Counselling on Smoking Cessation: Findings of the Second Survey Among All Swiss Doctors in 2008

Abstract Book

March 28, 29 & 30 2011 Amsterdam The Netherlands European Conference Tobacco or Health Shape the future

for a smoke free future

Program at a glance

Monday 28 March Page 9.15-9.40 Conference opening 9.40-10.30 Plenary speaker Laurent Huber: Implementing FCTC guidelines in Europe, how are we doing? 10.30-11.00 Coffee break 11.00-11.50 Plenary speaker Anna Gilmore: Countering smokefree hospitality in Europe, tobacco industry strategies to undermine smoke free legislation in Europe. 11.50-13.30 Lunch & posters - Policy related poster presentations 193 13.30-15.00 Parallel sessions 1 5 15.00-15.30 Coffee break 15.30-17.00 Parallel sessions 2 38 17.30-21.30 MIRO conference: The state of the art and challenges in smoking cessation: United Kingdom vs the Netherlands 18.30-21.30 Ladies film night in Tuschinski Theater playing Vicky Christina Barcelona - smoking in movies

Tuesday 29 March 7.00-8.45 Pfizer breakfast symposium: EQUIPP on FCTC article 14 9.00-9.10 Welcome day 2 9.10-9.55 Plenary speaker Johan Mackenbach: the Netherlands Epidemiology of social inequalities in smoking/tobacco related health disparities. 9.55-10.45 Plenary speaker Amanda Amos: Reaching the unreachable, disadvantaged populations. 10.45-11.15 Coffee break 11.15-12.45 Parallel sessions 3 71 12.45-14.00 Lunch & posters - Intervention related poster presentations 259 14.00-15.30 Parallel sessions 4 101 15.30-16.00 Coffee break 16.00-17.30 Parallel Sessions 5 139 18.30-0.00 Dinner buffet, the Chain of Fools and surprise acts and award winning ceremony ECL/ECToH Young Professional award

Wednesday March 30 9.00-9.10 Welcome day 3 9.10-10.30 Plenary session: Case study and disucssion on interference of tobacco industry in policy and science 10.30-11.15 Plenary speaker Neil Collishaw: A supply-side approach to tobacco control. 11.15-11.30 Coffee break 11.30-13.00 Parallel sessions 6 169 13.00-14.00 Lunch 14.00-15.15 Plenary ‘Shape The future’ session 15.15-15.45 Plenary speaker Florence Berteletti-Kemp: FCTC and beyond, emerging new policy options. 15.45-16.00 Closing of the conference 3 Parallel Sessions

Symposia and oral presentations

4 Parallelsessions 1 Monday March 28, 13.30-15.00

1A - Symposium: The monitoring of Tobacco Control Policies in Europe at country level: the tobacco control scale

Chair: Luk Joossens, Advocacy Officer, Association of European Cancer Leagues, Tobacco Control Expert, Belgian Foundation against Cancer Introductory presentation: Wendy Yared, Director, Association of European Cancer Leagues: Presentation of the updated 2010 TCS scores in Europe

The Tobacco Control Scale quantifies the implementation of tobacco control policies at country level and is based on six policies described by the World Bank, which they say should be prioritized in a comprehensive tobacco control program. The six policies are: • price increases through higher taxes on tobacco products; • bans on smoking in public and work places; • better consumer information, including public information campaigns, • comprehensive bans on the advertising and promotion of all tobacco products, • large, direct health warning labels on tobacco products; • treatment to help dependent smokers stop, including increased access to medications

TCS scores, reflecting the tobacco control policies in 30 European countries, exist for the years 2004, 2005 and 2007 and updated 2010 scores will be released one week before the ECTOH conference in Amsterdam in March 2011. The purpose of the symposium would be to discuss the monitoring of tobacco control policies at country level and the use of the Tobacco Control Scale in the past, present and future.

