During 2 years, 297 cases of essential hypertension among men and 103 cases among women were identified. Hypertension incidence was 2.8 times higher among men. The incidence was increased sixfold in women and threefold in men who smoked at least 20 cigarettes per day compared with never-smokers, and the rate in female heavy smokers exceeded that of never-smoking men. The cardiovascular stress-reactivity was greater in smoker group vs. never smoker group (healthy subjects). So, tachycardic and pressure effects of stress were less pronounved in never-smoker group than in smoker group. During stress the total peripheral resistance was increased in smoker group and was decreased in never-smoker group. The recovery of hemodynamic parameters was more prolonged in smoker group vs. never-smoker group. Notice, that women compared with men demonstrated greater cardiovascular stress-reactivity in smoker group and less cardiovascular stress-reactivity in never-smoker group. Moreover, stress-induced pressure and tachycardic responses lasted longer in women vs. men also in smoker group than butn't in never-smoker group. Thus, in never-smoker group but not in smoker group women compared with men demonstrated more favorable pattern of cardiovascular stress-responses. Summary, our rerults suggest that smoking was a stronger risk factor for essential hypertension in middle-aged women than in men. Relative risks associated with high cardiovascular stress-reactivity despite large sex differences in hypertension incidence rates.

Esophageal cancer: Quantification of risk factors from a large cohort study

Min Kuang Tsai, Chi Pang Wen, Yen Chen Chang, Chiu Wen Cheng

National Health Research Institutes, China

E-mail: [email protected]

Objectives: Contribution of known risk factors: betel quid chewing (B), cigarette smoking (C), and alcohol drinking (A) to esophageal cancer is examined by comparing relative risks and prevalence.

Methods: The cohort consisted of 177,271 male subjects who participated in medical screening program since 1994.

Results: The number of deaths from esophageal cancer nearly tripled and age-adjusted rate increased by 37% among males during 1986-2006. The cancer risk significantly increased for those having the lifestyle in consuming alcohol (A), betel quid (B), cigarette (C), or in any combination, when compared with those with none of the three risks. The size of the risk magnified when they interacted with each other: Only A (RR=12.63), only C (3.17), A+C (26.68), B+C (7.87), or A+B+C (52.10). Subjects with all three risks, amounting to 4.9% of the cohort, had the cancer risk increased by as many as 52 times. Any combination with smoking habit had synergy in raising the risks, 7.87 with chewing or 26.68 with drinking. Smoking, acting as a solo risk or coexisted with others, had the most impact on esophageal cancer, with its large RR, 9.99 for all smokers, and with its high prevalence, involving more than half the cohort (52.2%).

Conclusion: Each of the three risk factors, smoking, chewing and drinking, contributed substantially to the recent increase in esophageal cancer in Taiwan. Smoking, being most prevalent, and chewing, having the largest increase in its consumption, acted together and contributed substantially to the current epidemic of esophageal cancer, and accounted for the large gender difference.

The long-term effects of participating in a lung cancer screening trial on smoking cessation

Carlijn Van Der Aalst, Karien Van den Bergh, Rob Van Klaveren,

Harry De Koning

Department of Public Health, ErasmusMC - University Medical Centre, Netherlands

E-mail: [email protected]

Background: Smoking cessation will lead to a substantial reduction of the burden of tobacco related diseases. Few preceding studies addressed smoking cessation in a lung cancer screening trial, but based on these scare data, screening positively affects smoking behaviour. The Dutch Belgian lung cancer screening trial (NELSON) provides an unique opportunity to determine the effect of lung cancer screening on smoking cessation while comparing the high risk participants in the screen and control group.

Objectives: The aim of this study is to investigate the long-term effects of participating in a lung cancer screening trial on smoking cessation. Additionally, the factors that are associated with smoking cessation will be determined.

Methods: Data were taken from the NELSON study that examines the effectiveness of CT-scanning on lung cancer mortality among 50-74 years old individuals (n=15,882) at high risk for developing lung cancer. Data about smoking cessation will be compared between a sample of the smokers within the screen arm (n= 942) and control arm (n=518) who received a questionnaire that address issues about smoking, smoking cessation and the determinants. The questionnaire was sent after 1.5 year of follow-up.

Results: The hypothesis is that lung cancer screening positively affect the factors that are positively associated with smoking cessation. Moreover, the expectation is that lung cancer screening increases long-term smoking abstinence. The first results will be available in autumn of 2008.

Epidemiological association of exclusive and dual tobacco products' use with tuberculosis in South Africa

Lekan Ayo-Yusuf, Greg Connolly, Scott Tomar, Carrie Carpenter

University of Pretoria, South Africa

E-mail: [email protected]

Background: Both tobacco use and tuberculosis (TB) are significant public health problems in South Africa. Smokeless tobacco (SLT), commonly used by nasal application, is used predominantly by black South Africans. This study therefore sought to determine the influence of exclusive smoking or SLT use and combined smoking and SLT use on the prevalence of TB.

Methods: This study involved secondary data analysis of a cross-sectional, nationally representative sample of black Africans in 15 years (n = 6067) that participated in the 2003/2004 South African Demographic and Health Survey. Data analysis methods included the use of chi-square statistics and multiple logistic regression analysis. Outcome measure: tuberculosis, defined as self-reporting a past diagnosis of TB by a doctor or nurse and/or reporting current use of TB medication.

Results: Of the respondents, 2.8% (n=169) had a history of TB. Current or past exclusive ST use, exclusive smoking and concurrent use of both products were reported at 8.8%, 19% and 1.3% respectively. Compared to never tobacco users, ever SLT users (OR=2.38; 95%CI=1.12-5.04), ever smokers (3.09; 1.81-5.22) and those who had ever combined smoking and SLT use (5.11; 1.58-16.55) were significantly more likely to report a history TB. Compared to those never exposed to second-hand smoke (SHS), those with a lifetime history of exposure to SHS were also more likely to present with TB (2.08; 1.27-3.43).

Conclusions: This study's findings challenge the use of any harm reduction strategy that seeks to promote SLT as a much safer alternative to smoking among the studied population.

New links found between smoking and colorectal cancer among Norwegian women

Inger Torhild Gram, Tonje Braaten, Eiliv Lund, Loic/Elisabete Le Marchand/Weiderpass, Elisabete Weiderpass

University of Tromsψ, Norway

E-mail: [email protected]

Background: The relationship between cigarette smoking and colorectal cancer is not established.

Objectives: Given the dramatic rise of this disease in Norway, we examined the association between smoking and colorectal cancer and calculated how many colorectal cancers could have been avoided if Norwegian women did not smoke.

Methods: We followed 68,160 women, aged 30-69 years, from the Norwegian Women and Cancer Study who completed a questionnaire in 1996 or 1998 with linkages to national registers through December 31, 2005. We used Cox proportional hazard regression models to estimate relative risks (RRs) of colorectal cancer with 95% confidence intervals (CIs) associated with different measures of smoking exposures adjusting for potential confounding factors. Altogether, 425 [284 (67%) colon and 141 (33%) rectal] incident cases of primary, invasive colorectal cancer were identified.

Results: The age-adjusted incidence rates of colorectal cancer were 83 and 65 per 100,000 woman-years among ever (current and former) versus never smokers, respectively. Ever smokers had a 20% increased risk of colorectal cancer [RR=1.2 (95% CI 1.0 - 1.5)], a 30% increased risk of colon cancer [RR=1.3 (95% CI 1.0 - 1.7)], and a non-significantly increased risk of rectal [RR=1.1 (95% CI 0.7 - 1.5)] cancer, compared with never smokers. Furthermore, at a population level approximately 13.5% (n=239) of the 1,767 colorectal cancers diagnosed among Norwegian women in 2006 may have been prevented if women had not smoked.

Conclusion: Our results support the notion that cigarette smoking may be a preventable cause of colorectal cancer.

  Health impact of public smoking bans Top

Italy & Austria before and after study: Second-hand smoke exposure in hospitality premises before and after two years from the introduction of the Italian smoking ban

Giuseppe Gorini, Hanns Moshammer, Maria Jose Lopez,

Antonio Gasparrini

Institute of Research and Prenvention of Cancer (ISPO), Italy

E-mail: [email protected]

To compare second-hand smoke (SHS) exposure in hospitality premises (HPs) in Italy and in Austria before and after two years from the introduction of the Italian smoking ban (January 10, 2005). Nineteen Austrian (Vienna) and 28 Italian (Florence, Belluno) HPs were sampled before and after two years from the Italian ban. Post-ban samples were also collected in 27 HPs in Turin, Milan, Naples. The SHS marker was vapour-phase nicotine, measured using passive samplers, following the method by Kathy Hammond. We analyzed 262 samples from 74 HPs. In Vienna the medians of pre and post-ban nicotine concentrations were, respectively, 11.00 μg/cubic meter (mean:23.58;Inter-Quartile Range[IQR]:2.53-30.38) and 15.76 μg/cubic meter (mean:17.73;IQR:2.22-31.93), with no significance differences. In Florence and Belluno bars, restaurants, and discos/pubs, nicotine concentration significantly decreased, in median, from 19.02 to 0.25 μg/cubic meter ; from 2.03 to 0.10 ; from 35.16 to 0.01 μg/cubic meter, respectively. Overall, median decreased significantly ( P<0.001) from 8.86 (mean:45.25;IQR:2.41-45.07) to 0.01 μg/cubic meter (mean:1.32;IQR:0.01-0.41). Post-ban measurements in Naples, Turin, and Milan (mean:2.79; median:0.01 μg/cubic meter; IQR:0.01-0.16) confirmed post-ban measurements in Florence and Belluno. This study showed a drop of more than 95% in SHS exposure in a sample of 28 HPs located in 2 Italian towns after 2 years from the introduction of the ban, confirmed by post-ban measurements collected in other 27 HPs from 3 different Italian towns, whereas in Vienna, where no anti-smoking law entered into force up to now, SHS exposure levels were non-significantly different from those recorded 2 years before.

Respiratory health in bar and restaurant workers in Neuquιn City, Neuquιn Province, Argentina, before and after the enactment of a 100% smoke-free environments law

Mariela Alderete, Ernesto Ruiz, Veronica Schoj

Hospital Italiano De Buenos Aires, Argentina, Argentina

E-mail: [email protected]

Introduction: Scientific evidence has proven that second-hand smoke (SHS) is dangerous for human health. Nicotine concentrations are high in bars and restaurants, which causes waiters to be highly exposed to smoke. Studies conducted in other countries have proven that waiters' respiratory symptoms and respiratory function improve when 100% smoke-free environments are implemented.

Objectives: To evaluate respiratory symptoms and respiratory function in waiters from Neuquιn City before and after the implementation of a 100% smoke-free environments law.

Methodology: Prospective before and after. Respiratory symptoms and function were evaluated by questionnaire (self-report) and by spirometry, 2 months before and after law implementation.

Outcomes: 80 non-smoker workers completed the questionnaire and spirometry (35 completed the questionnaire only). Within this sample, the average age was 34,34΁ 12,56; 38,8% were women; 6,3% had asthma. 97,5% reported an average of 8 hours per day of exposure to SHS at their workplace. After the entry into force of the 100% smoke-free law, the incidence of respiratory symptoms decreased significantly. FVC increased by 7% (89%-102%) P=0,001.

Conclusions: The implementation of 100% smoke-free environments is associated with a subjective improvement of respiratory and irritative symptoms, and also an objective improvement in respiratory function. We have confirmed the evidence obtained by similar studies conducted around the world.

A gender and diversity based analysis of the social impact of the scottish smoke-free legislation

Jude Robinson, Deborah Ritchie, Amanda Amos,

Sarah Cunningham-Burley

University of Liverpool, United Kingdom

E-mail: [email protected]

Background: In response to concerns about the health risks of secondhand smoke, and to contribute to reducing levels of smoking, a ban on smoking in public places was introduced in Scotland in 2006.

Objectives: To use gender and diversity based analysis to explore how the ban affected behaviours, attitudes and norms around smoking in public places, among male and female smokers living in four socio-economically contrasting communities.

Methods: A qualitative longitudinal study involving semi-structured interviews conducted with 40 respondents before and after the introduction of the smoke-free legislation. Interview data were analysed using gender and diversity based analysis.

Results: The findings demonstrate diverse and important effects of the legislation in relation to gender, age, and socio-economic location. Particularly pronounced were the multiple impacts on feminine and masculine smoker identities, which often lead to the disruption of social networks and the restriction of smoking behaviours. These differences were felt most in less affluent communities where fewer facilities had been provided to accommodate new patterns of outdoor smoking.

Conclusions: Gender and diversity-based analysis contributes a rich and textured understanding of the impact of smoke-free legislation and should be incorporated into the development of future tobacco control policy and action.

Characteristics of low birth weight babies one-year before and after the Irish workplace smoking ban

Zubair Kabir, Vanessa Clarke, Ronan Conroy, Sean Daly

Tobacco Free Research Institute (RIFTFS), Ireland

E-mail: [email protected]

Introduction: Adverse birth outcomes, such as low birth weight (LBW) births [<2,500 grams] are associated with prenatal maternal smoking. Evidence suggests a 2-fold increased risk of LBW in mothers exposed to second-hand-smoke. Ireland introduced a comprehensive workplace smoking ban nationwide in March 2004. This study examined the smoking characteristics of mothers with singleton LBW live-births one year before and after the smoking ban (2003 and 2005, respectively) in a Dublin maternity hospital.

Methods: Detailed information on socio-demographic and clinical characteristics of individual mothers (n=15000) was collected, including self-reported smoking history. Descriptive, univariate and multivariable logistic regression analyses were performed, using SAS software.

Results: There were 7,441 and 7,559 pregnant mothers for 2003 and 2005, respectively. Prenatal maternal smoking reduced from 22.2% in 2003 to 20.1% in 2005 ( P=0.0009); LBW prevalence among current smokers increased from 5.9% to 8.1% [ P=0.02];and overall LBW prevalence increased from 3.5% to 4.1% [ P=0.07], respectively. After multivariable adjustment, the odds of LBW were greater in 2005 (adjusted OR: 1.41; 95% CI: 1.04-1.90). Pregnant mothers currently smoking were twice as likely as the non-smokers to have LBW births (adjusted OR: 2.32; 95% CI: 1.64-3.29).

Conclusions: The role of the ban in causing the significant reduction in smoking in mothers is unclear but still 20% of mothers smoke. Therefore, smoking remains an important correctable risk factor for LBW in Ireland. This is the first Irish study to show that current parental maternal smoking increases the LBW risk by greater than two-fold.

Impact on staff and environment of a total smoking ban in a university hospital

Jean-Paul Humair, Patricia Borrero, Valιrie Benz Duborgel,

Josiane Mascarini

University Hospitals of Geneva, Switzerland

E-mail: [email protected]

Background: Smoke-free policies in public and work places are effective tobacco control strategies to reduce exposure to tobacco smoke and smoking prevalence.

Objectives: We describe the impact on staff and environment of a total smoking ban in a hospital. This intervention aims to minimize indoor exposure to tobacco smoke and to promote smoking cessation among patients and staff.

Methods: Our hospital implemented on 1.1.2006 a total indoor smoking ban. We applied posters with a new layout at all entrances and placed ashtrays outside of buildings. Tobacco sales were prohibited. Employees who smoke were offered free consultations by occupational health nurses, access to the smoking cessation clinic and nicotine replacement products at lower prices. Fourteen months later we mailed a questionnaire to 4500 employees with a 64% response rate. We measured mean air concentrations of fine particles PM 2.5 in 19 indoor sites before and after the ban.

Results: 92% of employees support and understand the indoor smoking ban. Compared to 1999, smoking prevalence among staff decreased from 22% to 15%. 16% of employees, who smoked before the ban, have quit smoking. 27% of employees still report exposure to tobacco smoke. In most areas, air quality improved dramatically as PM 2.5 levels dropped to healthy or acceptable levels although unhealthy levels persist in 2 sites.

Conclusions: Implementing a smoke-free policy in a hospital reduced passive exposure to tobacco smoke in most places and contributed to reduce smoking prevalence among staff. We must intensify ban enforcement to further reduce passive smoking.

Impact on patients of a total smoking ban in a University Hospital

Jean-Paul Humair, Hilda Brandstatter, Patricia Borrero,

Sarah Kupferschmid

University Hospitals of Geneva, Switzerland

E-mail: [email protected]

Background: Smoke-free policies effectively reduce exposure to tobacco smoke and smoking prevalence.

Objectives: We describe the impact on patients of a total smoking ban in a hospital to minimize exposure to tobacco smoke and to promote smoking cessation among patients and staff.

Methods: Our hospital implemented on 1.1.2006 a total indoor smoking ban. We applied newly designed posters at entrances, placed ashtrays outside and suppressed tobacco sales. Smokers are offered minimal counseling with a leaflet about services, smoking cessation consultations for inpatients and outpatients, nicotine replacement and self-help brochures. Fifteen months later, a survey on quality of care including questions about tobacco was mailed to 2686 patients hospitalized during one month, of whom 69.2% responded. Hospital statistics quantified some smoking cessation services for inpatients.

Results: 64.9% patients understood correctly the total indoor smoking ban supported by 84.9%. 10% of patients report exposure to tobacco smoke. Among the 24.8% of smokers, a half received help for smoking cessation by brochures (15.3%), nicotine replacement (14.5%), leaflets (12.9%) physician or nurse advice (both 11.8%) or a nurse specialized in smoking cessation (9.1%). Among 80% of smokers who quit for at least 24 hours during hospitalization, 15.3% sustained cessation after discharge. During the year after the ban, smoking cessation activity increased to 1099 consultations and costs for nicotine replacement doubled.

Conclusions: Most patients support a total smoking ban in a hospital. Compliance is suboptimal with persisting exposure to tobacco smoke. A half of smokers received help to quit smoking followed by significant cessation.

Association between exposure to secondhand smoke of non-smoking workers with reported respiratory symptoms and health care cost: A cross-sectional study in the Lao people's democratic republic

Kounnavong Sengchanh, Houamboun Keonakhone,

Vongphosy Maniphanh, CVaslo Menchi

National Institute of Public Health, Ministry of Health, Laos Pdr

E-mail: [email protected]

Background: Lao PDR as a member country of WHO has initiatives to implement smoke-free regulations in the country as we learned that SHS provides the acute and chronic respiratory ill health to non-smokers.

Objectives: to collect data on secondhand smoke (SHS) exposure, health symptoms, and cost of treatment related to health symptoms

Methods: The cross-sectional study was carried out using structured interview questionnaires with 300 restaurant workers and 300 staff in smoke-free offices in Vientiane Capital city and Luangprabang Province, Lao PDR. The Collected data were entered into Epi-info dataset and analyzed by SPSS statistical packages.

Results: Restaurant workers had higher rate of reported respiratory symptoms than officers in the smoke-free offices (10.0% and 6.7% in VTE, and 19.3% & 6.7% in LPB, respectively, P=0.001). Respondents who were spend more time with clients who are smokers reported of having respiratory symptoms than those who are spending less time with clients (15.2% & 8.2%, respectively, P=0.015). Multivariate analysis identified that worksites were statistically associated with respiratory symptoms (OR, 2.4, P<0.0001) and spending more time with clients who are smokers (OR, 1.9, P<0.0001). Restaurant workers in both Luangprabang and Vientiane capital city were spend more than those office workers for health related symptoms.