Interactive panel discussion on the use of the Tobacco Control Scale in the past, present and future with the participation of: • Greece: Panagiotis Behrakis (President ENSP): the perspective of a high smoking prevalence country • Germany, German Cancer Research Center, Heidelberg : Martina Pötschke-Langer: the perspective of a country with a well organized tobacco industry lobby • United Kingdom, UK Centre for Tobacco Control Studies, University of Nottingham: Ann McNeill: the perspective of a country with a high TCS score • Turkey, Turkish Coalition on Tobacco or Health, Elif Dagli : the perspective of a high smoking prevalence country which has introduced recently important tobacco control legislation • European Commission, TBC : the perspective of DG SANCO on the monitoring of tobacco control policies at national level • Smoke Free Partnership: Florence Berteletti Kemp, Director: the perspective of an European campaigner on the monitoring of tobacco control policies at national level

Parallelsessions 1: March 28, 13.30-15.00 5 Questions to panelists: • Does the TCS reflect the tobacco policy in your country? • Does the publication and the ranking have an impact on the policy in your country? • What will be the priorities of tobacco control in your country and in Europe in 2015? • The 100 points of the TCS does not include points on the tobacco industry interference on public health (FCTC article 5.3). How do we monitor article 5.3? Should we include article 5.3 in the next TCS?

Title Tobacco Control Policies in Europe in 2010: The Tobacco Control Scale.

Author Dr Wendy Yared, Director Association of …uropean Cancer Leagues

Objective Monitoring tobacco control policies in Europe

Methods Results of a survey of tobacco control activities in 31 European countries in 2010, using the Tobacco Control Scale (TCS), first described in our 2006 paper, The Tobacco Control Scale: a new scale to measure country activity. The TCS, which quantifies the implementation of tobacco control policies at country level, is based on six policies described by the World Bank, which they say should be prioritized in a comprehensive tobacco control programme. The six policies are: 1) price increases through higher taxes 2) smoke free public and work places 3) better consumer information, including public information campaigns, media coverage 4) comprehensive bans on the advertising and promotion 5) large, direct health warning labels 6) treatment to help dependent smokers stop

Results The 31 countries are ranked by their total score on the scale out of a maximum possible score of 100 based on tobacco control policies in 2010.

Conclusion A comparison will be made between tobacco control activities in 2007 and 2010.

Implementation Based on the results of the TCS in 2010, recommendations will be made on tobacco control activities and research projects for the period 2010-2015 in Europe.

Parallelsessions 1: March 28, 13.30-15.00 6 1B - Session Cessation tools

1B.1: The impact of the introduction of smokefree legislation on prescribing of stop-smoking medications in England

L.C. Szatkowski, S.L. Lewis, A.M. McNeill, T.C. Coleman University of Nottingham, NOTTINGHAM, United Kingdom

Objectives Survey findings suggest that the introduction of smokefree legislation may lead to short-term increases in smokers attempting to quit, though little is known about the pathways through which this happens. Ensuring smokers are offered, and access, the cessation support available through primary care may be one way to maximise the impact of smoking bans. This study uses data from The Health Improvement Network (THIN), a large database of primary care records, to investigate whether there were changes in the rate of prescribing of smoking cessation medications in the months leading up to, and after, the introduction of smokefree legislation in England in 2007.

Methods Monthly rates of prescribing of NRT and bupropion were calculated from THIN from 2001 to 2009 for all smokers aged 16+ and for subgroups defined by patient sex, age group, history of chronic disease and quintile of the Townsend Index of Deprivation. ARIMA interrupted time series analysis was used to model these monthly rates and assess whether there were changes in prescribing before and after the introduction of smokefree legislation above and beyond any long-term and seasonal trends.

Results A 7.3% increase in NRT prescribing and a 13.2% increase in bupropion prescribing occurred in the three months before smokefree legislation was introduced in England, and a 5.5% decline in NRT prescribing and a 13.7% decline in bupropion prescribing in the nine months post-legislation. These declines were offset to an extent, but not completely, by an increase in prescribing of varenicline which was first available on prescription in December 2006. The patterns of change in prescribing do not differ by patient sex, age group, medical history or social class.

Conclusions The impending introduction of smokefree legislation may have caused some smokers to seek cessation support from primary care, or a doctor to offer unsolicited support to quit. However, there appears to have been a temporal displacement of quitting behaviour rather than an increase in the overall volume of quitting activity - during 2007, quit attempts which otherwise might have been made later in year appear to have been brought forward. The similar results in all population subgroups suggest that the changes in prescribing will neither widen nor reduce the health inequalities caused by smoking.

Implementation Promoting and ensuring the availability of cessation support through primary care both before and after smokefree legislation is enacted may help to maximise the impact of a smoking ban.