Conclusion: There is a need to underline the importance of 100% smoking bans in the restaurant, pubs, and bars in protecting the health of non-smoking restaurants workers as other officers stated in the article 4 of the policy tobacco control in Lao PDR.

  Marketing and new products Top

Cross border advertising strategies of TTCs in the Middle East: Circumventing regulations to reach 'dark markets'

Rima Nakkash, Kelley Lee

American University of Beirut, Lebanon

E-mail: [email protected]

Background: The Middle East (ME) has been a highly profitable and expanding market for the tobacco industry. Despite strengthening tobacco control regulation elsewhere in the world, transnational tobacco companies (TTCs) in the region have continued to spend substantial resources on marketing and advertising.

Objectives: This article analyses how TTCs have strategically used crossborder marketing and advertising based in Lebanon to reach neighbouring countries in the ME, and considers implications for tobacco control in the region.

Methods: This paper is based on detailed analysis of internal tobacco industry documents from the BAT Document Archive and Legacy Tobacco Document Library, supplemented by Arabic language secondary sources and industry publications.

Results: Lebanon has occupied an important position in the marketing strategies of TTCs given its relatively permissive tobacco control environment. Documents show that the country's weak governance, coupled with its geographical location, led tobacco advertisers to seek to use the country as a base to potentially reach more strictly regulated markets such as Syria, Jordan, Gulf Cooperation Council Countries, and the Kingdom of Saudi Arabia (so-called "dark markets"). Crossborder advertising continues by the industry to the present day.

Conclusion: This research provides the first account of how TTCs use crossborder advertising in the ME. Findings illustrate how national tobacco control regulations must be adopted within a regional and global context, as they can be undermined if neighbouring countries fail to collaborate. Under the FCTC, ratified by most countries in the region including Lebanon, such crossborder practices must be addressed in a forthcoming protocol.

Comparison of asean countries on youth exposure to indirect advertisement by tobacco industry

Nithat Sirichotiratana, Sin Sovann, Tjandra Yoga Aditam,

Khampone Insixiengmay

Faculty of Public Health, Thailand

E-mail: [email protected]

Tobacco use is a major preventable causes of premature death and disease in the world. All ASEAN Member Countries, except Indonesia, have ratified the World Health Organization Framework Convention on Tobacco Control (WHO FCTC), which urges countries to develop action plans for public policies, such as bans on direct and indirect tobacco advertising. The purpose of this paper is to examine differences and similarities in indirect advertisement exposure by adolescent, using Global Youth Tobacco Survey (GYTS) data collected in each country.

Methods: The GYTS uses a standardized methodology for constructing sampling frames, selecting schools and classes. Representative samples of students in grades associated with ages 13-15 in Cambodia, Indonesia, Laos (Vientiane), Malaysia, Myanmar, Philippines, Singapore, Thailand, and Vietnam (Hanoi) were selected.

Results: Four in 10 students have an object with a tobacco logo on it, a form of indirect advertising, in Cambodia (39.7%) and Thailand (42.0%). Indirect advertising exposure was lowest in Indonesia (10.3%), while Philippines (11.1%), Vietnam (Hanoi - 11.7%), Myanmar (14.3%) and Malaysia (14.7%) are a little higher than Indonesia.

Conclusions: Since Thailand has a total tobacco advertising ban in 1992, the tobacco industry uses indirect advertisement to get Thai youths exposed to tobacco products. When compared to Indonesia, which does not have a law on total tobacco advertising ban, the rate of indirect advertisement is lower. ASEAN Member Countries need to develop and implement national comprehensive tobacco prevention and control programs to reduce the burden of chronic diseases and tobacco-related mortality.

Direct and indirect tobacco advertisement and tobacco promotion in four cities of China

Yuan Jiang, Yan Yang, Yi Nan

Tobacco Control Office, China CDC, China

E-mail: [email protected]

Background: The FCTC provides a comprehensive ban on tobacco advertisement, promotion and sponsorship in any form. This study determines whether direct or indirect tobacco advertisements are present, as well as to ascertain public opinions regarding restricting or banning tobacco advertisement, and to collect information about the sponsorship activities of Chinese tobacco companies in recent years.

Objectives: To collect related information on direct and indirect tobacco advertisements as well as tobacco promotion and sponsorship activities, as well as charitable activities; To ascertain whether students and adults in four cities (Beijing, Shanghai, Wuhan and Kunming) have been exposed to tobacco advertising or promotion in the past 6 months; To determine the level of recognition of students and adults in the four cities of selected and indirect tobacco advertisements

Methods: Review of Tobacco Company Websites; tobacco promotion, sponsorship activities charitable activities Observation selected streets, waiting rooms of airports, bus, railway and subway stations, and in four media, including TV, radio, newspapers, and magazines. Population Survey Adults Students

Results: There are lots of tobacco promotion, sponsorship and charitable activities Indirect tobacco adv and sponsorship found in radio, TV. Magazines and newspaper; 74% of major streets in four cities found direct and indirect tobacco adv. Most of student and adult thought the indirect adv. are tobacco adv.

Recommendations: Gap exists between China's tobacco administration measures and the FCTC implementation requirements. The state needs to further improve the measures to administrate the tobacco advertisements, make judgments to identify indirect tobacco adv., and ban adv. comprehensively.

Open source marketing: Consumers design their own cigarette pack

Becky Freeman

University of Sydney, Australia

E-mail: [email protected]

Increasingly strict tobacco advertising bans have positioned the cigarette package as the cornerstone of tobacco company marketing plans. R.J. Reynolds [RJR] has proven to be particularly innovative in designing cigarette packaging. The Camel brand has recently come under public scrutiny for the overtly young and feminine packaging of its sister product, Camel No 9. This paper outlines how RJR utilised an emerging marketing strategy and consumer collaboration technique, termed "open source marketing", to develop their Camel Signature Blends packaging. This paper then explores how innovations in Internet communications coupled with this "open source marketing" technique pose a significant risk to undermining tobacco advertising bans.

Cross-Border Campaign to end tobacco sponsorship of a U.S. Jazz Singer's concert in Indonesia

Anna White, Dina Kania

National Commission for Child Protection (NCCP), Indonesia

E-mail: [email protected]

Background: In November 2006, an Indonesian advocate discovered that U.S. jazz singer George Benson would be performing a concert sponsored by a tobacco company in Jakarta five days later.

Objectives: She alerted the Global Youth Action on Tobacco Network and asked for assistance in stopping tobacco sponsorship of the event; a U.S. member volunteered. The GYAT members hoped to, at very least, discourage George Benson from being sponsored by the tobacco industry again.

Methods: An email was sent to Benson's international booking agent in London, encouraging the singer to: 1) Stop the tobacco sponsorship, or pull out of the concert. 2) Pledge not to be sponsored by tobacco again. A Globalink petition targeting the booking agent was also set up. The New York-based booking agent responsible for the Jakarta concert was subsequently identified.

Results: The booking agent confirmed that there would be no presence of tobacco sponsorship on site at the concert. However, an Indonesian advocate went to the event and did see some tobacco company logos there. The booking agent later explained that they stopped all that was possible at such a late date, that signage was personally removed by Benson's tour manager, and that they were adding a clause to their contracts to eliminate the problem in the future.

Conclusion: This case study of cross-border collaboration highlights the value of monitoring tobacco industry activities, sharing that information with others who might be able to do something about them, and mounting quick internet-based campaigns that leverage international networks.

The cigarillo scam: How new products were marketed to slip past Canada's laws and surveillance system

Atul Kapur, Cynthia Callard, Flory Doucas

University of Ottawa, Canada

E-mail: [email protected]

Background: Lax laws over cigarillos have led to a hidden new problem of youth smoking in Canada. Canadian law distinguishes between tobacco products which are wrapped in paper made from tobacco leaves (cigarillos) and those which are wrapped in paper made from trees (cigarettes). Unlike cigarettes, which cannot be sold in packages with fewer than 20 units, cigarillos can be sold individually and without health warning messages. Tobacco companies have exploited this situation to market brightly-coloured, fruit flavoured cigarillos in single packages which display no health warning.

Objectives, Methods and Results: Teenagers are at a three times higher risk of having smoked a cigarillo in the past month as Canadians over 25. Canadians who smoke cigarillos but who do not smoke cigarettes are excluded from official estimates of smoking rates. In the first half of 2007, if cigarillo use is included in measurements of smoking, the prevalence of current smoking (daily and occasional) among Canadian men increases from 21% to 23%, among all Canadians from 19% to 20%, and among youth (aged 15-19) from 15% to 20%.

Conclusions: The Canadian experience with cigarillos illustrates the vulnerabilities both of marketing controls and surveillance systems to tobacco industry ingenuity.

Marketing new smokeless tobacco products: Insights from tobacco industry consumer research and development

Adrienne Mejia, Pamela Ling

United States of America

E-mail: [email protected]

Background: Since 2005 there has been a marked increase in smokeless tobacco market entrants and product development. In the USA, R.J. Reynolds (RJR) introduced Camel Snus and Phillip Morris developed Marlboro Snus and Marlboro Moist Snuff. Internationally, British American Tobacco sells snus in South Africa, Sweden, and Canada.

Objectives: Describe the history of RJR's consumer research, smokeless product development, and marketing to understand current smokeless tobacco marketing strategies and improve public health counter-marketing strategies.

Methods: Analysis of previously secret tobacco industry documents.

Results: RJR invested in smokeless research, development, and marketing since 1968, and in the 1980s developed new moist snuff products. RJR research indicated most smokeless tobacco users were low-income, rural, and low-education populations; RJR targeted them using free samples and sponsorship at fishing tournaments, rodeos, and other sporting events, and advertising portraying the user as "in control" or "hard working". Wintergreen flavored products were positioned as something that "keeps you going" or for "refreshment". RJR also recognized that it would be desirable to increase the appeal of smokeless products to urban users and women.

Conclusions: Current Camel Snus campaigns depart from historic smokeless marketing plans targeting rural low-income males, and appeal more to the urban and female users RJR has long desired. Enticing smokers to adopt smokeless temporarily to circumvent indoor smoking bans also appears to be a new objective. These efforts may expand the overall tobacco market, undermine smoking cessation, and recruit new users to smokeless. Counter-marketing campaigns need to address these new messages and targets.

  Media and public opinion as policy and advocacy tools Top

Using public opinion polling to support grassroots smoke-free efforts in Ukraine

Serhiy Honchar, Nataliya Toropova, Nichole Veatch, Miranda Wang

Parity (A Cherkassy Regional Charity Foundation), Ukraine

E-mail: [email protected]

In Ukraine, 41 percent of all adults smoke, as do another 26 percent of youth aged 13 to 15. The country's current smoke-free law was enacted in 2005 and is not enforced. Following implementation of the law, a study by the International Center for Policy Studies found that 53 percent of the population reported they were exposed to secondhand smoke. Despite the national law being somewhat weak, it does allow local jurisdictions to pass stronger smoke-free policies, and some local governments have taken the initiative to do so. The cities of Cherkasy, Kherson and Lutsk took the initiative to strengthen their law by passing 100 percent smoke-free laws in workplaces, however the law still allows smoking areas in bars and restaurants. Parity, a regional charity foundation in Cherkasy, is working to enforce the existing law in workplaces and expand the 100 percent smoke-free law to restaurants and bars. In 2008, Parity is conducting a public opinion poll in these three cities to assess knowledge of secondhand smoke and public support for smoke-free policies. The foundation will use the results to inform their advocacy campaign and media efforts. Currently, there is little knowledge about public opinion on tobacco control policies in Ukraine. This poll intends to fill the gap in attitudes around tobacco control and, more specifically, to inform Ukraine's grassroots smoke-free campaigns. This presentation will provide an overview of the poll results and how Parity applied the poll results to their local smoke-free campaigns in Cherkasy, Kherson and Lutsk.

Promotion of tobacco use reduction through effective media and information campaigns and actions, and improvement of legislation in this field

Artur Vakhitov

Regional Environmental Centre of Central Asia, Uzbekistan Branch, Uzbekistan

E-mial: [email protected]

Background: About 50% of the population, including children, smokes In Uzbekistan. The percentage of people sick with tuberculosis, oncological, and cardiovascular diseases grows. Tobacco products' advertising is widespread, but at present there are no any institutions, legislative acts dealing with the problem of tobacco products use.

Objectives: Support of solving of problems will be promoted by information and propaganda campaign, and lobbying of adoption of relevant legislative acts at the governmental and local levels, aimed to optimization of price policy, regulating sale and consumption of tobacco products.

Methods: Carrying out social information propaganda campaign about smoking injure. Lobbying of the recommendations regulating smoking at working and public areas, direct and indirect advertising of tobacco products in the authorities.

Results: Preparation and discussion in related state bodies of the legislative acts and regulation aimed to decreasing of tobacco products use; - Involving population, NGOs, Media and authorities into solving of the problem of smoking is begun.

Conclusions: Public organizations working in the field of environment and sustainable development could be the best executors in solving this problem at present in Uzbekistan.

Mobilising the media for tobacco control

Gawaya Tegulle

Uganda Health Communication Alliance, Uganda

E-mail: [email protected]

One direct consequence of the WCTOH in Washington DC, July 2006 was the formation of the Uganda Health Communication Alliance (UHCA), for purposes of engaging the media for tobacco control initially, but also for health in general. Tobacco control is a huge task that requires the engagement of many sectors of an economy or country, and the cooperation of the public. Many people often talk of the role of the media and how important it is in tobacco control, and indeed many have taken a step to use the media. But these efforts do not often bear much fruit because there is seldom deliberate, calculated, systemic and sustained efforts to engage the media. Part of the problem is that interaction with the media by governments and organizations is often event-based and short of context and continuity. On the contrary, the tobacco industry maintains an organized, well-oiled and systemic public relations and marketing machine that often has little difficulty keeping Big Tobacco afloat. Engaging the media should never be an event, but a process that begins as a part-science because it has clear, albeit unwritten rules of engagement; and ends up as a part-art because perfecting it to bear fruit takes creativity, innovation and persistence. This paper seeks to use the Uganda Health Communication Alliance model to suggest better ways of engaging the media in tobacco control so as to create impact in the community and country.

Adult focused mass media cessation campaigns point youth in the right direction

Donna Perez, Trish Cotter, James F Bishop

Cancer Institute New South Wales, Australia

E-mail: [email protected]

Background: Adult focused mass media cessation campaigns have also been shown to be an effective way of influencing adolescent smoking. In NSW, a downward trend in adolescent smoking prevalence has been observed since 1993, with recent smoking declining from 13.3% in 2002 to 8.4% in 2005.

Objectives: The aim of the study was to assess recognition and response of adolescents to adult focused mass media cessation campaigns.

Methods: An online survey of 413 adolescents aged 13-17 years was conducted in NSW mid 2006 - a second survey is being conducted mid 2008 and will be compared with the previous survey to identify changes over time. The survey included smokers and non-smokers and assessed advertising awareness to determine impact on attitudes towards smoking and smoking behaviours. Reactions were assessed after respondents were played a graphic health effects ad, an ad featuring common excuses used for not quitting and a supportive Quitline services ad.

Results: The results of the survey show that knowledge of the health effects of smoking is high among adolescents and those aware of advertising were more likely to be positively pre-disposed towards anti-smoking attitudes. Around 90 per cent of adolescents surveyed agreed that the 'Amputation' ad was attention grabbing, shocking and believable and eight in ten indicated that the ad made them less likely to smoke and made smoking seem uncool and very unattractive.

Conclusions: Evidence of declining smoking prevalence and positive impact of advertising indicate that youth are getting the message.

Using public opinion polling for policy change

Johanna Birckmayer, Nichole Veatch, LaToya Armstrong,

Miranda Wang

Campaign for Tobacco Free Kids, United States of America

E-mail: [email protected]

Within a public health advocacy campaign, polling offers a strategic tool to shape and strengthen political will and influence governments to take action on policy measures. Public opinion polls allow for an assessment of the public's support for various public health measures and simultaneously work to inform policy makers on public support for such measures. Timed effectively around the deadline for the passage of a major bill, for example, public opinion can push decision makers/policy makers to take decisive political action. This presentation will provide an overview of how polling can be used within a tobacco advocacy campaign, highlighting how polling has been used to: a) generate earned media; b) demonstrate public support to decision makers/policy makers; and c) develop a research-based message strategy for a specific issue or campaign within international advocacy efforts. Case studies from 4 countries funded through the Bloomberg Global Tobacco Initiative (Turkey, Ukraine, Indonesia, Mexico) will exemplify how various countries incorporated public opinion polls into ongoing tobacco control advocacy campaigns to influence policy will.

Gauging public opinion to facilitate change in tobacco control: Population surveys in England

Martin Dockrell, Amanda Sandford, Deborah Arnott

Action On Smoking And Heatlh, United Kingdom

E-mail: [email protected]

Background: The value of collecting public opinion data was apparent during the campaign for smokefree legislation. Opinion polls were used to demonstrate public support for a comprehensive smokefree law. The surveys demonstrated the popularity of interventions which could be 'sold' to the public; used to convince policy-makers of support for the measures; and used to dispel myths about perceived unpopular measures.

Objectives: To demonstrate the importance of measuring public opinion as part of a comprehensive tobacco control strategy

Methods: Periodic opinion polling was undertaken to measure changes in attitudes and support for smokefree legislation and other tobacco control policies.

Results: Surveys have shown public support for further measures, contrary to the supposition that the public would be hostile to more controls. Qualitative data revealed clear majority support both for measures that were imminent (eg sanctions against retailers for repeated sales to minors; pictorial health warnings) but also for measures that have not yet received parliamentary approval (eg ban on tobacco product display at point of sale, ban on vending machines). Data was shared with tobacco control partners and policy makers to shape and promote a broad agenda for further reform.

Conclusion: Gaining public support is an important component of any tobacco control strategy. Independently conducted opinion polls and qualitative surveys played a key part in the successful smokefree campaign in England and continue to be a vital tool in the ongoing tobacco control strategy.

Message testing effective smoking cessation ads in an international context: A report from the bloomberg initiative

Sandra Mullin, Melanie Wakefield, Trish Cotter

World Lung Foundation, United States of America

E-mail: [email protected]

The Bloomberg Initiative has developed a tobacco control mass media resource that includes a dvd reel of international 'best ads.' As an ad with an evidence base of success in one country may have similar impact in another, the Bloomberg Initiative encourages countries to consider adapting high quality mass media content when developing mass media campaigns. But the initiative also strongly recommends in-country message testing before use. The World Lung Foundation along with the Cancer Council and Cancer Institute, Australia, have developed and implemented a message testing effort with in-country research agencies and NGO's in several Bloomberg priority countries to determine message impact and acceptability of cessation ads. The investigators of this project will report on the message testing results completed thus far, and report on the feasibility of using this cross-national, cross-cultural approach to run ads in international media markets.

  Mental health and correctional facilities Top

Effectiveness of two community-based tobacco cessation interventions for persons with mental illnesses

Chad Morris, Jeanette Waxmonsky, Mandy Graves, Alexis Giese

University of Colorado Denver, United States of America

E-mail: [email protected]

Background: Persons with mental illnesses use tobacco at twice the rate of the general population and suffer excess mortality and morbidity. Effective tobacco cessation strategies specific to this population are needed.

Objectives: Evaluate the effectiveness of tobacco cessation interventions in a statewide study. Primary hypotheses are: (1) Brief assessment and quitline (telephonic counseling and nicotine replacement therapy) will significantly reduce cigarette consumption, and; (2) Compared to quitline only, addition of a wellness group will result in significantly greater reduction of cigarette consumption.

Methods: We enrolled 123 patients from four community mental health sites. Participants were English-speaking adults with mostly schizophrenia, bipolar disorder, or major depression. Participants were randomized to quitline only or quitline plus wellness group interventions. Assessment was done at baseline, 3, 6, and 12 months, to measure self-reported smoking, nicotine dependence, psychiatric and general health symptoms, self efficacy, motivation to change, and CO levels.

Results: Repeated measures analyses will compare baseline to 3, 6 and 12 month data. To date, 6-month analyses demonstrate a significant decrease in average cigarettes smoked per day for both groups. There was a significant decrease in depression and psychotic symptoms for both groups. There was not a significant change on the health scale and self-efficacy measure over time. Both groups had significantly lower rates of tobacco dependence from baseline. The wellness group increased study retention compared to the quitline only group.

Conclusions: 12-month cessation data will be presented which will have implications for how to effectively facilitate tobacco cessation for this population.

A captive audience: Outcomes from a cessation program for prisoners

Molly Miranda Kate McCarthy, Judi Brewster

Quit Victoria, Australia

E-mail: [email protected]

Background: A recent study of Australian prisoners suggested that as many as 79% of prisoners are current smokers, and that 58% currently had plans to quit. Internationally, there is a paucity of research on effective interventions for smoking cessation in prison populations.

Objectives: We aim to provide guidance for developing and implementing smoking cessation interventions in prison settings and to present evaluation findings from a tailored cessation program for prisoners ("Quitters are Winners"), developed by Quit Victoria and Corrections Victoria, Australia.

Methods: The program is delivered over a 6-week period, and addresses unique aspects of the prison setting. A total of 358 prisoners across seven jails in Victoria participated in the course (2002-2007). Of these, 136 prisoners completed a post-course questionnaire one month following the course, and 86 completed a three-month follow-up questionnaire.

Results: In developing the Quitters are Winners program, issues such as low literacy, a strong smoking culture and fewer social and environmental support options were considered and integrated into the course structure. Preliminary results indicate that at one month follow-up, 34% of those who completed the course had quit and 71% of those still smoking had cut down, while at 3 month follow up 18% were quit and 38% still smoking had cut down.

Conclusions: A prison-based cessation program presents an opportunity to improve health outcomes for a significantly disadvantaged population with high smoking rates and a range of poor health correlates.

Evolution or Revolution? Moving towards smoke-free mental health services in Scotland

Linda Bauld, Ann McNeill, Janet Ferguson

University of Bath, United Kingdom

E-mail: [email protected]

Background: This study examined the evidence for moving towards smoke-free environments in mental health services in Scotland.

Objectives: To review: The evidence on international smoking policy and mental health. Existing policy within Smoke-Free Scotland. Policy in mental health facilities that had introduced smoke-free environments.

Methods: Review of the research literature. Interviews with key stakeholders. Case study visits.

Results: Stakeholders were overwhelmingly in favour of moving towards smoke-free environments within mental health settings in Scotland. Evidence from international literature and from case studies suggests it is achievable and supported by decisions in England and Northern Ireland, where a one year exemption from smoke-free laws for mental health facilities is being lifted. In moving towards smoke-free, there are a number of options regarding how extensive the policy should be and what it should include. There was almost universal support for smoke-free policies in acute psychiatric settings, but views on continuing care environments were mixed. Having a designated, safe, external area for smoking was felt to be very important. Case studies indicate that total (ie with no designated areas for smoking) smoke-free policies can be introduced in both acute and continuing care mental health settings.

Conclusion: Existing evidence from Scotland and elsewhere suggests that revolution with some phasing-in of policies, is often more successful than evolution where resistance to the smoke-free policy can build up. The importance of smoking cessation provision as a key component of smoke-free policies in this and in other settings is also discussed. "

Implementation of smoke-free policies in mental health and addiction treatment in Ontario, Canada

Joan Brewster, Homa Kameh, Jake Crookall, Roberta Ferrence

Ontario Tobacco Research Unit, Canada

E-mail: [email protected]

Background: Those with addiction or mental health problems have high rates of smoking and tobacco-related illness. However, treatment often ignores smoking. The Smoke Free Ontario Act, implemented in June 2006, requires indoor public places and workplaces, including treatment facilities, to be smoke-free.

Objectives: To examine smoke-free policies in addiction and mental health facilities in Ontario, Canada, and to describe issues in the implementation of these policies.

Methods: A link to an electronic questionnaire was e-mailed to key informants in 102 addiction treatment and 57 mental health treatment facilities, all of which provide inpatient treatment. Non-respondents received one reminder. In addition, semi-structured interviews were conducted with 12 inpatients and staff on a mood disorders unit of a large addiction and mental health hospital.

Results: In 2008, all inpatient treatment facilities are smoke-free indoors, by provincial legislation. We identified differences between addiction and mental health treatment facilities in policy implementation, provision of cessation services, and resistance to policy change. Some staff resistance continues after policy implementation, and we identified needs for information and support from policy makers. The interviews revealed additional issues related to outdoor smoking areas, provision of cessation support, and staff escorting patients outside to smoke.

Conclusions: Taken together, our studies suggest that smoke-free policies in inpatient addiction and mental health treatment can be implemented effectively if treatment providers are well informed about the policy and can support patients in quitting. In addition, consistent rules about outdoor smoking, if allowed, are needed.

Smoking and second-hand smoke among prison employees: It's time to act!

Michael Cantinotti, Ann Royer

McGill University, Canada

E-mail: [email protected]

Background: Scientific studies report that the smoking prevalence amongst inmates is between 60 and 85% and that prisons constitute living spaces where the highest levels of second-hand smoke (SHS) can be found. This has a severe health impact not only on the inmates but also on the correctional service officers (CSO) who guard them. To deal with this problem, state governments started legislating tobacco use in prisons and by the end of 2006, 58% of American states and in 2008, 85% of Canadian provinces and territories had introduced complete smoking bans in their facilities.

Objectives: To evaluate tobacco use, SHS exposure and the views of employees preceding the introduction of a partial smoking ban in a provincial detention centre in Canada.

Methods: Self-completed questionnaires were returned by 140 CSO and by 47 administrative workers (AW) (response rates were respectively 53% and 63%).

Results: 28% of CSO and 23% of AW were smokers. However, 92% of CSO and 65% of AW reported being exposed to SHS during the month preceding the survey (compared to 22% exposure in the Canadian population). More than 75% of employees would have preferred a complete smoking ban. One third of the smokers indicated that a complete smoking ban would help them quit smoking and 84% of CSO reported that a complete smoking ban would improve their health.

Conclusions: There is a strong support from the prison staff for a complete smoking ban. This action is strongly recommended to protect the health of prison employees.

Mental health workers' views on tobacco use in mental health services

Maxie Ashton, Sue Bertossa

Central Northern Adelaide Health Service, Australia

E-mail: [email protected]

Background: The rate of tobacco use among people with mental illness in Australia is still very high with many experiencing serious physical effects, poor finances and reduced quality of life. Mental health professionals do not tend to address tobacco with people with mental illness and environmental factors within services can promote tobacco use and discourage quitting.

Objectives: This study was designed to evaluate mental health professionals' views about tobacco and their level of interest in helping people with mental illness to quit or reduce. It also aimed to identify environmental and cultural factors within mental health services which prevent addressing tobacco.

Methods: Written questionnaires were sent out to over 40 hospital and community based mental health services across the Adelaide metropolitan area. Mental health professionals were asked to complete the questionnaire which were then collated and analysed using SPSS Text Analysis.

Results: Over 300 questionnaires were completed. Mental health professionals raised a range of different views about tobacco and identified significant barriers to addressing tobacco with their client group. Respondents also made important suggestions about how policy and practices within mental health services should be changed to facilitate addressing the high rate of tobacco use.

Conclusions: Mental health workers have a range of views about tobacco however overall they are increasingly aware of the importance of addressing tobacco and the need for mental health services to provide training, support, resources and policy and practice change.

How preparing for a smoke free mental health service in England improved more than just air quality

Paul Hooper, Hilary Wareing

Department of Health In The West Midlands, UK, United Kingdom

E-mail: [email protected]

On 1 July 2008, a limited exemption from the English smokefree law for residential Mental Health Units expired and smoking was not allowed in any enclosed or substantially enclosed part of any mental health establishment. This includes smoking by patients, visitors or members of staff. This measure will improve the living conditions of mental health patients but there is also a need to provide effective and appropriate support for people with mental health issues who want to stop smoking. Many mental health units were already smokefree before the law came into force but others needed considerable support to help them prepare for the change. This paper describes the learning from two initiatives 1 Work carried out nationally by the Tobacco Control Collaborating Centre including - Delivery of 'best practice' workshops and training sessions across England - Site visits to individual mental health units - Management of enquiries - Production of a CD ROM support pack of relevant resources - Regular newsletters 2 Regional Support for building capacity in both local stop smoking services and the mental health field including - Encouraging closer working between mental health services (public and private) and NHS Stop Smoking Services - Training of Mental Health staff to refer clients to local stop smoking services and/or deliver direct stop smoking support - Building capacity in stop smoking services to deliver support to persons with mental health issues - Demonstration projects for developing and sharing best practice

  Partnerships and capacity building I Top

Local NGOs, key partners with government in law enforcement

Anonna Rahman, Syed Alam

WBB Trust, Bangladesh

E-mail: [email protected]

Government officials typically have too many responsibilities to always be effective at implementation of tobacco control law. Rather than criticize their ineffectiveness, local NGOs have a vital role to play in ensuring local enforcement of law through support of those officials. This role includes collecting information (particularly on placement of ads, compliance with regulations on pack warnings, and on whether mandated places are in fact smoke-free), and sharing that information with government officers. Since officers often are rotated through different posts, many are new and unaware of the provisions of a law. NGOs can play a critical role in educating officials about the content of the law, sharing publications, and highlighting key issues. Successes brought about through this approach in Bangladesh include arrests of BAT officers for engaging in an illegal sponsorship campaign; capturing and burning bags made from cigarette posters; creating smoke-free and tobacco ad-free markets; and conducting a nationwide survey on law enforcement. The response of government officials is often positive, and many request the posting of signs for no-smoking places. When officials are transferred, if they have already been motivated through their interactions with local NGOs, they often take that enthusiasm to their new posting, thereby supporting law enforcement and ensuring that previous efforts are not lost. Finally, writing of thank you letters to officials when they take action serve as a very low-cost yet effective means of motivating officials to enforce the law.

What makes for effective overseas development assistance programs in tobacco control

Matthew Allen

Allen And Clarke Policy And Regulatory Specialists Ltd., Newzealand

E-mail: [email protected]

The presenter will outline the findings of a recent review into what makes for effective and valued overseas development assistance (ODA) programs in tobacco control. A case study will be shared of a multi-country, comprehensive tobacco control ODA program implemented over 2003 to 2007 in six Pacific Island countries, funded by the New Zealand Agency for International Development (NZAID). This program was a partnership between a project team led by the presenter and country-based project leaders, and was focused on supporting developing countries to implement comprehensive and FCTC-compliant national tobacco control programs and interventions. The ODA program was highly valued by partner countries, achieved immediate population-level intervention targets (eg FCTC ratification; passage of legislation implementing comprehensive advertising bans and bans on smoking in workplaces, public places and public transport; mass media programs, etc), and appears to have assisted in 'locking in' long term tobacco control efforts in the partner countries. The presentation will draw on an independent evaluation of the NZAID-funded project to outline what worked well - and what didn't, specific lessons learned, and how best to implement effective tobacco control ODA programs in the future. Guidelines on ODA more generally, with a focus on tobacco control specifically, will be outlined. These guidelines draw on a range of sources and are being developed into a guide for those interested in funding and/or implementing future ODA tobacco control programs.

Supporting access of tobacco control driven NGOs to public funds collected from tobacco products taxes

Munteanu Adriana Laura, Radu-LoghinCornel

Romanian Network for Smoking Prevention, Romania

E-mail: [email protected]

In order to ensure the sustainability of the tobacco control activities in Romania by securing resources for funding this kind of activities Romanian Network for Smoking Prevention has initiated a lobby initiative targeting the Ministry of Health / Ministry of Finance for supporting access of Tobacco Control driven NGOs to public funds collected from tobacco products taxes. The following activities were envisaged to reach this objective: Desktop survey on existing similar initiatives in other countries The research was performed using existing contacts with different organisations around the world via GLOBALINK and FCA Members. Issuing a draft of the Order of the Ministry of Health & Ministry of Finance The draft document was prepared by the RNSP expert in tobacco and economics in cooperation with relevant peoples working for the Ministry of Health & Ministry of Finance. Organizing roundtable meetings with political representatives coming from the medical commissions in both chambers of the Parliament and Proposing and discussing the draft order. The role of the roundtable meetings was to agree with all involved parties the final format of the Order. Promoting the Order within both ministries (Health & Finance) by organizing a workshop during of which possible programs to be developed at national level were presented. This workshop was addressed to high level officials and focused on specific examples how the NGO's can use in an efficient and effective way the fund obtained from the state budget.

Partnering with media to expose tobacco industry interference in public health policy

Bobby Ramakant, Kathy Mulvey

Indian Society Against Smoking (ISAS) And Citizen News Service (CNS), India

E-mail: [email protected]

Objectives: To sensitize media on public health and corporate accountability issues to negate the CSR influence of tobacco industry on media corporations To protect public health policy from tobacco industry influence and partnering with media

Methods: NATT members and allies reported stories with evidence of tobacco industry interference in public health policy from around the world - These have been documented and published as CAI reports periodically - Through NATT allies media agencies in Asian and African countries were approached, sensitized and their support sought to publish more opinion-editorial articles exposing tobacco industry interference in public health policy in their countries - These stories have been sourced to and published as opinion-editorials in mainstream English media in Asia and Africa regularly to expose the industry's interference - These articles were circulated widely through electronic forums, put in public domain to increase mutual transparency and accountability.

Results: Opinion-editorial articles exposing tobacco industry interference in public health policy were published in major media houses of more than 20 countries in Asia/ Africa Learning - Working with media on a sustained basis for ongoing sensitization on key issues and fostering partnerships is of key value - The influence of CSR programmes of tobacco industry was a major obstacle, where some media outlets refused to publish our stories

Advocating tobacco control in indigenous communities in Australia

Viki Briggs, Nicole McMillan

Centre for Excellence In Indigenous Tobacco Control, Australia

E-mail: [email protected]

Successes seen in broader tobacco control area in Australia over the last 20 years have not been reflected in Indigenous communities, for example reductions in smoking prevalence rates have not been replicated. Around 50% of Indigenous people in Australia smoke tobacco and there has been no reduction in this rate in the last 16 years. Mainstream health promotion messages and programs aimed at prevention and cessation are not penetrating Indigenous communities and are having little or no effect. The Centre for Excellence in Indigenous Tobacco Control was funded by Health and Ageing in 2003 for 6 years to conduct research and to advocate for tobacco control in the Indigenous population. There are many issues and health needs competing for time in Indigenous communities and these issues more often than not have more immediate effects than tobacco and are therefore given priority. Any advocacy, research or program delivery initiatives must be culturally sensitive and based in reality to gain acceptance from Indigenous communities. Forming equal partnerships with Indigenous communities and organisations is the key to effective communication and therefore effective advocacy for any health promotion issue including tobacco control. Encouraging self determination, sustainability and capacity building are also vital to building effective partnerships. The CEITC endeavors to form respectful partnerships with both Indigenous and non-Indigenous organisations. This presentation will discuss what partnerships might mean to both the Indigenous and tobacco control communities.

Coalition building and advocacy efforts to support tobacco control in Brazil

Paula Johns, Monica Andreis

ACT - Alliance for The Control of Tobacco Use, Brazil

E-mail: [email protected]

The objective of this session is to present the experience of civil society advocacy efforts to promote tobacco control policies in Brazil. ACTbr - Alliance for the Control of Tobacco Use, former RTZ, is a coalition of more than 400 individuals and institutions committed to tobacco control efforts. It was created as an informal coalition in 2001-2002 and became incorporated in January 2007. ACT's mission is to support FCTC and its protocols implementation efforts in the country. The session will be based on the concrete Brazilian experience, deal with past sucesses and discuss current challenges. ACT is exploring advocacy instruments not previously used in the Brazilian scenario with the purpose of broadening the scope of tobacco control in the country and to raise awareness and debate within the judiciary power. We are currently developing an advocacy campaign for a total ad ban in the country through our participation in a constitutional challenge in the supreme court against current ad restrictions. We will also present our experience in using earned media to expand the reach of our advocacy campaigns as well as our efforts to monitor and counter tobacco industry marketing activities, including corporate social responsibility. We will also present a short analysis of advances and obstacles found in our campaign for higher prices and taxes in Brazil and challenges in the area of smuggling of tobacco products.

  Plain packaging Top

The impact of plain packaging on young people: An experimental study

Karine Gallopel-Morvan, Emmanuelle Bιguinot, Yves Martinet, Sylviane Ratte

University of Rennes, France

E-mail: [email protected]

Background: According to tobacco industry internal documents, cigarette packaging is a promotional vehicle to attract young smokers and drive brand imagery. Thus, plain packaging (PP), which consists in the removal of colours, imagery and logos but the name of the brand, is recommended by experts to implement FCTC.

Methods: To test the influence of PP, an experimental study was implemented in 2008 on 680 French smokers and non smokers aged 15 to 25. They were shown one of 5 cigarette packs : an attractive pack (Gauloises, a popular French brand) or a "normal" red Marlboro pack or a white, grey or brown PP with Marlboro brand printed in black. On the front of these 5 packs, textual French warnings covering 30% were written ("smoking kills"). Respondents answered several questions about the pack they saw.

Results: (significancy: P value < 5%) Compared to the 2 branded packs, PP were significantly perceived as less attractive, less beautiful, cheap-looking, of worst quality and reduced the motivation to buy cigarettes. Besides, they enhanced the ability to note health warnings in contrary to the 2 branded packs that distracted from them.

Conclusions: While the research body on the effects on PP is limited and the international tobacco control measures are limited on this topic, our study reveals that generic pack is a real opportunity to reduce the impact of cigarettes advertising and enhance the impact of health warnings.

How does plain packaging influence adult smokers' perceptions about brand image? An experimental study

Melanie Wakefield, Sarah Durkin, Daniella Germain

The Cancer Council Victoria, Australia

E-mail: [email protected]

Background: The Framework Convention on Tobacco Control requires nations that have ratified the convention to ban all tobacco advertising and promotion. In the face of these restrictions, tobacco packaging has become the primary vehicle for communicating brand image. Proposals to introduce 'plain' packaging are emerging, yet there are few empirical studies to guide decisions about exactly what elements of branding ought to be removed.

Objectives: We aimed to assess the effect of increasingly plain packaging on smokers' perceptions about brand image.