Parallelsessions 1: March 28, 13.30-15.00 7 1B.2: Psychological determinants of using evidence based smoking cessation aids in the Netherlands

R.A. Willems1, M.C. Willemsen2, H. De Vries1 1Maastricht University, MAASTRICHT, The Netherlands 2STIVORO, the Dutch expertise centre for Tobacco Control, D…N HAAG, The Netherlands

Objectives The utilization of effective cessation aids, such as professional help and pharmaceutics, will increase the likelihood of successful quitting. In the Netherlands, there is a wide array of effective smoking cessation aids available. A combination of behavioral therapy and pharmaceutics is regarded as the most effective method, boosting success rates with a factor 2 to 4. However, uptake of cessation aids is low: currently only 26% of Dutch quitters use effective cessation aids, which is lower compared to many other countries. This study sought to understand why some smokers do and others do not use these aids, in order to be able to develop better implementation strategies for these evidence based methods.

Methods We used the I-Change model (De Vries, Lezwijn, Hol & Honing, 2005) to select determinants of using cessation aids when making a quit attempt. This model integrates elements from various models of behavioral change. Behavior is the result of intentions and abilities. If one is not able to make specific plans for executing a certain behavior, it will be less likely for the behavior to occur. This implies that being unable to make plans regarding quitting smoking and using cessation aids will decrease the likelihood of using smoking aids. Intention is influenced by motivational factors (i.e., attitudes, social influences and self-efficacy regarding smoking cessation and using cessation aids). Finally, the model incorporates influences of predisposing factors, such as age, gender, socio-economic status, and level of tobacco addiction as measured by the Heaviness of Smoking Index.

A representative sample of 982 Dutch smokers aged 15 years and older, who took part of the Continuous Survey of Smoking Habits, completed the questionnaire. Participants only filled in the questionnaire section on determinants of using cessation aids, when they indicated they wanted to quit at least in some point in their life. Data will be analyzed using a hierarchal regression model.

Results The results will be presented during the conference. Additionally, we will present a strategy outlining how to better reach and inform smokers about evidence based methods for smoking cessation.

Implementation In 2011, pharmaceutics for smoking cessation will be reimbursed through the Dutch national health care insurance system when one attends behavioral therapy. The results of this study can be used to develop interventions, particularly mass media approaches as well as tailored interventions, to effectively reach and inform smokers about using evidence based cessation aids and to increase the adoption of these aids for quitting.

Parallelsessions 1: March 28, 13.30-15.00 8 1B.3: Counselling on smoking cessation: Findings of the second survey among all Swiss doctors in 2008

A-K. Burkhalter1, H. Krebs2, J. Cornuz3 1Swiss Cancer League, B…RN, Switzerland 2Public Health Research, ZURICH, Switzerland 3University Hospital, Dep. Community Medicine, LAUSANN…, Switzerland

Objectives This 2008 survey intended to assess clinical practice of Swiss primary care physicians in smoking cessation counselling and to check for a possible improvement of number and quality of doctors interventions since 2002. An initial survey of physicians regarding the status of smoking cessation counselling is available for 2002. In 2002 the National Stop Smoking Program had just started, and it included a training program for smoking cessation in primary care. In order to improve physicians’ smoking cessation knowledge and skills, the project ‘vivre sans tabac - Live smokefree’ offered educational courses together with documentations like a reference manual, guidelines, several algorithms or patients’ brochures. A total of sixty teachers were trained in 2002/05 in several instruction courses in order to disseminate the smoking cessation program all over Switzerland.

Methods The survey of Swiss physicians addressed all 8552 primary care physicians, all Swiss pneumologists, gynaecologists und paediatricians, together with a sample testing of 1029 physicians in clinic. Using the national registry of the Swiss primary care physicians, an invitation letter and a questionnaire were mailed to them, with a single reminder letter eight weeks later. Evidence-based smoking cessation interventions that were asked for consisted of prescription of NRT, of bupropion or varenicline, direct smoking cessation counselling, recommendation to attend group smoking cessation therapy, and referral to a smoking cessation specialist for counselling. Data were processed anonymously.

Results With a response rate of 41 %, 3629 primary care physicians out of those 8552 doctors state that their current practice includes smoking cessation counselling. 90% of responders that had attended a course in smoking cessation counselling offer assistance to all those patients who are motivated to stop smoking.