Methods: We employed a three (brand types) by four (extent of plain packaging) between-subjects experimental design, using an internet online method to expose 813 Australian adult smokers to one randomly selected cigarette pack, after which respondents completed ratings pertaining to perceived attributes of the brand, perceived attributes of smokers of the brand, and expected taste/quality of the cigarette.

Results: Compared with a usual branded pack one could purchase today, packs with the least amount of branding were perceived as significantly less attractive and as having less appeal in terms of the perceived characteristics of smokers of the brand. Expected taste and perceived quality of the cigarettes in each pack did not vary by plain packaging condition.

Conclusions: This study provide early evidence that efforts to promote plain packaging should aim to remove as many pack design elements as possible.

Power of the packet: A case study for the introduction of plain packaging

Kylie Lindorff

Quit Victoria & VicHealth Centre for Tobacco Control, Australia

E-mail: [email protected]

Background: In 2004/05 Dunhill cigarettes (made by BAT) were ranked 29 th in the Top 100 Grocery items in Australia. By 2007, their ranking had considerably improved to be 19 th .

Objectives: To investigate what tactics BAT used to improve sale of Dunhill products so dramatically and to develop policy responses to halt these practices.

Methods: Investigation of changes in Dunhill package design and format and BAT's use of other marketing and sponsorship mechanisms to promote their product. Review of cigarette grocery market size and share in Australia.

Results: From 2006 to 2007 premium brands of cigarettes in Australia increased their% share of the overall market of cigarettes. Most of the increase in premium brand% market share can be accounted for by an increase in the% market share by Dunhill products. The main driver appears to be BAT's aggressive use and regular updating of package design and format. The most recent Dunhill packaging change was radical with packs taking on bright colours and an innovative package format, promoting an overall retro feel that appears to be clearly aimed at attracting youth and young adults.

Conclusions: BAT has been effective in increasing Dunhill's market share and using packaging as an advertising tool in a country where almost all other forms of advertising are prohibited. This case study provides strong evidence of the need for plain packaging as a policy response and strong FCTC Article 11 & 13 Guidelines.

Misleading information on cigarette packages and plain packaging

David Hammond

University of Waterloo, Canada

E-mail: [email protected];[email protected]

FCTC Article 11 includes provisions for removing deceptive and misleading information on packages; however, until recently there has been relatively little evidence to guide regulators. This talk will review recent findings from experimental and population-based studies on: 1) potentially misleading brand descriptors, such as "light" and "mild", as well as terms such as "smooth" that have been used as substitutes; 2) potentially misleading package designs; and 3) the impact of "plain" packaging. The findings indicate that participants perceive cigarettes labelled as "smooth", and "silver" much the same way as they perceive "light" and "mild" descriptors: cigarettes in these packages are perceived as lower tar delivery and lower heath risk. Consumers also interpret the use of tar numbers on packages as indicators of risk-regardless of whether these numbers are incorporated by manufacturers into the brand name (E.g. "Marlboro One") or whether they are required to be displayed by regulators. Consumers also based their perceptions of risk based on the colours and design of packages, with cigarettes in lighter package colours consistently rated as lower health risk and lower tar delivery. When the colours and brand imagery were removed-so called "plain" packaging-brands are typically rated as less appealing and lower quality than the original packages designs. "Plain" packages also increase the salience and recall of health warnings on packages. Overall, the findings suggest that many of the packaging elements currently used by manufacturers are inherently misleading to consumers and provide strong support for the effectiveness of "plain packaging".

Plain packaging: Striking at the heart of brand image marketing

Melodie Tilson, Garfield Mahood

Non-Smokers' Rights Association, Canada

E-mail: [email protected]

Background: Tobacco advertising in Canada is heavily restricted and 12 of 13 provinces/territories have banned the visual display of tobacco products at retail. With few promotional avenues left, tobacco companies are focusing their marketing might on the pack, providing the lynchpin in the already-strong case for plain packaging.

Objectives: To present a definitive case in support of mandatory plain packaging of tobacco products and to highlight the efforts in Canada to secure plain packaging legislation.

Methods: A detailed search was performed of tobacco company documents, tobacco control research, and business publications (marketing/retail sector), to find evidence of the role of the package in promoting tobacco products and tobacco use. The advocacy activities of key national health groups and their allies related to plain packaging reform were reviewed.

Results: Thirty years ago tobacco companies foresaw the day when the pack alone would convey "the total product message." Both tobacco-specific and general marketing research provide strong evidence of the importance of the package in creating brand image, in bringing attention to the product, and in promoting use. Armed with this evidence, Canadian health groups are urging the federal government to end the tobacco companies' ability to exploit the tobacco package as a 'miniature billboard' that receives more than 40 billion exposures each year.

Conclusions: The failure to implement a complete advertising ban in Canada together with the recent actions of tobacco companies to bring unprecedented attention to the pack renders urgent the need for legislated plain packaging of tobacco products.

  Tobacco control policy impact and public perception I Top

Surveys of public attitudes towards smoking and tobacco control policy in Russia

Kirill Danishevskiy, Anna Gilmore, Martin McKee

Russian Anti-Tobacco Advocacy Coalition (ATACA), Russian Federation

E-mail: [email protected]

Since the political transition in 1991, Russia has been targeted intensively by the transnational tobacco industry. Already high smoking rates among men have increased further; traditionally low rates among women have more than doubled. The tobacco companies have so far faced little opposition as they shape the discourse on smoking in Russia. This paper asks what ordinary Russians really think about possible actions to reduce smoking. A representative sample of the Russian population (1600 respondents) was interviewed face-to-face in November 2007. Only 14% of respondents considered tobacco control in Russia adequate, while 37% felt that nothing was being done at all. There was support for prices keeping pace with or even exceeding inflation. Over 70% of all respondents favoured a ban on sales from street kiosks, while 56% believed that existing health warnings (currently 4% of packs) were inadequate. The current restriction on public places smoking was supported by less than 10% of respondents, while almost a third supported a total ban. Older age, non-smoking status and living a smaller town all emerged as significantly associated with the propensity to support of antismoking measures. Three-quarters believing that tobacco industry bribes politicians. Knowledge of impact of smoking on health was limited with significant underestimation of dangers and addictive qualities of tobacco. A third believed that light cigarettes are safer than normal. The majority of the Russian population would support considerable strengthening of tobacco control policies but there is also a need for effective public education campaigns.

Determining responsibility for smoking in society: Accountability continuum for Jordanian college students

Hala Madanat, Michael Barnes, Eugene Cole, Rebecca Njord

San Diego State University, United States of America

E-mail: [email protected]

Jordan was one of the first developing countries to have a nation-wide ban on smoking in public places and hospitals which went into effect in 1971 along with advertising bans and legislation demanding tar and nicotine warnings on every package of cigarettes. However, the country suffers from lack of enforcement, which has led to high smoking rates especially among college students. The purpose of this study was to identify whether Jordanian students believed smoking is an individual right or a social issue, as well as their support of more stringent policies and enforcement. The sample (n=1211) was taken from undergraduate students attending universities in Jordan. Results showed a strong level of support for tobacco-related policies and their enforcement. Not surprisingly, smokers scored significantly higher on their mean level of agreement with all individual right items and the overall factor score. Furthermore, the highest mean level of support for policies (4.18) was for the item that "more governmental measures should be taken to enforce restrictions on youth tobacco access", while the lowest mean level of support (3.42) went to "the government should raise taxes on tobacco products". While results of this study highlight the importance of more policy enforcement especially in youth access and increased health education in regards to the dangers of smoking, it is most beneficial in understanding where smokers stand on the issue of individual rights related to smoking.

Public opinion and publicity on smoke-free workplaces in Finland

Mervi Hara

Finland΄s ASH, Finland

E-mail: [email protected]

Public opinion and publicity on smoke-free workplaces in Finland In democratic decision-making legislation needs public support in order to be enforced effectively. Since 1977 there have been several efforts to create smoke-free workplaces in Finland. In 1995, the law prohibited smoking at most workplaces. In 2000, smoke-free areas in bars and restaurants were introduced. The Act of 2007 banned smoking at bars and restaurants, with a grace period for some until June 2009.

Objectives: The paper describes the changes in public opinion over the years. It will also illustrate the differences and similarities in media publicity at the very beginning of smoke-free legislation in 2007 and a year after the ban.

Methods: The changes in public opinion are depicted by opinion polls carried out in 2002, 2004, 2006, 2007 and 2008. Concerning the Finnish media sources, the changes of the tone, topics discussed and those participating in the discourse were monitored. The field work was carried out from the end of May to the beginning of June in 2007 and 2008.

Results: Over time public opinion has become more supportive of smoking restrictions. Media publicity was at its most critical before the ban, became but favourable soon after enforcement of the ban. Conclusions The findings highlight the importance to understand the process in public opinion formation and media publicity. The strategy to have smoke-free bars and restaurants needs scientific facts, public debate and media support as well as active co-operation.

Smokers attitudes toward increased government intervention in/regulation of, the tobacco industry: Findings from the ITC surveys

David Young, Ron Borland

Cancer Council Victoria, Australia

E-mail: [email protected]

Purpose: To examine smokers' support for increased government intervention in the tobacco industry in a diverse range of countries; from Asia, Europe, the Pacific and the Americas

Method: ITC surveys are conducted on representative samples of smokers, using either telephone or face-to-face surveys. Respondents were asked about their support for greater government intervention in/regulation of, the tobacco industry.

Results: Strongest support for government intervention came from developing countries in Asia (e.g. China, Thailand, Malaysia around 85%) and lowest support came from the USA (around 45%). Other countries studied fell between these extremes. Opposition to regulation came from smokers holding self-exempting beliefs about smoking's risks, with positive attitudes to smoking, who do not accept smoking is denormalised, and do not hold tobacco companies responsible for smoking's harms.

Conclusions: These findings suggest strong community support for vigorous implementation of FCTC policies, especially in the developing countries studied. The USA stands out as an exception; with less confidence in the capacity of government to act in the interests of its citizens, and an emphasis on individual responsibility to act. Governments in most parts of the world can be reassured that smokers are likely to support increased interventions that lead to robust tobacco control policies.

"Quote me…it's the best bit of legislation": Public perceptions of smoking in a disadvantaged english district

Sue Lewis

University of Durham, United Kingdom

E-mail: [email protected]

Background: As part of a research project to evaluate Smoke Free North East Office (SFNEO), the first regional Tobacco Control Office (TCO) in England, we studied public perceptions of smoking in Easington, a deprived community where 37% of adults smoke (England, 26%).

Objectives: Investigate changes in smoking behaviour and attitudes to smoking over the course of the three-year research project.

Methods: Semi-structured interviews in Easington businesses (before and after the smokefree legislation, 1 st July 2007), participant observation and interviews in working men's clubs and community centres, focus groups with young people.

Results: Respondents agreed with or accepted tobacco control legislation introduced to date. Compliance is high (confirmed by observation in working men's clubs). Smoking is less 'cool', or smokers are said to be 'sad'. Smokers wish they had never started, but the link between smoking and socialising is seen as a barrier to quitting. Concern was expressed about the detrimental effects of tobacco control on traditional social life in the north-east. All respondents reported awareness of cheap and illicit tobacco use. Further legislation was unwelcome, unless to protect young people.

Conclusions: There are signs of tobacco 'denormalisation' in behaviour and attitudes, but progress is hampered by illicit tobacco and resistance to any additional further erosion of the community's 'way of life'. However, attitudes to intervention shift when the focus is placed on protecting future generations, which may have implications for tobacco control media.

Perceived risk among failed quitters: Findings from the international tobacco control (ITC) four country survey

Omid Fotuhi, Geoffrey Fong

University of Waterloo, Canada

E-mail: [email protected]

Perceived risk plays an important role in motivating quit attempts. Yet given that the vast majority of quit attempts end unsuccessfully, it is surprising that few studies have looked at how perceived risk changes after a failed quit attempt. To explore this issue, we analyzed data from the ITC Four Country Survey, a cohort telephone survey of nationally representative samples of adult smokers in Canada, United States, United Kingdom, and Australia during Waves 1 and 2 (2002 and 2003), of whom 2,402 reported a quit attempt between the two waves, of which 1,722 reported failing. Our outcome measure was a composite measure of worry about future health damage and lowered quality of life due to smoking, measured at each wave. As expected, this measure decreased significantly for successful quitters (P<.001). But a decrease also occurred for those whose quit attempt was NOT successful (P<.001). This irrational effect is consistent with a dissonance reduction account: smokers who fail to quit experience cognitive dissonance and are motivated to reduce their dissonance. Reducing perceived risk and worry about the future consequences of continued smoking is one way of reducing dissonance. Further analyses will focus on identifying other dissonance reduction strategies that smokers who have failed to quit may use, for example, increasing their level of justifications for smoking, or a reduction in regret over smoking. Research identifying maladaptive dissonance reduction strategies can be valuable in designing effective methods for continuing to encourage and assist smokers after a failed quit attempt.

  Tobacco industry monitoring III Top

Racialized geography, corporate activity, and health disparities: Tobacco industry targeting of inner cities

Valerie Yerger, Jennifer Przewoznik, Ruth Malone

University of California, San Francisco, United States of America

E-mail: [email protected]

Although there have been significant reductions in overall smoking rates in some parts of the World, smoking rates are higher among poor, less educated, and underserved racial/ethnic populations. The tobacco industry has been identified as "disease-promoting", and its activities, including targeted marketing, thwarting and undermining tobacco control efforts, deceptive scientific practices, and influencing leadership groups, are arguably among the most powerful corporate influences on health and health policy. We analyzed over 400 internal tobacco industry documents to explore how during the past several decades specific places - inner cities populated predominantly by poor black residents in the United States - were targeted with highly concentrated menthol cigarette marketing that emanated from across an entire industry. We present a case study of how major tobacco companies aggressively competed against one another in "menthol wars" fought within these urban cores. No work thus far has analyzed the way in which the inner city's complex geography of race, class and place shaped the multiple avenues used by tobacco corporations to increase tobacco use in low income communities of color. Our analysis shows how the tobacco industry's activities may have contributed to the racialized geography of today's tobacco-related health disparities. California Tobacco-Related Disease Research Program, Grant #12AT-1700

Transnational tobacco companies and NAFTA: Implications for the future of tobacco control

Joanne Lim, Jeff Collin

University of Edinburgh, United Kingdom

E-mial: [email protected]

Background: Broader debates regarding the public health impacts of international trade agreements have particular resonance for tobacco control. Industry challenges to proposed Canadian health legislation under the North American Free Trade Agreement (NAFTA) highlight important barriers to the future development of national and international tobacco control.

Objectives: To investigate how transnational tobacco companies (TTCs) have used NAFTA provisions to undermine health proposals and advance commercial interests.

Methods: Analysis of tobacco industry documents available via online databases, supplemented by a review of official documents, academic and grey literature and media reports.

Results: Analysis of corporate documents highlights the strategic utility of NAFTA to TTCs. Philip Morris strongly supported NAFTA because it offered expanded market opportunities and increased protection of intellectual property (IP) rights. NAFTA's IP provisions were highlighted by Philip Morris and RJ Reynolds as a basis for challenging Canada's plain packaging proposal. Documents indicate how TTCs undertook a concerted lobbying campaign to convince the Canadian government that its proposed legislation contravened trade agreements, including direct lobbying of the Canadian Prime Minister.

Conclusions: The tensions between IP protection under NAFTA and the public health case for plain packaging assumes particular significance in the context of WHO's Framework Convention on Tobacco Control (FCTC). Given the FCTC's silence on its relationship to trade agreements, there is a clear need for increased scrutiny by researchers and policy makers of the implications of such agreements for future tobacco control initiatives.

The moral discourse of responsibility: Tobacco companies use of 'good agricultural practices' corporate social responsibility schemes to conceal the socio-ecological costs of tobacco

Marty Otanez

Anthropology Department, United States of America

E-mail: [email protected]

Background: Tobacco companies are associated with tobacco-related deforestation, pesticide exposure and nicotine poisoning of tobacco farmers. Through its website, Philip Morris communicates messages about its "Tobacco Farmer Partnering Program" and "Agricultural Leadership Development Program" with imagery of tobacco farmers and farmer-company alliances. British American Tobacco and other tobacco companies also operate similar websites.

Objectives: To examine tobacco companies' strategies to use the Internet to circulate farm imagery, and examine how companies use this imagery to counter criticism of tobacco-related deforestation and disseminate a corporate vision of ethical behavior.

Methods: The study uses political ecology and visual discourse analysis to analyze imagery of tobacco farmers on tobacco industry websites.

Results: Tobacco companies use Internet-based imagery of tobacco farms and CSR reforestation schemes to promote positive reputations, manage threats to companies, and deflect attention from agricultural practices that harm farmers and environments. The association of tobacco companies with the moral discourse of responsibility concealed actual immoral behavior of companies whose farming practices are characterized by pesticide poisoning, soil depletion, water pollution and deforestation in developing countries.

Conclusions: Tobacco industry web imagery that portray the industry as a friend of farmers and steward of the environment reveal CSR schemes and industry multimedia and electronic communication strategies that promote tobacco and undermine health policy. The research findings will help policymakers and advocates understand and weaken industry tactics to use the Internet for promoting tobacco.

Tobacco, farming and development: British American Tobacco's efforts to control academic discourse

Nathaniel Wander, Preeti Patel, Jeff Collin

University of Edinburgh, United Kingdom

E-mail: [email protected]

Background: In the early 1980's, transnational tobacco companies (TTCs) came under increasing attack within the international development community. British American Tobacco (BAT) saw its African ambitions threatened by this activism, and particularly by reports of misconduct emerging from Kenya.

Objectives: To understand how TTC's manipulate academic discourse that threatens their investments in developing countries.

Methods: Using industry documents, key informant interviews, and secondary materials, we identified and analysed BAT's strategies to censor unfavourable research and promote positive assessments of its impacts on economic development.

Results: When BAT learned of proposed research in Kenya by University of Lancaster sociologists on 'the impact of advertising campaigns on consumption and the effects of multinational tobacco companies on the structure of local economies,' the company attempted to monitor the researchers' findings and to influence them through demonstrations of good will and generosity. As potentially damaging results began to appear in academic venues and the media, BAT: (1) pressurized the researchers and their university; (2) mobilized Kenyan officials to protest to both the university and the British government; (3) manipulated intra-departmental conflicts and sponsored competing researchers; (4) employed outside researchers to write counter-analyses; and (5) pressurized the publisher of a development journal to publish BAT rebuttals.

Conclusions: TTCs have long been aware of the potential impact of tobacco control gaining prominence within broader development agendas. In the context of the WHO Framework Convention on Tobacco Control, vigilance about industry strategies for manipulating not only public debate but its technical and scientific underpinnings assumes particular salience.

Tobacco industry responses to the international code of marketing of breast-milk substitutes

John Paterson, Jeff Collin

University of Edinburgh, United Kingdom

E-mail: [email protected]

Background: The 1981 WHO/UNICEF International Code of Marketing of Breast-milk Substitutes sought to regulate the activities of transnational corporations (TNCs) in the interest of public health. Negotiated amid UN concern about TNC conduct in developing countries, the Code was perceived as a precedent-setting initiative heralding regulation of other industries.