Today, 82% of all physicians always ask patients about smoking (vs. 78% in 2002), 76% are asking patients about their motivation to stop smoking (vs. 64% in 2002). Here, pneumologists perform best at 97% while gynaecologists have barely changed their practice at 66% (vs. 55% in 2002) and offer support to a mere 43% of patients (vs. 40% in 2002).

Conclusions and Implementation The majority of participating Swiss physicians practice recommended smoking cessation interventions to patients which showed motivation to stop smoking. However, the number of physicians practicing these interventions could be increased and the implementation of the interventions improved. Smoking cessation training courses like those offered by this program are an effective measure to achieve both goals.

Parallelsessions 1: March 28, 13.30-15.00 9 1B.4: Barriers, bottlenecks and possible solutions for smoking cessation treatment in primary care: a qualitative investigation

C. van Rossem, D. Kotz, J.C.R. Kleijsen, M. Hendricx, M.G. Spigt, C.P. Van Schayck CAPHRI, MAASTRICHT, The Netherlands

Objectives To explore barriers and bottlenecks of smoking cessation treatment in primary care, from the perspective of smokers, ex-smokers, general practitioners (GPs) and practice nurses, and to study possible solutions for improving the effectiveness of such treatments.

Method A qualitative investigation was applied in a large Dutch primary health care network. The study had a descriptive and explanatory design with an inductive approach. Data were collected by means of focus groups with 11 smokers and 3 ex-smokers, and semi-structured interviews with 4 general practitioners and 5 practice nurses. Data analysis was completed by applying the constant comparative method with a grounded theory approach.

Results Three main barriers to smoking cessation treatment from an (ex-)smokers perspective were found. First, (ex-)smokers felt that quitting smoking is mainly depending on the motivation of the individual and not influenced by health care providers. On the other hand, (ex-)smokers thought that health care providers should more actively address the relevance of smoking cessation and provide concrete support and treatment. Second, (ex-)smokers often had negative prejudices against cessation aids and did not have confidence in their effectiveness. Finally, (ex-)smokers felt not being accepted by society anymore and irritated by current anti-smoking campaigns. From the health care providers perspective, lack of motivation from an individual was also reported as the most important bottleneck for quitting smoking. Although they considered it as an individual’s own responsibility, they believed that it is the professional’s task to focus more on underlying causes for that lack of motivation. Finally, also health care providers did not always think medication is advantageous and minimize the prescription of medication.

Conclusion From the perception of (ex-)smokers and health care providers, many barriers exist towards smoking cessation treatment. Most important are the lack of motivation in smokers, the fact that many smokers are not aware of smoking cessation treatments available in their primary health care centre, the lack of information on availability and perceived low effectiveness of cessation aids, and GPs’ lack of time to discuss smoking cessation with patients.

Implementation In daily practice it can be recommended to Dutch GPs to address more often a person’s smoking behaviour and, if necessary, make smokers aware of the available smoking cessation treatments in the health care centres and give concrete options and support. Since GPs lack time they could refer motivated patients to the practice nurse for counselling. Furthermore, more information should be given about the different treatment options and aids, for patients as well for health care providers. This information might decrease the amount of negative prejudices about the therapies and increase the smokers’ and health care providers’ confidence in the treatment effects.

Parallelsessions 1: March 28, 13.30-15.00 10 1B.5: A survey of use, opinions and preferences for smoking cessation medications: nicotine, varenicline and bupropion

J.F.E. Etter University of Geneva, G…N…VA 4, Switzerland

We conducted an Internet survey (French/English, 2008-2010) to identify use, compliance and preferences among smoking cessation medications in a “real world”sample (n=1080, 42% smokers, 58% former smokers). The most used medications were, in order: nicotine patch, varenicline, nicotine gum, nicotine lozenge, bupropion, nicotine inhaler and nicotine tablet. Results showed more varenicline users were former smokers than those using other medications. Perceived efficacy was best for varenicline and lozenge, poorest for gum. Craving and withdrawal symptoms were best relieved by lozenge/tablet, with daily use good for lozenge (9/day) but lower than recommended for gum (6/day) and inhaler (2/day). A majority of users of nicotine medications received no professional advice. By smoking status, former smokers had more education, used medications properly (daily, over time) and reported more satisfaction and relief of craving and withdrawal than current smokers. Improving outcome may require better education on pharmacotherapies or simpler-to-use, cost-effective medications.