Objectives: To analyze tobacco industry responses to international efforts to regulate transnational corporations, specifically the WHO/UNICEF International Code of Marketing of Breast-milk Substitutes.

Methods: A comprehensive literature review combined with analysis of internal tobacco industry documents from the Legacy and BAT Tobacco Document Archives.

Results: Analysis of corporate documents indicated that the capacity of NGOs to set the policy agenda via consumer boycotts, the Code's evidence of increased civil society influence within international organizations, and the ambitious scale of WHO's regulatory initiative were all seen as having important implications for the development of tobacco control. The tobacco companies also paid considerable attention to the strategies of infant formula manufacturers in responding to the code.

Conclusions: The International Code stands as an important precedent for the WHO Framework Convention on Tobacco Control (FCTC) from both corporate and public health perspectives. Tobacco company responses to the FCTC substantially mirror those of infant formula manufacturers. The strengths and weaknesses of the Code must be understood if the FCTC is to be successfully implemented, while both initiatives offer important insights into the broader challenges of regulating TNCs in a global economy.

British american tobacco, social reporting and control over independent validation

Gary Fooks, Anna Gilmore

University of Bath, United Kingdom

E-mail: [email protected]

Background: Tobacco companies attach considerable importance to social reporting as a means of securing independent validation for their respective Corporate Social Responsibility (CSR) programmes. In addition to providing a platform on which to build marketing campaigns aimed at rebranding themselves as socially responsible, the practice provides a useful means of pulling civil society organisations into a dialogue with the industry on its own terms and, as such, provides an important role in its continued efforts to frame the agenda of tobacco control.

Methods: Analysis of British American Tobaccoa's and Brown and Williamson's internal documents made publicly available as a result of US litigation.

Objectives: To examine the ways in which British American Tobacco and Brown and Williamson exercise control over the social reporting process.

Results: Social reporting provides a range of reputational and framing benefits to the tobacco industry, many of which are realised as a result of the control that companies exercise over the process. These include: control over who validates (which arises from the power to exclude unreceptive civil society organisations from the reporting process); control over what is validated (which follows from the power to determine the range of issues that comprise social responsibility within the reporting process); and control over what constitutes validation (which stems from the absence of measurable targets within the reporting process).

Conclusions: The control that tobacco companies exercise over the reporting process suggests that civil society organisations should refuse to participate in tobacco industry social reporting.

Wolf in sheep's clothing: Why preemption is good for the tobacco industry and bad for your health

Cynthia Hallett, Liz Williams

American Nonsmokers' Rights Foundation, United States of America

E-mail: cynthia.ha[email protected]

Background: After several attempts at passage of state laws in the U.S., the nonsmokers' rights movement stumbled on using local legislation in the 1970's as the most effective strategy to protect nonsmokers from exposure to secondhand smoke. In response, the tobacco industry initiated a full-court press in state legislatures to pass preemption. Preemption is a provision in state, national, or Federal law that eliminates the power of local/sub-national governments to regulate tobacco issues, including smokefree regulations. Now with progress around the world, the industry is pushing preemption in countries with sub-national authority to pass smokefree regulations.

Objectives: Illustrate the tobacco industry's history of enacting preemption, provide real-life examples of how to prevent or repeal preemption, provide resources and materials, and discuss how weak, preemptive legislation harms public health and could interfere with full implementation of FCTC's Article 8.

Methods: Review of internal tobacco industry documents, as well as personal communications with campaign managers and news clips, to document historical background and current industry tactics for achieving preemption to prevent the spread of strong smokefree regulations.

Results: Preemption remains a key goal of the tobacco industry to undermine the benefits of smokefree policy change internationally. Approaches and methods to achieve preemption have adapted over time in response to the increase in public education and strong smokefree regulations.

Conclusions: Preemption is often misunderstood and, therefore, advocates do not recognize it as an industry interference strategy. Several state and country examples will be discussed to illustrate how to recognize and oppose preemption.

  Warning labels I Top

Development of the new Brazilian health warnings

Cristina De Abreu Perez, Tβnia Cavacante, Eliane Voulchan,

Rejane Sptiz

National Cancer Institute - Brazil, Brazil

E-mail: [email protected]

Background: The packages are usually used as a marketing strategy, and so does the Tobacco Industry to make the youth start smoking. Since 2001 the Health Ministry has been using graphic health warnings on all tobacco product packages as counter-marketing.

Objectives: The goal is to produce effective health warnings to inform smokers about the hazards of smoking, encourage smokers to quit, discourage non-smokers from starting to smoke and principally turn attractive packs into aversive ones.

Methods: A study group developed 10 warning labels for the Brazilian Program, based on scientific evidence and considering the state of art, which support the idea that aversive pictures with strong and direct messages will generate a greater repulsion to the product. The group evaluated the emotional content of each picture in two affective dimensions: hedonic valence and arousal through a Psychometric Instrument to achieve more aversive images.

Results: After 20 months, the 3 rd set of health warnings were approved by the Ministry of Health and it will be launched on May 31 st . The images are more repulsive than the ones in the first and the second sets and have a new layout, using a highlight phrase at the top, the picture, and the Health Ministry warning with the Quitline number at the bottom.

Conclusions: The Brazilian warnings are products of an innovative project, which was developed in partnership with three important Institutions and provided more repulsive warnings. A future study measuring the impact on the population is necessary to compare with the preceding warnings.

Evaluation of proposed graphic health warnings for Malaysian cigarette packs

Mohamad Haniki, Nik Mohamed, Samsul Draman,

Mohd Aznan Mat Aris, Norny Syafinaz Ab Rahman

International Islamic University Malaysia (IIUM), Malaysia

E-mail: [email protected]

Background: Graphic health warnings (GHW) on cigarette packs can increase cessation behaviour among smokers. Malaysia ratified the WHO FCTC in 2005 but yet to implement Article 11 which calls for the use of GHW.

Objective: To assess the ranking of selected graphic health warnings on consequences of tobacco by smoking and non-smoking adults and adolescents.

Methods: Ten selected GHW on consequences of smoking obtained with permission from Thailand (7), Vietnam (1), Singapore (1) and Malaysia (1) were used. Translated text messages were then added. Each subject agreed to participate was given a one-page form and instructed to independently rank the GHW from 1 till 10 (1 for the least effective to encourage people from quitting or prevent others from starting and 10 as the most effective). Each commented on reason (s) for selecting the worst and best GHW.

Results: Of 492 subjects, 292 (59.3%) males and 200 (40.7%) females. 287 (58.3%) adults and 205 (41.7%) adolescents (13 to 18 years). 217 (44.1%) subjects admitted to smoking vs. 273 (55.5%) non-smokers, 2 unknown. Overall, cancer-related consequences were chosen as most effective, especially lung (29.5%) and throat cancer (23.4%). Reasons: 'side effects of smoking' (30.9%) and 'scary' (29.9%). Lung cancer selected as most effective by adolescents (35.6%) vs. throat cancer by adults (28.9%), P = 0.024. The least effective GHW for both smokers and non-smokers: diseased teeth (37.2%) and impotency (18.9%). Reasons: 'not dangerous' (34.1%) and 'not scary' (16.1%).

Conclusion: The use of tobacco-related cancer on Malaysian cigarette packs is highly recommended.

Emerging role of warning labels in effective tobacco control policy implementation

Tatyana El-Kour MS RD, Hashim El-Zein El-Mousaad

World Health Organization, Jordan

E-mail: [email protected]

While tobacco control policies were introduced in Jordan since 1977, Jordan witnessed a marked growth in smoking prevalence in the last few decades, with noticeable socioeconomic differentials. On-pack warning labels were one of the main strategic tobacco control policies identified in 2004 with a clear mandate towards more prominent appearance of on-pack text warnings. The current legislation concerning the printing of health warnings on cigarette packages is adequately enforced and controlled, but the actual on-pack text warnings needs strengthening and enhancement towards culturally-appropriate, gender-sensitive, warning labels to contribute to reducing tobacco use among smokers, and at a rate sufficient to reducing both gender and socioeconomic differentials in tobacco use. This study aims at exploring the role of new on-pack warning labels in effective tobacco control policy implementation. It presents an analytical perspective of a representative survey of smokers and non-smokers in Jordan. The study found that enhanced warning labels can lead to increased awareness and processing of warning messages and can help reduce both gender and socioeconomic differentials among smokers. The study also demonstrated that the media could be a valuable and effective tool in communicating on-pack health warnings when used as an adjunct to product regulation and law enforcement. We conclude that a stepwise path towards meaningful and comprehensive new on-pack warning labels, with appropriate media intervention plan, is a valuable tool in effective tobacco control policy implementation.

Graph preferred for cigarette pack health warning: A result of qualitative study in indonesia

Zulazmi Mamdy, Nina Dewi

Faculty of Public Health, Indonesia

E-mail: [email protected]

Background: Government of Indonesia has obligate all tobacco companies to put textual health warning. Based on various study, the graphic health warning is more effective compared to textual only. To advocate the government to change the textual health warning with graphic one, a study regarding graphic health warning should be conducted.

Objectives: The objectives of the qualitative study is to figure out the most effective graphic health warning among available graph that appropriate to various groups of people.

Methods: This qualitative study employed focus group discussion to identify the most effective graph through ranking the presented graphs. The effectiveness is seen from its attractiveness, informativeness, persuasiveness, and threatens. FGD were conducted among white collar, blue collar, civil servant, adolescence and young adult, both male and female in urban and rural area.

Result: Almost all group has chose graph taken from WHO poster as the most attractive and effective, since it describe all of diseases related cigarette smoking. Male groups preferred picture describing second hand smoke to their children, but women chose the pictures showing a man smoking with skull that reflect the relation between smoking and death. Smoking group chose symbolic picture, while non-smoker preferred threatening pictures.

Conclusion: Informative, straight forward, and threatening graphs were preferred as a health warning by various groups. A series graph health warning should be prepared to be used alternatively to cover all groups.

Colors of cigarette packs: are they influencing consumers' perceptions of cigarette strength? Evidences from Brazil a country where cigarette packs descriptors terms were ban

Valeska Figueiredo, Leticia Casado, Josι Lozana, Liz Almeida

Brazilian National Cancer Institute, Brazil

E-mail: [email protected]

Background: Light cigarette have been marketed by the tobacco industry as being a healthier smoking choice and an alternative to quitting. Descriptor terms were prohibited in Brazil on 2001. As an innovation strategy to face descriptors ban, tobacco industry started to use colors on packages to influence consumers' perceptions of cigarette strength.

Goal: Determine if "soft" and "bright" colors of the packages are associated to the idea of a weaker and stronger cigarette among smokers and non-smokers in Brazil.

Methods: A cross-sectional population-based survey among individuals 15 or + y.o., was conducted in 16 Brazilian cities in 2002-2003. A total of 17,145 individuals reviewed a card with a picture of three cigarette packages, from a same family-brand, differing in color, and were asked what does the different colors in the packages means. Percentage of individuals who answered that the colors distinguish lighter from stronger cigarettes was estimated.

Results: Percentage of smokers and non-smokers who answered that the colors from the packages distinguish lighter from stronger cigarettes was, respectively 66.4% and 45.5%. For these two groups, no gender difference was observed. However, this association inversely increases with age, for both smokers and non-smokers. 74,3% of 15 a 24 years old smokers related colors to cigarette strength.

Conclusions: The use of colors is a successful tobacco industry market strategy to convey the message that some kinds of cigarettes may be lighter and healthier than others. The greater perception by young people may promote tobacco use initiation and maintenance.

Do smokers exhibit avoidance behaviours to new graphic health warnings? An observational study

Judy Li, Richard Edwards, Janet Hoek, Nick Wilson, George Thomson

University of Otago, Newzealand

E-mail: [email protected]

Background: In New Zealand, graphic health warnings (GHWs) on cigarette packets started to be introduced progressively from early 2008 (with a final compliance date on 31 August 2008). The GHWs cover 30% of the front and 90% of the back of a packet and graphically show smoking caused health effects, such as gangrene and mouth cancer.

Objectives: This study compares the degree to which smokers' attempt to obscure packets when smoking in public places before and after the introduction of GHWs, and to assess changes over time after the introduction of GHWs. An increase in avoidance behaviours following the introduction of GHWs would suggest that the GHWs are having a psychological impact on smokers, whilst a decrease over time would suggest habituation to the impact of GHWs was occurring.

Methods: Cafιs, restaurants and bars with an outdoor seating area in Wellington were observed in February (n=269) and April 2008 (n=255). Observations will be repeated in September 2008 and February 2009 when all packets should carry GHWs.

Results: Avoidance behaviours observed include smokers putting their packets inside a bag/pocket when not in use; using cases or pouches to cover packages, and covering GHWs with objects like lighters or cell phones. Preliminary results suggest that avoidance behaviours increased in Time 2 compared to Time 1 (e.g. an increase in those using a tin). Results from Times 1, 2 and 3 will be presented.

Conclusions: Preliminary results suggest that GHWs induce avoidance behaviours among smokers. Final conclusions will be presented at the conference.

Comprehensive tobacco package labelling: Forcing the tobacco industry to tell the truth about its products

Garfield Mahood

Non-Smokers' Rights Association, Canada

E-mail: [email protected]

Background: Packaging experts understand that the package is the most important component of tobacco marketing. As such, the package holds the potential for governments to force the tobacco industry to tell the truth about the risks of its products while, simultaneously, de-marketing the contents of the package.

Objectives: To show how to use comprehensive package labelling systems to create the most cost-effective public education tool available to governments and tobacco control interests.

Methods: The presentation will show how the effective use of language, standardized packaging, creative messaging and graphics, and the occupation of all available package surfaces can combine to produce a comprehensive, no-cost-to-government disease prevention system perfectly targeted at potential starters, smokers, and families and friends of smokers. Package labelling systems in leading jurisdictions will be analyzed for their strengths and weaknesses.

Results: Evidence of the impact of improved labelling systems will be discussed with a special emphasis on Canada where the presenter has personal experience in the design of model warning systems, has influenced the development of the Canadian warnings and has led national campaigns for these warnings. Conclusions: In the Canadian experience, various federal governments, when left to their own devices, failed to produce imaginative, forceful, compelling labelling systems. On the other hand, those same governments, working cooperatively with the non-profit sector, have pushed the limits of reform and achieved precedent-setting results. The presenter will offer insight into how advocacy led to landmark labelling reform in Canada.

  Youth tobacco use II Top

School-related factors of smoking initiation and quitting smoking among European GYTS participants

Tatiana Andreeva

School of Public Health, University of Kyiv-Mohyla Academy, Ukraine

E-mail: [email protected]

Background: In the countries of the former Soviet Union tobacco control is commonly considered as lectures at schools while many of the developed countries have shown limits of such approach.

Objectives: To consider educational programs at schools and smoke-free policies as potential determinants of smoking initiation and quitting smoking among school children.

Methods: Global Youth Tobacco Survey (GYTS) data from most European countries participating in 1999-2005 was used. To analyze smoking initiation those who started smoking within one year were compared to those who never started smoking (43000 participants), for quitting smoking those who stopped smoking within last year were compared to those who still smoke (15000 participants).

Results: Smoking initiation was higher in boys and increased with age. In school classes discussing dangers of smoking in general and short-term effects of smoking was associated with decreased and discussing reasons to start smoking with increased risks of smoking initiation. Lower chances of smoking on the school premises indoors and outdoors had a protective impact. Quitting smoking is increased if smoking is never allowed on the school premises. Compared to those who never had tobacco-related classes those who had them some time ago have higher odds of both smoking initiation and quitting smoking. Indefinite answers about teachers' smoking is associated with higher smoking initiation and lower quitting.

Conclusions: Smoke-free policies on school premises are more likely to facilitate smoking prevention and quitting smoking by school children than tobacco-related classes which have inconsistent effects. Country-specific information will be presented as well.

Linking global youth tobacco survey data to tobacco control policies in the Philippines

Marina Baquilod, Burke Fishburn, Wick Warren, Nathan Jones

Department of Health, Philippines

E-mail: [email protected]

Objectives: To present data from the Global Youth Tobacco Survey (GYTS) conducted in the Philippines in 2000 and 2003 which can be used as baseline measures to monitor provisions of the 2003 Tobacco Regulatory Act and Articles of the WHO FCTC.

Methods: The GYTS is a school-based survey which uses a two-stage sample design to produce representative, independent, cross-sectional estimates. In both 2000 and 2003, the GYTS was conducted in three geographic zones in the Philippines. The zones are then combined to produce a representative national estimate each year. Data in this report are limited to students aged 13-15 years.

Results: The findings in this study show that in the Philippines changes occurred between 2000 and 2003 in that: students were less likely to smoke cigarettes or use other tobacco products, less likely to be exposed to SHS in public places, more likely to support bans on smoking in public places, more likely to have learned in school and from the media about the health hazards of tobacco use, and less likely to have been offered "free" cigarettes by a tobacco company representative.

Conclusion: The synergy between the Philippines' leadership in passing the Clean Air Act in 1999 and the Tobacco Regulatory Air in 2003, in ratifying the WHO FCTC in 2005, and in supporting the conduct of the GYTS offers the Philippines a unique opportunity to develop, implement and evaluate the youth component of their comprehensive tobacco control policy that can be most helpful to the country.

Major changes in smoking behaviors and attitudes among polish school children - results from three rounds of the global youth tobacco survey (1999-2008)

Jakub Lobaszewski, Krzysztof Przewozniak, Witold Zatonski

Cancer Center And Institute, Poland

E-mail: [email protected]

Background: WHO Survey on Health Behavior in School-Aged Children (HBSC) showed that smoking is one of the major health problems for Polish schoolchildren. The Global Youth Tobacco Survey (GYTS) makes possible to characterize smoking patterns and determine smoking trends in youth.

Objectives: To evaluate major changes in smoking behaviors and attitudes among schoolchildren in the past ten years in reference to tobacco control policy.

Methods: National school-based randomized surveys conducted among Polish schoolchildren at age of 13 to 15 in 1999, 2003 and 2008.

Results: The 1999 GYTS showed that about 20% of Polish students smoked cigarettes in last 30 days. However, these smoking rates were not so high as observed in Ukraine (34%) and Russia (33%). In Poland, children were also massively exposed to secondhand smoke (SHS) in their homes and public places (66%). At that time, about 90% of Polish schoolchildren were exposed to cigarette advertising. By the end of 1990s, Polish parliament introduced a total ban on tobacco advertising, promotion and sponsorship and government enforced the national tobacco control program. The 2003 GYTS results show that such policy had a impact both on tobacco industry and youth behaviors. The new HBSC survey from 2006 confirms these observations. Results of the 2008 GYTS will show if those trends are constant.

Conclusions: GYTS results suggest to intensify tobacco control program for youth. Most important is to ban smoking in public places, introduce pictorial health warnings on cigarette packs, substantially rise cigarette prices and denormalize smoking as a social norm.

Difference in prevalence of youth cigarettes' smoking according to the global school health survey and the global youth tobacco survey

Omar El Shahawy, Leanne Riley

Egyptian Smoking Prevention Research Institute, Egypt

E-mail: [email protected]

Background: Tobacco prevalence is recorded through tobacco specific surveys or other generalized surveys.

Objective: To assess the difference in youth smoking prevalence according to two similar surveys performed in the same schools. Global Youth Tobacco Survey (GYTS) is a single risk factor survey and Global School Health Survey (GSHS) is a multi risk factor survey that share same methedology.

Methods: A Comparison was done in eight countries that co-implemented the surveys. The same sampling procedure was followed till the final level where different classes were selected in the same schools. These countries are Guyana (2004), Libya (2007), Namibia (2004), Philipines (2007), Saint Lucia (2007), Saint Vincent & the Grenadines (2007), Trinidad & Tobago (2007) and Uruguay (2007). The only question used in comparison was current cigarettes use as it had the same wording across the two surveys.

Results: GYTS reported higher current smoking prevalence among the eight countries. Prevalence recorded by GSHS ranged from 4.2% (3.1-5.3) in Libya to 17.7%(15.7-19.7) in Uruguay. GYTS ranged from 4.6% (2.9- 7.2) in Libya to 20.2% (18-22.6) in Uruguay. There was a significant difference in Philipines and Saint Lucia. Philipines GSHS recorded 9.7% (7.7-11.7) and GYTS recorded 17.3% (14.7-20.4). For Saint Lucia GSHS recorded 7.8% (5.7-9.9) and GYTS recorded 12.7% (10.4-15.3).

Conclusion: GYTS recorded a higher trend in current cigarette use. A possible cause is "Reponse Fatigue" in GSHS. Another cause could be the "Framing Effects" as GYTS is targeted only to tobacco topics, it could be more sensitive to detect consumption.

Trends in smoking among 12- to 15-year-old Indigenous and non-Indigenous Australian secondary students between 1996 and 2005

Toni Mason, Victoria White

The Cancer Council Victoria (Quit Victoria), Australia

E-mail: [email protected]

Background: Preventing smoking among Indigenous youth may reduce the long-term health effects of smoking among Indigenous adults. There has been little attention paid to whether population based tobacco control policies are associated with reductions in smoking prevalence among Indigenous youth.

Objectives: To examine and compare trends in smoking prevalence amongst students of both Indigenous and non-Indigenous backgrounds.

Methods: Triennial surveys of around 15,000 students were conducted in randomly selected secondary schools throughout Australia. Students were selected at random from school rolls. They completed surveys anonymously and from 1996 onwards self-identified as being Indigenous or not. Key outcome variables were: prevalence of: ever-smoking; smoking on any of previous 7 days; smoking on 3 or more days of previous 7.

Results: At each survey, 3-4% of students identified as being Indigenous. Smoking was significantly more common among Indigenous students at each survey. The smoking prevalence declined significantly between 1996 and 2005 among both Indigenous (37% decline) and non-Indigenous (61% decline) students, although at a different rate (interaction P<.01). Among non-Indigenous students, prevalence decreased steadily between 1996 and 2005, particularly between 2002 and 2005. Among Indigenous students, most of the decrease occurred between 1999 and 2002, with a non-significant decrease found between 2002 and 2005.

Conclusions: Most change in smoking prevalence among Indigenous students occurred between 1999 and 2002. This coincided with a period of increased national tobacco control activity including tobacco control advertising and cigarette price increases, suggesting that these activities may positively influence the smoking behaviours of Indigenous youth in school.

Preventing tobacco use among youth in India: Project MYTRI

Monika Arora, Cheryl Perry, Melissa Stigler, K. Srinath Reddy

HRIDAY (Health Related Information Dissemination Amongst Youth), India

E-mail: [email protected]

Background: The epidemic of tobacco use is shifting from developed to developing countries, including India, where increased use is expected to result in a large disease burden in the future.

Objectives: To test a school-based, multi-component intervention, Project MYTRI (Mobilising Youth for Tobacco-Related Initiatives in India) designed to reduce tobacco use among adolescents in 6 th -9 th grade in Delhi and Chennai, India

Methods: Thirty-two schools were randomized to receive the intervention (n=16 schools) or serve as a delayed program control (n=16 schools). The intervention consisted of classroom activities, school posters, parent postcards, and peer-led health activitism. Students (n= 14,063), were in a surveyed three times throughout the study to assess their tobacco use and related psychosocial risk factors. Growth curve analyses were used to assess changes in behavior and psychosocial risk factors over time.

Results: Program activities were implemented with high participation rates and good fidelity. Over two years of intervention, current tobacco use increased by 68% in the control group and decreased by 17% in the intervention group. Intentions to smoke increased by 5% in the control group, and decreased by 11% in the intervention group. Intentions to chew tobacco decreased by 12% in the control group and by 28% in the intervention group. Changes in psychosocial risk factors were consistent with these behavioral changes, too.

Conclusions: Project MYTRI was a successful prevention intervention that reduced tobacco use among adolescents in Delhi and Chennai and holds the potential to be replicated in other urban areas in India.

The missing link: Utilization of evidence to shape policy

Sonalini Khetrapal

World Bank, United States of America

E-mail: [email protected]

Background: In India cigarettes are heavily taxed while bidis are not. This has implications for high smoking burden among the poor as bidis become affordable to them. There is scientific evidence that raising taxes decreases their use. Among smokers in India nearly 80% smoke bidis while 20% cigarettes and other smoking products. However, this has not been examined in the context of young and adolescent smokers. WHO and CDC developed the Global Youth Tobacco Survey using identical anonymous questionnaire, field methodology and analysis for tobacco surveillance among youth. This paper examines whether the results of GYTS have been properly utilized for policy formulation.

Objectives: The paper compares national estimates data from GYTS conducted in India in 2003 and 2006 and examines the relationship between tobacco taxation policy and the prevalence of tobacco smoking products.

Methods: Global Youth Tobacco Survey (GYTS) data was used, which represents, a two stage probability sample of school going students aged 13-15 years interviewed with an anonymous, self-administered questionnaire.

Results: In 2006, 4.2% of the students currently smoked cigarettes. Between 2003 and 2006, current cigarette smoking did not change statistically. In 2006, 3.5% of students currently smoked bidis. Between 2003 and 2006, current bidi smoking increased significantly.

Conclusions: The control of bidi smoking in India has many challenges. However research on tobacco surveillance among youth is a clear indication for policy makers to have a comprehensive tobacco taxation policy and raise taxes on bidis to protect the health of young people.

  Harm reduction: ally or adversary? Issues in science, policy, and law - constructing a regulatory framework Top

The strategic dialogue and legislative approaches

Mitchell Zeller

Pinney Associates, United States of America

E-mail: [email protected]

The tobacco industry is marketing a new generation of products around the world with claims of "reduced exposure" or " reduced risk." These new products have raised concerns among public health experts because they have the potential to mislead health-concerned smokers into believing that the risk associated with cigarette smoking has been reduced. Many fear that this new generation of products is simply a more sophisticated version of the "light" cigarette. The "lights" disaster resulted in two generations of would-be quitters being lost to the false promises of reduced intake of tar and nicotine from so-called "light" products. The global implications from the marketing of "lights" and the newer generation of products are profound. There is a potential for these products to adversely affect prevention and treatment efforts if the public believes health claims for tobacco products that science cannot support. There is a need to take advantage of the relevant product regulation provisions of the Framework Convention on Tobacco Control. This presentation will describe a two-year effort called the Strategic Dialogue on Tobacco Harm Reduction. The Dialogue brought research, policy, and communications experts together to create a blueprint for action on issues related to tobacco harm reduction. A long term vision and detailed short term objectives will be shared. This presentation will also describe how legislative initiatives were mounted in the U.S. to create a system that would subject any products and claims purporting to reduce exposure or risk to science-based regulation by an independent regulatory agency.

Science on tobacco harm reduction products and future research needs

Dorothy Hatsukami

University of Minnesota, United States of America

E-mail: [email protected]

The primary goals of tobacco control have been to reduce mortality and morbidity by preventing the initiation of tobacco use and promoting cessation of all tobacco products. In recent years, attention has been focused on tobacco harm reduction, that is, strategies that would reduce tobacco-related mortality and morbidity, on a population and individual level, even with the continued use of a tobacco or nicotine containing product. These strategies could include reducing the number of cigarettes per day, reducing the toxicants in tobacco products, switching from an extremely toxic product to a less toxic product (e.g., combustible to noncombustible) or rendering a tobacco product non-addictive. Tobacco harm reduction has been a controversial topic within the tobacco control community, in part, because of the limited science that is available to make informed policy decisions. This presentation will discuss the existing science on the various strategies for tobacco harm reduction, promising avenues of pursuit based on this science and the type of research that will be needed in the future to make important regulatory policy decisions.

WHO's perspective

Raman Minhas

World Health Organization, Switzerland

E-mail: [email protected]

The use of all forms of tobacco-based products which tenuously claim to reduce exposure to toxicants and risk of disease is a significant barrier in the fight against the global tobacco epidemic. These claims are particularly pertinent when discussed in the context of harm reduction and their potential to impede prevention and treatment efforts to reduce death and disease from tobacco use. WHO's view that tobacco harm reduction consists of all methods used to reduce tobacco-related morbidity and mortality is in stark contrast to tobacco industry strategies which promote unsound assertions that non-cigarette sources of tobacco are safer than combustible products. Oral tobacco products that, for example, are targeted at young males could increase initiation and overall tobacco use. WHO is strongly concerned about the plethora of readily available combustible and non-combustible tobacco products which effectively mask the deleterious consequences of tobacco via marketing and advertisement. Though WHO does support the use of evidence-based pharmacotherapy in the context of cessation, it must be emphasized that current evidence indicates that all tobacco products are hazardous to human health, and all are addictive. It is for this reason that WHO recommends that all tobacco products should be subjected to comprehensive regulatory oversight by an independent, science-based, governmental agency which must require disclosure of contents and emissions by manufacturers. In addition, because exposure reduction claims may be interpreted as harm reduction claims, no exposure reduction claims should be permitted in the absence of evidence of a reduction in risk.

Smokeless tobacco use for harm reduction - a South African perspective

Lekan Ayo-Yusuf

University of Pretoria, South Africa

E-mail: [email protected]

Context: The use of some smokeless tobacco (SLT) products has been suggested to be effective in reducing tobacco-related deaths. This paper provides a South African (SA) perspective on the harm reduction potential of SLTs used in SA.

Methods: This paper reviews existing epidemiological data on smoking and SLT use in SA. The preliminary findings of a 2007 national survey of smokers' likelihood of switching to SLT use are also presented.

Results: Smoking remains highest among those of mixed race (41%) and lowest among black Africans (17%). The limited epidemiological evidence available challenges the notion that SLT use is much safer than smoking among the predominant SLT users - black women. Of the survey respondents (N=2,868), 10%, 47% and 29% respectively chose the responses that indicated that compared to smoking, SLT is "more dangerous" or "equally as dangerous" or chose "do not know". However, only 24% of smokers, predominantly blacks (32%) indicated they were likely to switch to SLT if told it was 99% safer. Compared to exclusive smokers, dual users (1.7%) were no more likely to report being confident of success in quitting smoking. However, those who were subjected to smoking restrictions at work and at home, were significantly more confident of their success in their next attempt to quit smoking.

Conclusions: SLT use is culturally inclined and may not be an effective harm reduction strategy in SA. Policy initiatives should therefore not be diverted from effective harm reduction efforts such as restricting public smoking and providing evidence-based cessation services.

Governmental policy perspectives on harm reduction

Yumiko Mochizuki-Kobayashi

National Cancer Center, Japan

E-mail: [email protected]

Background: Tobacco control policy in Japan is relatively bad compared to the others. One reason for this is a tight political and financial linkage between the government and the tobacco industry. Although Ministry of Health (MoH) would like to promote tobacco control, there is a legal obstacle under the Tobacco Business Act of Ministry of Finance (MoF), which covers most of the important tobacco control policies such as health warnings, marketing and product regulation.

Objectives: To examine the future possibility for the government (MoH) to retrieve the regulatory authority over tobacco products.

Methods: All regulatory frameworks within the government applicable to tobacco products were considered. Industry's tactics to escape the appropriate regulation as well as its marketing strategies to introduce new or novel products into the market were analyzed. Examples from other countries were examined if they are applicable to Japan.

Results: The current Tobacco Business Act covers tobacco products in terms of the definition and smoke testing but it does not cover ingredients (except that tobacco products should be made of tobacco leaf) nor product design. On the contrary, the only MoH's existing law applicable for tobacco products is the Household Goods Regulation Act because it does 'not exclude' tobacco products from household goods.

Conclusions: There is a room for the MoH to take the regulatory authority over tobacco products but it solely depends on the interpretation of the law and its political will.

  WHO report on the global tobacco epidemic: Opportunities for tobacco control Top

Legal analysis of the second WHO global report on the tobacco epidemic: Successes, challenges and opportunities

Erin Smith

World Health Organization, Switzerland

E-mail: [email protected]

Background: The second phase of MPOWER will focus on smoke-free environments and, for the first time, will include an analysis of smoke-free laws at the sub-national level.

Objectives: 1) Monitor and assess current policies and the enforcement status of smoke-free environments at the national and sub-national level and 2) provide an overview of best practices and challenges in enacting and implementing smoke-free environments laws.

Methods: National data collectors in each country complete a survey, including all legislation and regulations regarding smoke-free environments. WHO TFI will review and analyze the legislation, regulation and enforcement data with support from a network of regional and country-level legal experts. Analysis will cover both assessments of individual law and a broader overview analysis of smoke-free environments laws of the 193 Member States.

Results: The second WHO Report on the Global Tobacco Epidemic will contain the most comprehensive analysis of smoke-free environments laws, creating a more precise evaluation of the number of people who are protected from exposure to secondhand smoke. Comparisons of legal text based on enforcement and compliance data will reveal the type of instrument and particular text that leads to the highest level of compliance.

Conclusions: Smoke-free laws have different approaches and are enacted at different levels of government. We will present some of the best practices and the challenges in legislation, regulations and enforcement of smoke-free environments laws.

The WHO Report on the global tobacco Epidemic: A statistical review of prevalence estimates

Gauri Khanna

World Health Organisation, Switzerland

E-mail: [email protected]

To describe the methods applied in the WHO Report on the Global Tobacco Epidemic, 2008 to obtain comparable prevalence estimates and to report main results obtained. A detailed questionnaire on tobacco was sent out in 2007 to Member States to collect the latest available country-information on prevalence. Crude prevalence estimates were adjusted for smoking definitions, coverage and survey year. Static analysis was followed by trend analysis where projections of tobacco use were made. Prevalence data were finally age-standardized using WHO Standard Population. There were large differences in smoking patterns across countries ranging from as low as 8% (0.3%) to as high as 70% (52%) for current smoking of tobacco in males (females). In general smoking prevalence increased with age up to mid 30s age group and usually declines thereafter. Regional analysis for the six WHO regions shows highest prevalence in males observed in the Western Pacific group of countries and in females in the European countries. Nearly two-thirds of the world's smokers live in ten countries - China and India alone account for nearly 40% of smokers. Monitoring of tobacco use prevalence is fundamental in assessing the scale of the tobacco epidemic and to guide the design and monitoring of tobacco control interventions. The WHO Report on the Global Tobacco Epidemic, 2008 thus serves as a benchmark with which to compare and monitor tobacco use over time and to evaluate national efforts to control tobacco use.

One year of MPOWER data: looking back and moving forward

Christopher Fitzpatrick

World Health Organization, Switzerland

E-mail: [email protected]

Background: In February 2008, in its first Report on the Global Tobacco Epidemic, WHO launched the MPOWER package of six key tobacco control policies. At the same time, WHO provided a snapshot of the state of MPOWER policy implementation, with data from 180 countries and territories representing 99% of the world population. Data collection for the 2 nd WHO Report is now well under way.

Objectives: This presentation will document successes and failures in the first year of the MPOWER data in promoting policy change for tobacco control. It will also provide a glimpse of how data will be analyzed and presented in the 2 nd WHO Report.

Methods: A review of the press and an analysis of web traffic provide indicators of the diffusion and use of MPOWER data. The presentation is also informed by anecdotal evidence of how this data has been used by both governmental and non-governmental organizations.

Results: The launch of the MPOWER brand in 2008 was one of the most successful media events in World Health Organization history. Maintaining sustained interest in and use of the MPOWER data over the past year has been more of a challenge.

Conclusion: Preliminary analysis of data collected for the 2 nd WHO Report highlight some areas of policy movement over the past year. While it is too early to assess the impact of MPOWER, important lessons have been learned for the 2 nd WHO Report on improved diffusion and use of data aimed at promoting policy change.

The global tobacco control report

Katherine Deland, Kerstin Schotte

World Health Organization, Switzerland

E-mail: [email protected]

The Global Tobacco Control Report (GTCR), a worldwide tobacco control monitoring programme, is a key component of WHO's work as one of the Partners in the Bloomberg Initiative, a global effort scale up tobacco control efforts in developing countries where the health burden is the highest. The objective of the Report is to monitor a core of essential tobacco control policy initiatives, and to report on their implementation on a regular basis. The GTCR provides a highly structured and focused framework through which progress towards the implementation of defined, concrete tobacco control measures at country level can be compared in a standardized manner across countries. Essential surveillance indicators are measured through a questionnaire that is completed by national data collectors. The questionnaire asks for information on national prevalence of tobacco use, tobacco price and taxes, packaging and labelling of tobacco products, advertising and smoking bans, the availability of tobacco dependence treatment, and existence of national tobacco control policy objectives. Results of the GTCR data collection and analysis are presented in the Report itself, which uses gaps between optimal and existing policies revealed in these data and analyses to develop a strong advocacy message. The GTCR is a key element of WHO's worldwide tobacco control strategy, and enhancing the Report's strategic aspects with sharp and focused messages and communication approaches is an integral part of the project.

Assessing national capacity for the implementation of the MPOWER policies:

A new methodology

Peruga Armando, Luminita Sanda

World Health Organization, Tobacco Free Initiative, Switzerland

E-mail: [email protected]

As part of WHO's work with the Bloomberg Initiative to Reduce Tobacco Use, Tobacco Free Initiative (TFI), in collaboration with international partners assists governments, on a country by country basis, to assess the capacity to enact and implement the most effective tobacco control policies (MPOWER core package of six policies). The process relies on a methodology based in part on STOP TB Partnership's successful program review. The purpose is to visit with key informants to learn about the structure, process and outcome of tobacco control activities in the country with a focus on the most effective tobacco control policies, but also on national circumstances and priorities. After several months of planning between the country and WHO, a team formed by international and national experts visits in-country key- institutions / organizations and produces a set of recommendations to guide the government and the civil society for further developing, implementing or evaluating their approach to tobacco control. The assessment includes an analysis of the level of political commitment to implementing effective tobacco control policies and examines the program structures, partnerships (within the government and between the government and interested parties outside the government), human and financial resource needs, and the technical, managerial and political processes indispensable to effectively implement the MPOWER policies.

  Cessation: WATI- Web assisted tobacco intervention Top

Web-Based social and professional support for smokers trying to quit: Content analysis of first posts from 2562 members

Peter Selby, John Cunnningham, Trevor van Mierlo, Danielle Parent

Centre for Addiction And Mental Health (CAMH), Canada

E-mail: [email protected]

Background: Social support and group therapy are associated with successful smoking cessation. However, many smokers do not have access or time to join traditional support services. Would Internet-based support groups assist quitters who can not access traditional cessation services?

Objectives: There is limited research in the area of online social support for smokers. This study aims to gain further understanding in this growing field.