Parallelsessions 1: March 28, 13.30-15.00 11 1C - Session ETS health impact

1C.1: Impact of Smoke-Free Law on Indoor Air Quality - Turkey Experience

N.B. Bilir, H.O. Ozcebe, D.A. Aslan Hacettepe University, Faculty of Medicine, ANKARA, Turkey

Turkey has become complete smoke-free country with the “amended”Anti-Tobacco Law No. 4207 in July 2009. Having a “Law”is an essential element of tobacco control, however implementation is also important. In order to see the impact of the Law on indoor air quality, PM2.5 levels were measured before and after the implementation of the Law at various closed places in Ankara. PM2.5 measurements were done for 30 minutes using SKC Sidekick 224-52TX model Dust Sampler. Several thousand mcg/m3 values were found during “before implementation”measurements, and considerable reduction was observed after smoke-free implementation. The most striking reduction was observed at a public office (from 2900 to 80 mcg/m3) and a small stationary shop (from 1800 to 400 mcg/m3). Pre and post implementation values at some of the places are seen in the table below. Although the post-implementation levels were still above the permissible limit, the improvement in indoor air quality is promising. Better implementation and enforcement of the smoke-free law is needed to achieve the complete smoke-free indoor places.

1C.2: Health impact in hospitality workers of a smoking ban in Vaud, Switzerland

C.K.H. Huynh1, A.D. Durham2, X.M. Morisod3, S.B. Bergier3, J.C. Cornuz3 1Institute for Work and Health, LAUSANN…, Switzerland 2Policlinique Médicale Universitaire (PMU), LAUSANN…, Switzerland 3Policlinique Médicale Universitaire (PMU), LAUSANN…, Switzerland

Objectives This work addresses the impact and implementation issues, in the hospitality sector, of the new cantonal law banning smoke in public areas and the workplace.

Methods A letter inviting hospitality workers to participate in this study on the impact of the forthcoming smoke-free cantonal law was sent to owners of all the 1798 hospitality venues listed in the canton. 36 establishments responded positively and 105 hospitality workers were recruited before the law took effect on 15.09.2009.

Environmental tobacco smoke (ETS) exposure was measured by using a passive sampling device. These personal Monitors of NICotine (MoNIC) were carried by the subjects during one workshift in the hospitality venue. The inhaled Cigarette Equivalents (CE) was calculated, based on a reference of 0.2 mg of nicotine per cigarette. These measures were combined with biomonitoring of salivary cotinine and nicotine. 1 ml of saliva was collected by a non- stimulated method and products were quantified by liq-liq extraction with CH2Cl2 and GC-NPD.

Lung function tests were performed with an EasyOne portable spirometer at the work setting. Each participant underwent at least three forced expiratory maneuvers and the result-

Parallelsessions 1: March 28, 13.30-15.00 12 ing output was analyzed by a pneumologist for validation.

The participants were also invited to answer a questionnaire as well as the SF-36 health survey, a short-form, multipurpose health survey.

These analyses were then repeated at six and twelve months from study initiation.

Results Since the introduction of the new smoke-free law in the canton of Vaud in september 2009, exposure to ETS has declined significantly among both non-smokers and smokers using inhaled CE as measured by MoNIC badges.

Lung function tests show a significant improvement in FEV1 (forced expiratory volume in 1 second) in self reported asthmatics as well as in younger subjects (<40 years) at 6 months from study initiation, after the ban took effect.

Moreover, analysis of the SF-36 forms at 6 months reveals a significant improvement in role limitations because of physical health problems in men, physical pain in men as well as global physical score in men.

Conclusions The smoke-free law allowed a significant decrease in hospitality workers’ exposure to ETS. The most immediate benefits appear to be improvements in lung function tests in the especially vulnerable asthmatic group and more interestingly in younger subjects as well. Men exhibit an improved subjective physical health already 6 months after introduction of the law.

Further analysis of results, especially at one year from study initiation, will be crucial to better understand the impact of the smoke-free law.

Implementation This study shows the beneficial impact of the law banning smoking in public places in the canton of Vaud. It shows the importance of implementing smoking bans in all workplaces including hospitality venues.