Methods: Demographics, usage data and content were collected from Qualitative analyses of posts were conducted to explore message themes, content, frequency and patterns.

Results: 16,764 smokers registered between November 6, 2004 and May 15, 2007 (mean age was 38.9; 65.4% female). The mean number of cigarettes smoked per day was 20.6 and the mean score for users who completed the Fagerstrom test was 5.6. A total of 15.3% (n=2,562) registered members made at least one post in the support group with 25% of first posts receiving replies within 12 minutes. The most frequent first posts were from recent quitters struggling with their quit attempts. Most responses were from members who had quit for a month or more.

Conclusions: Peer-to-peer responses to new users are rapid, indicating that online Support Groups may be a particular benefit to recent quitters. Interactions appear consistent with in-person support groups. Further research is required in the effectiveness of online support groups and their possible limitations. Results of a web based smokeless tobacco cessation program for adults

Herb Severson, Judith Gordon, Brian Danaher, Judy Andrews

Oregon Research Institute, United States of America

E-mail: [email protected]

Background: An estimated 12 million people in the United State currently use smokeless tobacco (ST) products (snuff and chewing tobacco) and there are few resources to assist them in quitting.

Objectives: To develop and evaluate a web program for smokeless tobacco cessation and evaluate the efficacy in a randomized clinical trial.

Methods: Participants were recruited primarily through promotional mailings to media outlets in 31 states, paid online advertising and targeted mailings, Participants completed consent and enrollment online, and were randomized to either a website that provided linear, text-based ST cessation information (Basic Condition) or an interactive, tailored ST cessation program (Enhanced Condition) that offered streaming video, tailored cessation planning and social support via two forums ("Talk with Others" and "Ask the Expert"). Follow up data was collected at 6-weeks, 3-months, and 6-months post enrollment.

Results: The study enrolled 2,523 participants. Participants in the Enhanced Condition reported significantly higher cessation of tobacco than for those in the Basic Condition at all time points. Participants in the Enhanced Condition visited their Web-based content significantly more often and showed longer overall duration of visiting.

Conclusions: Web-based programs can offer broad access to cessation assistance for ST users who may not have access to other cessation support. This is the first study to show the efficacy of a cessation program for ST users via the Web. Results indicate that users of the enhanced site had significantly more engagement with the site and their engagement was highly related to ST cessation.

Randomized controlled trial of a fully automated internet-based cessation programme for adolescents and young adults

Marc-Dennan Tensil, Peter Lang, Mareike Strunk, Peter Tossmann

Delphi-Company, Germany

E-mail: [email protected]

Background: "Smoke free" ("rauchfrei") is a fully automated web-based smoking cessation programme. The main target population are adolescents and young adults. The programme provides motivational computer-tailored information and learning trials based on behavioural intervention. The programme includes additionally social support via a peer-to-peer-forum. Weekly questionnaires with tailored and motivational feedback are presented up to 4 weeks after stop-day.

Objectives: The aim of the study was to test the short term (4 weeks, 3 months) efficacy of a fully-automated internet-based smoking cessation, the "smoke free" programme for adolescents and young adults.

Methods: Randomized controlled trial. All participants were preparing to quit smoking. Recruitment was conducted via, a website for adolescents and young adults containing information about illegal and legal drugs. The Intervention-group (IG) was randomly selected and was invited to take part in the "smoke free" programme. Participants of the control-group (CG) received no intervention. They were asked to take part in a research project on smoking cessation. Subjects of both groups were surveyed at baseline. Follow-ups were carried out 4 weeks and 3 months after registration (CG) or stop day (IG).

Results: The ongoing study already shows significant group-differences at four weeks and three months follow-ups (7-day-prevalence). Final results are still to come when recruitment period is terminated.

Conclusions: The evaluation results suggest that a fully-automated smoking cessation programme for adolescents and young adults can be successfully delivered via the internet. The quit rate is in line with other smoking cessation websites.

Forced abstinence and free nicotine

Grant Hocking, Ben Youdan

ASH New Zealand, Newzealand

E-mail: [email protected]

Background: Nicotine replacement therapy (NRT) is a safe effective smoking cessation treatment. Opportunities to try NRT for short term abstinence may potentiate its use for long term cessation attempts. Barriers to its use include cost and misperceptions about the dangers and effects of nicotine. We addressed these barriers by providing smokers with free NRT at an event in a smokefree stadium.

Objectives: To trial the provision of free nicotine lozenges to promote NRT as a safe cessation aid, support smokers to abstain from smoking short-term, and prompt its use in long term quit attempts.

Methods: Trained smoking cessation advisers offered two free 1mg nicotine lozenges to smokers, regardless of intention to quit, at a national level rugby league game in New Zealand. Smokers were also invited to approach trained on-site quit coaches for support. They could enter a competition to win a mobile phone by texting their evaluation of the lozenges and/or texting for more quit support.

Results: The results of the mobile phone texting competition and feedback from the quit smoking coaches will be presented.

Implications: The results will inform smoking cessation interventions which demystify nicotine replacement therapy and proactively reach out to smokers with effective treatment.

  Health effects of tobacco use and biomarkers II Top

Can ethanol and menthol's effect on the permeation and reservoir formation of the tobacco carcinogen, N-nitrosonornicotine, explain large racial disparities in squamous cell cancers of the esophagus?

James Hebert, Carryn Purdon, James Chapman, Eric Smith

South Carolina Statewide Cancer Prevention And Control Program, United States of America

E-mail: [email protected]

Background: African Americans, who have anomalously high rates of squamous cell cancers of the esophagus (SCCE) SCCE, also tend to smoke mentholated cigarettes.

Objectives: To determine if the use of mentholated cigarettes may help to explain elevated rates of SCCE in African Americans.

Methods: Using a fully validated in vitro diffusion system, we quantified the effect of ethanol and menthol, substances that are commonly consumed together in high-risk individuals, on the rate of N-nitrosonornicotine (NNN) absorption from both normal saline and artificial saliva containing bovine submaxillary mucin.

Results: Water-soluble NNN permeated the membrane rapidly, and significantly different extents of reservoir formation were observed. Alcohol (at 5% concentration) did not influence the permeation of NNN from normal saline but did significantly increase the permeation from artificial saliva. In both normal saline and artificial saliva, 5% alcohol significantly increased the reservoir formation of NNN in the esophageal tissue. A mentholated donor solution (0.08%), in both normal saline and artificial saliva, increased the flux of NNN, and mentholated saliva significantly increased the tissue reservoir formation. The different delivery systems and the presence of penetration enhancers appeared to be key factors in the absorption and cellular binding processes of NNN.

Conclusions: These results support the hypothesis that the use of mentholated cigarettes, or the concomitant consumption of alcohol while smoking, may have marked effects on the fate of tobacco-borne chemicals. This finding may help to explain elevated rates of SCCE in African Americans who predominantly consume mentholated cigarettes.

Role of Dolichyl Phosphate deficiency in susceptibility to lung cancer among tobacco smokers

Galina Kuznecova, Sergejs Kuznecovs, Ivans Kuznecovs, Klara Jegina

Tobacco And Health Research Centre, Latvia

E-mail: [email protected]

Objectives: Role of tobacco smoking in the etiology of lung cancer is well established. However, only about 15% of tobacco smokers develop lung cancer, indicating that susceptibility factors are involved. Dolichyl phosphate functions as a potential apoptosis inducer as well as a rate limiting factor in proliferation and differentiation. With focus on a predictor of individual susceptibility to lung cancer the present study was carried out to estimate urinary levels of Dolichol (Dol) in tobacco smokers.

Methods: The samples obtained from 11670 persons. 7625 healthy smokers: 5760 males and 1865 females (18-72 years old). Smoking behaviour - more than 20 cigarettes per day for at least 5 years. Dol in urine was assayed by HPLC. The occurrence of lung cancer cases were registered for 12 years.

Results: Urinary Dol in healthy persons is 6 - 10 mkg/mmol. During 12 years of observation the elevated urinal Dol was evaluated in 13% of nonsmokers and 26% of smokers. 65% smokers with elevated urinal Dol excretion and 6,4% smokers with normal urinal Dol excretion were diagnosed with different forms of lung cancer. Dol has been reported to be 5 to 40 times the normal values in lung cancer patients, suggesting a metabolic abnormality of N-glycosylation in proliferation, differentiation and apoptosis. Individual susceptibility to tobacco smoke carcinogens could be related to Dolichyl Phosphate N-Acetylglucosamine-1 Phosphate Transferase (DPAGT1) polymorphism.

The cancer risks from chewing betel quid: A systemic carcinogen more deadly than smoking

Min Kuang Tsai, Chi Pang Wen, Wen Shen I. Chung, Yen Chen Chang

National Health Research Institutes, China

E-mail: [email protected]

Background: Betel Quid chewing, involving 600 million people, was classified by IARC as a carcinogen for oral cancer. What other cancers it caused have not been well defined.

Methods: The cohort consisted of 360,078 adults.

Results: One out of 4 adult males chewed in Taiwan, but most of them (90%) also smoked. RRs for all cancer were significantly increased among chewers (2.00). Six cancer sites were increased significantly: oral cavity (12.52), esophagus (5.64), liver (2.34), pancreas (2.67), larynx (6.24) and lung cancer (2.43). These RRs were increased among smokers, but were further raised to different significant levels when chewing was added. Smokers had 52% excess cancer risk (RR=1.52), but, when chewing was added, the excess risk over nonsmokers became 120% (RR=2.20). Smoking was responsible for 39% of all cancer deaths among smokers, but became 50% among chewers. Daily smoking quantity, more so than daily chewing quantity, influenced the chewer's cancer risks.

Conclusions: Chewing more than doubled the excess cancer risks among smokers, and was responsible for half of all cancers among chewers. Betel quid was associated with at least 6 types of cancer increases, behaving more as a systemic carcinogen than a local one. The combination of chewing and smoking, as practiced by most chewers of betel quid without tobacco around the world, caused far more cancer than chewing betel quid with tobacco added. Helping chewers quit smoking as well as chewing should be the number one priority in cancer control policy in places like Taiwan

Comparison of hair nicotine with salivary cotinine as a biomarker of tobacco smoke

Sungroul Kim, Benjamin Apelberg, Lisa Hepp, Jonathan Samet

Institute for Global Tobacco Control, United States of America

E-mail: [email protected]

Background: Cotinine is the most widely used biomarker of tobacco exposure; however, the need for collection, storage, and transportation of blood, urine, or saliva may limit its use in large field studies. During the past decade, hair nicotine has been used increasingly, but only limited studies have examined its utility as a biomarker of self-reported tobacco exposure.

Objectives: The purposes of this study are 1) to evaluate the association between hair nicotine and saliva cotinine concentrations, and 2) to evaluate the utility of hair nicotine as a biomarker of tobacco exposure.

Methods: We conducted a cross-sectional study of 295 participants (115 smokers, 103 passive smokers, 77 non-smokers) in Baltimore, Maryland (U.S.). Self-reported demographic characteristics and smoking behaviors were collected, along with a hair and saliva sample. Hair nicotine and salivary cotinine were measured using gas chromatography with mass spectrometry.

Results: In preliminary results, the median (IQR) hair nicotine concentrations for smokers, passive smokers, and non-smokers were 17.3 (4.3, 43.9), 0.35 (0.16, 2.66), and 0.23 ng/mg (0.08, 0.36 ng/mg), respectively. Among non-smokers, for each hour per day increase in time spent in environments with passive exposure, mean hair nicotine levels increased by 7% (95% CI: 7% to 8%). Among smokers, the Spearman correlation coefficient between hair nicotine and salivary cotinine concentrations was 0.4.

Conclusion: The current study provides preliminary information supporting the utility of hair nicotine to characterize tobacco exposure. We are currently conducting further analyses to identify the optimal hair nicotine cutoff for discriminating smoking status.

  Pediatric tobacco control: A global opportunity to improve the health of children and youth Top

Children and adolescents and international tobacco control

Ruth Etzel, Jonathan Klein


E-mail: [email protected]

The American Academy of Pediatrics (AAP) and the International Pediatric Association (IPA) are launching a multi-year project to increase the visibility and impact of international pediatric tobacco control efforts, and to engage and support international pediatric leaders and national pediatric organizations in a) advocacy and b) clinician education for tobacco control. The project's aims are 1) to disseminate best practices for tobacco control both for clinical interventions to prevent adolescent and adult tobacco use, and for community public health and policy interventions; and, 2) to provide technical assistance to help build support for children's tobacco control and prevention of secondhand tobacco smoke exposure. Our project team seeks to identify opportunities to modify tobacco prevention and control curricula for pediatric clinicians in collaboration with national partners in ways that are consistent with national child health and public health delivery systems, and with the educational efforts of IPA member organizations. In partnership with National and Regional IPA affiliated pediatric associations, in the next 2-3 years we plan to conduct 2-4 model programs, with priority given to high burden countries. We will report on the impact of these programs at the 26 th International Pediatric Association Congress of Pediatrics in August, 2010.

Comprehensive children's tobacco control: The American academy of pediatrics

Julius B. Richmond center of excellence

(Richmond Center)

Ruth Etzel, Dana Best, Mark Gottlieb, Jonathan Klein

American Academy of Pediatrics, United States of America

E-mail: [email protected]

Background: The american academy of pediatrics (AAP) Richmond Center, established in 2006 with support from the Flight Attendant Medical Research Institute, is dedicated to eliminating children's exposure to tobacco and secondhand smoke.

Objective: To describe our methods for changing the practice of child health care in clinical and community health settings through rapid translation of research into policy and practice.

Methods: The Richmond Center is a 'virtual center', linking physicians, lawyers, social scientists, epidemiologists, public health experts and staff at the AAP and 9 US academic centers. Communication is via email, interactive website ( conference calls, and occasional meetings. Projects and activities address associations between tobacco and health, building careers in children's tobacco control, dissemination of best clinical practices, legal and regulatory policy advocacy, and counseling and systems change effectiveness studies.

Results: Achievements to date include many publications, a comprehensive tobacco policy for AAP, clinician and tobacco champion trainings, additional grants accrued towards children's tobacco control activities, new investigators, and development of sustained collaborations with other FAMRI-funded centers and other tobacco control and primary care organizations.

Conclusions: Comprehensive children's tobacco control is underway through the Richmond Center. This 'virtual' structure has increased collaboration between key pediatric communities, leading to significant progress in engaging child health advocates in tobacco control in a short period of time. This model may be useful for other national and international efforts seeking to increase capacity for tobacco prevention and control targeting children's health.

Tobacco as a global pediatric disease

Bethany Hipple, Harry Lando, Jonathan Klein, Jonathan Winickoff

United States of America

E-mail: [email protected]

Tobacco use, exposure, and cultivation result in severe global pediatric disease. Multiple adverse effects on children throughout development and the common initiation of tobacco dependency long before adulthood make tobacco a threat to children's short and long term health. Tobacco contributes to malnutrition in low-income countries. Tobacco farming harms children by depriving them of educational opportunities, increasing debt burden, and exposing them to high levels of toxic pesticides. Effective countermeasures are available, including the recently adopted World Health Organization Framework Convention on Tobacco Control. The limited resources devoted to tobacco control, however, are disproportionately small compared to the strength of the tobacco industry and the magnitude of the global epidemic.

  Population Based Surveys/Prevalence I Top

The main reason of beginning and quitting smoking in Uzbekistan

Gulnoza Usmanova, Ayda Yurekli, Shuhrat Shukurov

Tashkent Medical Academy, Braun School of Public Health and Community Medicine, Uzbekistan

E-mail: [email protected]

Background: Quitting smoking represents the single most important step that smokers can take to enhance the length and quality of their lives.

Objectives: To explore the reasons for beginning and quitting among Uzbekistan adults.

Methods: 3,632 respondents (15 years of age and older) from 1,000 households completed a structured questionnaire about smoking behavior and other health issues in 2006.

Results: Smoking prevalence in this sample was 10.5% (95% CI 9.3, 11.3) - 20% among men and 1.1% among women. The answers to the question on the reasons why people begin to smoke was distributed as follows: 42.9% (95% CI 41.3, 44.5) example of friends, example of parents 7.2% (95% CI 6.3, 8.0), example of brothers and sisters 2.7 (95% CI 2.2, 3.2), example of stars, heroes, idols 4.5% (95% CI 3.8, 5.1), to wish to appear as adults 16.4% (95% CI 15.2, 17.6), doesn't know 1.3% (95% CI 0.9, 1.6), other reasons 25.2% (95% CI 23.8, 26.6). the main reasons for quitting smoking were: because of health problems 30.2% (95% CI 24.3, 36.5), became too expensive 16.4% (95% CI 11.9, 21.8), upon request of the family 6.5% (95% CI 3.7, 10.4), didn't wish to smoke anymore 28% (95% CI 22.3, 34.2), always wanted to stop smoking 16.8 (95% CI 12.2, 22.2), 2.1% (95% CI 0.7, 5.0) other reasons.

Conclusion: The results showed that in initiating smoking the environment is the most important. Meanwhile in stopping smoking health problems were the most important.

Swiss tobacco monitoring system

Theda Radtke, Roger Keller, Hans Krebs, Rainer Hornung

University of Zurich, Switzerland

E-mail: [email protected]

Objectives: We will present latest results of tobacco consumption, smoking habits of adolescents and second-hand smoke.

Background: The data are collected as part of the Swiss Tobacco Monitoring System (STMS). It is a representative, continuous survey of tobacco consumption among 14- to 65-year-olds in Switzerland. The Department of Social and Health Psychology, University of Zurich developed it on behalf of the Swiss Federal Office of Public Health.

Methods: The research instrument consists of a basic module and several specific modules. The basic module serves as a means of collecting key data on tobacco consumption (e.g., frequency of tobacco consumption, willingness to cease smoking) and on demographics. The basic module is applied in every survey wave (each quarter). The specific modules (e.g., questions on second-hand smoke, attitudes towards smoking) can be added to the basic module for one or more survey waves. Since January 2001, each quarter a new sample of 2,500 persons has been taken (i. e. 10 000 participants annually). The survey uses standardized telephone interviews in German, French and Italian. The study sample is selected using a two-stage random-random sampling technique (random selection at the household and person levels). In order to attain representative results, the data are weighted in four steps according to the distribution of language region, age, gender, and household size in the Swiss population.

Results: The smoking prevalence in Switzerland is still very high (20% daily, 9% occasional smokers in 2007).

Conclusions: The STMS provides data for public health educational programs and legislatives measures.

Use, perceptions, and correlates of single cigarette use among Mexican smokers

Ana Dorantes Alonso, James Thrasher, Victor Villalobos, Geoffrey Fong

National Institute of Public Health, Mexico

E-mail: [email protected]

Background: Single cigarettes are banned but widely available in Mexico. Qualitative research indicates that single cigarettes could help smokers reduce consumption or, alternatively, cue smokers to continue smoking.

Objectives: To assess the prevalence and perceptions of single cigarettes and their use among adult smokers in Mexico.

Methods: Cross-sectional data were analysed from the International Tobacco Control Policy Evaluation Project in Mexico (n=1080). Multivariate models controlled for age, sex, education, income, quit attempts and quit intentions.

Results: 10% of smokers purchased singles at their last cigarette purchase. Of these smokers, most had bought 1, 2, or 3 cigarettes (20%, 33%, and 20%, respectively) and paid double the cost per cigarette when purchasing a pack. In a multivariate model, purchase of single cigarettes in the last purchase was positively associated with being a non-daily smoker, greater intention to quit, more frequently noticing singles being sold and more frequently buying singles to reduce the number of cigarettes smoked. In another multivariate model, lesser age, having tried to quit and intention to quit were associated independently associated with greater frequency of purchasing single cigarettes to reduce the amount consumed. Finally, lesser age and being female were independently associated with experiencing cravings to smoke when seeing single cigarettes for sale.

Conclusions: Among adult smokers in Mexico, the sale, availability, and purchase of single cigarettes appear associated with quit behavior and intentions; however, any possible benefits of selling singles could be counteracted by the cues the provide to keep smoking and ease of access for youth.

East-West gap in smoking prevalence in Europe

Witold Zatonski, Krzysztof Przewozniak, Marta Manczuk,

Urszula Sulkowska

Division of Cancer Epidemiology And Prevention, At The Cancer Center and Institut, Poland

E-mail: [email protected]

Background: Tobacco epidemic is one of the major public health challenges in Europe. Estimates show differences in tobacco-attributable mortality between new and old members of the European Union (EU).

Objective: To examine differences in smoking prevalence between Western and Eastern Europe.

Methods: Nation-wide surveys or census studies conducted among adults in 2002 or neighboring years in 27 EU countries and Russia.

Results: Analysis shows that male smoking prevalence is higher in Central and Eastern Europe (CEE) than in Western Europe. At age of 20 to 64, current smoking prevalence in the new EU members of CEE region (EU10) is at average 43% whereas the rate in old EU countries (EU15) is 35%. However, the highest smoking prevalence is observed in Russia (66%). In women, smoking patterns are not so homogenous as in men. Although smoking prevalence is still slightly lower in the EU10 (25% for 20-64 aged women) as compared with the EU15 (27%), there are CEE countries with very low smoking rates (i.e. Lithuania - 13%) and another CEE countries with one of the highest rates in Europe (i.e. Bulgaria - 32%). This study has also revealed considerable variability across countries in survey methods. Raw comparisons of prevalence rates are highly misleading.

Conclusion: Although there is a need to develop more consistent and standardized methodology of tobacco surveillance in Europe, existing studies show differences in smoking prevalence between Eastern and Western Europe. In men, this gap tends to be smaller for Central Europe and bigger for Eastern European countries.

  Smokefree - New frontiers Top

At the frontier of smokefree policies: A review of public attitudes to smokefree parks, beaches and sports grounds

Richard Edwards, Nick Wilson, George Thomson

University of Otago, Wellington, Newzealand

E-mail: [email protected]

Background: The introduction of smokefree policies in various outdoor settings is one of the frontier areas of tobacco control development.

Objectives: To review published literature on attitudes to, and compliance with, smokefree policies that cover parks, beaches and sports grounds.

Methods: Medline and Google Scholar searches for studies published between January 1990 and May 2008. Synthesis of findings from relevant literature.

Results: We identified 14 studies that had attitudinal data and 5 studies on compliance that related to smokefree parks, beaches or sports grounds. The studies were from Australia, China (Hong Kong), New Zealand, and the United States. These studies indicate that there is usually majority public support for restricting outdoor smoking in these settings. All studies provided evidence of a degree of compliance with the outdoor smokefree policy, though the level of this was highly variable. One study also reported that restrictions on smoking in parks are not perceived as a major practical problem for park managers. Some studies provided data on respondent reasons for support. These included: parks being children's environments (with implications for protecting them from secondhand smoke (SHS) and/or adverse role modelling effects), litter control, and reducing youth opportunities to smoke.

Conclusions: The available evidence suggests that establishing smokefree parks, beaches and sports grounds is acceptable and successful in the countries where it has been studied. The themes of protecting children from adverse role modelling of visible smoking and from SHS exposure, may provide the strongest advocacy arguments for such policies.

Global warming and cigarette smoking: How weather affects smoking bans?

Feng Liu, Xuan Yin

Shanghai University of Finance And Economics, China

E-mail: [email protected]

Objectives: This study sought to examine the relationship between smoking and weather (temperature and precipitation).

Methods: Data of individual characteristics and smoking behavior are from Behavioral Risk Factor Surveillance System 1984-2000 in the U.S. Weather information are from National Climatic data Center.

Results: Higher temperature is associated with large probability of smoking participation and more daily cigarette consumption.

Conclusions: The relationship between weather and smoking behavior is statistically significant. The results imply that indoor smoking bans become more effective when adverse outdoor weather reduce smoking.

The last frontier: Second-hand smoke infiltrating apartments

Jack Boomer, Sharon Hammond, Bobbe Wood, Scott McDonald

Clean Air Coalition of British Columbia, Canada

E-mail: [email protected]

The Heart and Stroke Foundation of B.C. & Yukon and the BC Lung Association, which make up the Clean Air Coalition of British Columbia attempted to reduce the impact of exposure to second-hand on individuals who live in apartments. The effort focused on: researching the issue; developing educational materials; hosting meetings across the province and seeking feedback on next steps; working with residential owner, landlord, tenant and non-profit organizations to develop a multi-pronged strategy; working with residential tenancy staff to make residential policy changes; developing and delivering presentations; undertaking statistical research on the issue; linking with experts in the United States; and, tracking complaints. Education is helping ensure that landlords are aware of their right to include clauses in their residential tenancy agreements to prohibit smoking within the suite and around the building. Working collaboratively with non-traditional allies, we are helping lay the foundation for future policy change within residential tenancy guidelines. Baseline statistical information has been collected to identify the magnitude of the challenge. Individuals and organizations are learning that if they have issues about second-hand smoke infiltrating their apartments and resources exist to support them, particularly through the internet ( The initiative is incremental in scope and in order to achieve buy-in from affected organizations and groups. Baseline statistical data will be shared which allows the Clean Air Coalition to understand the future impact of the initiative.

On the horizon: Smoke-free multi-unit dwellings

Pippa Beck

Non-Smokers' Rights Association, Canada

E-mail: [email protected]

Background: Involuntary exposure to second-hand smoke in multi-unit dwellings is an emerging tobacco control issue in Canada. Now accustomed to smoke-free environments in virtually all enclosed workplaces and public places, many Canadians living in rental apartments, condominiums and housing co-operatives are beginning to demand protection from second-hand smoke in multi-unit housing as well. In 2006 the Canadian Smoke-free Housing Coalition, comprised of tobacco control and public health organizations, was formed in response to the growing demand for smoke-free accommodation.

Objectives: Many people, including landlords and property managers, believe that residential no-smoking policies are both illegal and discriminatory. As such, the demand for smoke-free multi-unit housing currently exceeds supply. By educating landlords, condominium corporations and builders about the law and encouraging them to voluntarily adopt smoke-free policies, the Coalition is working to increase the supply of smoke-free housing in Canada.

Methods: A national strategy has been developed which focuses on building capacity in the tobacco control community, networking with and educating the housing sector, increasing public awareness and creating favourable conditions for smoke-free housing.

Results: Momentum is building and media coverage is increasing in favour of smoke-free housing in Canada. With greater awareness and understanding of the issue, more landlords, condominium corporations and builders are beginning to adopt smoke-free policies.

Conclusions: There is market demand for smoke-free multi-unit housing. Through the work of the Canadian Smoke-free Housing Coalition, supply is catching up and smoke-free housing will soon become a social norm in Canada.

  Smokeless tobacco Top

The role of snus in the decline of smoking in Norway

Karl E Lund

Norwegian Institute for Alcohol And Drug Reserach, Norway

E-mail: [email protected]

As cigarette smoking has been declining in Norway, the use of snus is rapidly increasing. However, sceptics fear that availability to snus will increase overall tobacco consumption.

Objectives: To assess which role snus has played in smoking cessation.

Methods: Analysis of 6 cross-sectional samples collected in Norway in the period 2003-2007 (total N = 14 625) comprising data on snus use, cigarette smoking, cessation and abstinence from smoking.

Results: Snus is the most preferred method for quitting smoking. Data are consistent in demonstrating that quit-rates for smoking are significantly higher among males with daily (72%, 95% CI 71-73) and former (51, 95% CI 50-52) use of snus, than never snus-users (45 (95% CI 44-46). One study clearly indicated that abstinence from smoking at the time of the survey was higher among persons who had used snus (55% 95% CI 52-58) as a smoking cessation aid than those who had used NRT (37% 95% CI 32-42). 77% of successful quitters with snus were still using snus at the time of the survey. Data also shows that many smokers believe that health risks from snus are as serious as those arriving from cigarette smoking.

Conclusion: In Norway - with a long tradition on snus use - snus now clearly serves as an exit from smoking. Revealing information about differences in health risks between smoking and snus-use will adjust misconceptions and perhaps speed up the present transition from cigarettes to snus.

Cadmium in Swedish snus

Per Haglind, Victoria Lind Magnusson

Environment Administration, Sweden

E-mail: [email protected]

Background: Intake of low levels of cadmium over several years results in a build-up of cadmium in the kidney, and may result in kidney disease. Smokers can have double daily intake of cadmium compared with nonsmokers. Swedish snus is a moist product and consists of ground tobacco, water, salt, conservatives, softening agents and taste additives. It is mostly sold in boxes with portion pouches like teabags. Each pouch contains 4 to 14 mg of nicotine.

Objectives: The aim of this study was to determine the levels of heavy metals in commonly used snus products. Information to the public and assessment of the health risks among regular users, were the ultimate aims.

Methods: We bought five different brands of snus and the pouches were examined in an accredited laboratory. Results The mean values in our tests were consistently higher than producer levels. Nickel values in our tests were above the upper level range of the producer levels. Conclusion We suggest that the responsibility to inform consumers lies on the producers including the information on health risks, when the products are used on a regular basis. The information should be easily available on each box. We plan to continue by studying the bioavailability of these metals, in order to assess the risk for the consumers.

[Additional file 1]

Quantifying the effects of promoting smokeless tobacco as a harm reduction strategy

Adrienne Mejia, Pamela Ling, Stanton Glantz

United States of America

E-mail: [email protected]

Background: Despite being less dangerous than cigarettes, snus (a form of smokeless tobacco) is banned in the European Union (except Sweden) and in Australia. Some health professionals argue that snus should be promoted as a harm reduction strategy. Major U.S. tobacco companies (R.J. Reynolds and Phillip Morris) are test marketing snus products bearing cigarette brand names in metropolitan areas across the U.S. The population effects as these new tobacco products achieve greater market penetration will depend on the combined effects of changes in individual risk with population changes in tobacco use patterns.

Objectives: Quantitatively evaluate the health impact of smokeless tobacco promotion for harm reduction.

Methods: Use a Monte Carlo simulation of a decision tree model of tobacco initiation and use patterns to determine the health costs associated with five different patterns of increased smokeless tobacco use.

Results: With cigarette smoking having a health cost of 100, the base case scenario (based on current U.S. prevalence rates) corresponds to a health cost of 24.1 (95% CI 21.7- 26.5) and the aggressive smokeless promotion (less cigarette use and increased smokeless, health concerned smokers switching to snus, smokers in smokefree environments switching to snus) was associated with an increased health cost of 30.4 (25.9-35.2). The anticipated costs for additional scenarios with lower rates of smokeless uptake overlapped with the base case.

Conclusions: Promoting smokeless tobacco as a safer alternative to cigarettes will not result in a reduction of harm and may lead to an increase in harm at the population level.

Snus as smoking cessation strategy

Janne Scheffels

Norwegian Institute for Alcohol And Drug Research, Norway

E-mail: [email protected]

Background: Recently we have observed a significant decline in smoking prevalence in Norway, and an increase in snus use. The utility and risk of snus as an aid for smoking cessation is widely debated.

Objectives: The aim of this study is to look at the extent to which oral snus has been used as a strategy to quit smoking in a general adult population in Norway, compared to other strategies such as use of nicotine replacement therapy (NRT). It also investigates whether snus quitters differ from other quitters according to smoking history, health risk perceptions and socio-demographic background variables. Finally, cessation success rates and continuation of snus use after smoking cessation is described.

Methods: Repeated cross-sectional surveys have been conducted yearly since 1973 by Statistics Norway on behalf of the Directorate of Health. For this study, data from 2003 to 2007 has been pooled, producing a sample of 6399 respondents.

Results: Snus was used as cessation aid twice as often as NRT. Preliminary findings indicated that snus quitters more often managed to quit, but that 3 out of 4 successful snus quitters continued use after smoking cessation on a daily or occasional basis.

Conclusions: Snus accounted for a considerable fraction of cessation attempts, compared to NRT. This indicates a potential for snus as a user-friendly aid for smoking cessation. However, many snus quitters continued use after smoking cessation. Sustained nicotine addiction implies risk for falling back to smoking.

  Waterpipe Top

Subjective measures, puff topography, and exposure to CO in waterpipe users

Samer Rastam, Wasim Maziak, Kenneth Ward, Thomas Eissenberg

Syrian Center for Tobacco Studies, Syrian Arab Republic

E-mail: [email protected]

Aims: To assess subjective withdrawal/carving symptoms, puff topography parameters, and exposure to CO in 24-hour, CO <7ppm-verified, abstinent waterpipe users. Design and measurements: This clinical laboratory study involved 61 waterpipe users (56 males; mean age΁SD 30.9 ΁ 9.5 years; age range 18-56 years), who smoked the waterpipe at least 3 times/week. Study participants underwent pre-post waterpipe use assessment of subjective withdrawal/craving measures, CO boost, and continuous puff topography recording. Three subjective measures were used in this study; 1) Hughes and Hatsukami Withdrawal Scale 2) Tiffany-Drobes Questionnaire of Smoking Urges (QSU-Brief); 3) Direct Effects of Nicotine Scale, along with real-time recording of puff topographic parameters.

Findings: Several items of the subjective questionnaires, as well as factors I (intention to smoke) and II (anticipation of relief from withdrawal) of the QSU-Brief witnessed significant change pre-post waterpipe use compatible with tobacco-related dependence syndrome in waterpipe users. Average puff parameters in study participants were; session time 33.1 ΁13.1 minutes, puff duration 3.2 ΁ 1.2 seconds, puff volume 511 ΁ 333 ml, inter-puff interval 12.6 ΁ 5.9 seconds, and total smoke inhaled/session 79.1 ΁ 54.5 L. Average pre-post boost in exhaled CO was 31.5 ΁32.7 ppm, and was strongly correlated with puff parameters (r=0.7 with total smoke inhaled/session).

Conclusions: Waterpipe users experience deprivation-related symptoms of withdrawal and craving that are suppressed by waterpipe use. Puff parameters in waterpipe users indicate exposure to large amounts of smoke/session, and are strongly correlated with exposure to smoke-related toxicants such as CO.

National survey on Narghile use

Bassam Abou Alzahab, Houssam Baradi

Ministry of Health, Syrian Arab Republic

E-mail: [email protected]

Backgrpund: All tobacco products contribute in killing 5 million individuals yearly. Narghile tobacco is one of them. Narghile use is increasing in most Arab Countries.

Objectives: Objectives are to determine the size of problem and its characteristics.

Methods: It was conducted in 2006 by Ministry of Health in all Syrian Provinces. It was cross-sectional survey.The sample (3537) was multiphse, random and representative of more than 14 years age group. Face-to-face interview questionnaire was designed. It was household survey, and the family was the statistical unit for the clusters. SPSS Programme was used for analyzing the datd.

Results: 13.7% (20.1% for males, 7.7% for females) were current narghile users; 5.6% (9.8% for males, 1.6% for females)were dailly narghile users. 4.9% (7.4% for males, 2.5% for females) were narghile ex-smokers. 46.6% (43.8% for males, 53.8% for females) of users were of 15-29 years age groups. The results of KAP questions were not good to some extent.

Conclusions: Narghile use rate is high in Syria, especially among youth and females. Problem of narghile use should be taken into cosideration within tobacco control programmes and public health programmes, with emphasis on youth and females. That status needs more integrated efforts by concerned bodies (government, popular organizations, professional syndicates, private sector, NGOs and world organizations.

Water pipe smoking: Biomarkers of exposure

Thomas Schulz, Gerhard Dettbarn, Wolfgang Vφlkel, Jόrgen Hahn

Federal Institute for Risk Assessment, Germany

E-mail: [email protected]

Water pipe smoking is quite popular in Germany. However, information on health hazards related to this smoking habit is rare. The Federal Institute for Risk Assessment recently conducted an evaluation of the health risks associated to the consumption of water pipes ( Various biomarkers of exposure have been investigated in a group of 10 non-smokers vs 10 water pipe users. The water pipe smokers consumed one tobacco head containing five grams of tobacco. Blood samples were collected prior to and immediately after smoking. During the following 24 hours, the smokers also collected urine. The following biomarkers were investigated: nicotine, cotinine, CO-hemoglobin, hydroxynaphthalene, 1-, 2-, 3-, 4-, and 9-hydroxyphenanthrene, 1-hydroxypyrene, S-phenylmercapturic acid, N-acetyl-S-(2-carbamoylethyl)cysteine, (3-hydroxypropyl)mercapturic acid, arsenic, lead, and cadmium. Immediately after the smoking session, the mean nicotine content in blood was determined at 11.4 ΁ 9.3 μg/l. The level of CO-hemoglobin in water pipe smokers increased from 2.5% before smoking to 17% after smoking. The overall quantities of naphthalene, phenanthrene or pyrene metabolites were found slightly increased in the urine of water pipe smokers compared to non-smokers. In summary the results obtained suggest that water pipe smoking cannot be considered as a rather harmless alternative to smoking of cigarettes. Additional affiliations 4Official Food Control and Veterinary Laboratory of the State of Baden-Wόrttemberg, Sigmaringen, Germany

Shisha use in Pakistani urban youth

Javaid Khan, Ali Jawaid, Muhammad Muhammad Irfan,

Ahmed Suleman Haque


E-mail: [email protected]

Objectives: To explore into the awareness, perceptions and practice attributes of Karachi city youth regarding Shisha (water-pipe) smoking.

Design: Cross-sectional survey conducted on students belonging to four different universities of Karachi, Pakistan selected through random cluster sampling.

Results: A total of 450 participants comprising 59.6% males (n=268) and 40.4% females (n=182) were included in the study. About half of the participants reported having ever smoked shisha (53.6%, n=241). Upon exploration into factors associated with initiation of shisha smoking, curiosity was found to be the most common reason (61.4%, n=148) followed by pleasure-seeking (46.9%, n=113), peer pressure (22.8%, n=55), boredom (17.8%, n=43) and stress (10.8%, n=26).Out of 241 participants that had ever smoked water-pipe, majority (61.8%, n=149) were currently smoking it. A vast majority of participants (60%, n= 269) considered water-pipe smoking to be less hazardous than cigarette smoking. Boredom in youth, utility of water-pipe in leisure activities and peer pressure were identified as the most common reasons for the escalating popularity of water-pipe smoking in Pakistan.

Conclusions: Water-pipe smoking is very popular in Pakistani youth.However the knowledge regarding the hazards of water-pipe smoking is alarmingly low.There is a need to educate the youth regarding growing shisha use in Pakistan


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