1C.3: Exposure to second-hand smoke and compliance with national smoke-free workplace legislation

E.A. Heloma, S.H. Helakorpi, J.H. Honkonen, A.U. Uutela National Institute for Health and Welfare, H…LSINKI, Finland

Objectives The current study examined time trends and associations in exposure to second-hand smoke (SHS) in Finland in 1985-2008 in workplaces of different sizes, and compliance with national smoke-free workplace legislation that has been enforced since 1995. The legislation allows separately ventilated smoking rooms in workplaces. The legislation requires that nonsmokers are not at all exposed to SHS.

Methods The study population comprised respondents of nationally representative annual postal surveys. The annual sample size was 5000 persons between 15 and 64 years of age. The response rate varied between 64 and 82 per cent. The differences in the prevalence of

Parallelsessions 1: March 28, 13.30-15.00 13 SHS-exposed respondents were measured with particular reference to workplace size and workplace smoking arrangements.

Results From 1985 to 2008 daily exposure to SHS at work among non-smokers was reduced from 40% to 8%. After the implementation of the legislation in 1995 the exposure started to fall more sharply than before the enforcement of the law. The proportion of workplaces with designated smoking rooms was 48% in 1995-1996, and this proportion was unchanged in 2007-2008. The proportion of exposed employees in workplaces with designated smoking rooms was two-fold compared to employees in workplaces where no one smoked, and this ratio remained unchanged between 1995 and 2008. Workplace size was associated with the proportion of those exposed. Employees in small workplaces were exposed most and exposure to SHS was lowest in large workplaces.

Conclusions Enforcement of the smoke-free workplace legislation accelerated the decrease in employee exposure to SHS. Totally smoke-free workplaces should be preferred to workplaces with designated smoking areas to minimize the number of exposed employees and to achieve better compliance with the law. Employees of small workplaces are most vulnerable to SHS exposure. In the prevention of SHS exposure, special attention should be directed to workplaces with less than 20 employees.

Implementation The practical implementation of the results of the present study would be totally smoke-free workplaces without any smoking rooms or areas. The current legislation should be amended to abolish designated smoking rooms from all workplaces.

1C.4: Effect of smoke-free legislation on the incidence of sudden cardiac arrest in the Netherlands J.D. de Korte1, D. Kotz1, W. Viechtbauer1, H. Coenen2, A.P. Gorgels3, C.P. Van Schayck1 1Maastricht University, MAASTRICHT, The Netherlands 2GGD Zuid Limburg, G…L……N, The Netherlands 3Maastricht University Medical Centre, MAASTRICHT, The Netherlands

Objectives In the Netherlands, smoke-free legislation was implemented in two phases. On 1 January 2004, a workplace smoking ban came into effect. On 1 July 2008, the catering, sports, and cultural sectors lost their initial exemption from the 2004 ban. The aim of this study was to investigate whether the smoke-free legislation led to a decrease in the incidence of out-of- hospital Sudden Cardiac Arrest (SCA). To our knowledge, this is the first study in the Nether- lands investigating a health effect of smoke-free legislation.

Methods We used data from the ambulance registry of South Limburg. All records between 1 January 2002 and 1 May 2010 were manually searched for people aged between 20 and 75 years, who were either found dead or received resuscitation or defibrillation. These were considered to be SCA cases. The primary outcome measure was the weekly number of incident SCA cases. Poisson regression was used to test whether there was a change in this incidence following the 2004 and/or 2008 smoking ban. Therefore, three time periods were distinguished: the pre-ban period in which no smoking ban was operative (1 Jan. 2002 - 1 Jan. 2004), the first

Parallelsessions 1: March 28, 13.30-15.00 14 post-ban period in which the workplace smoking ban came into effect (1 Jan. 2004 - 1 July 2008), and the second post-ban period in which both smoking bans were operative (1 July 2008 - 1 May 2010). Weekly mean temperature, weekly range in temperature, weekly mean airborne particular matter, and weekly influenza activity were included as co-variates in the model. An estimate of the weekly population size was included as an offset variable.

Results A total of 2306 SCA cases were observed with a mean weekly incidence of 5.3 ± 2.3 cases per week. The adjusted Poisson regression model showed a small but significant increase in SCA incidence during the pre-ban period (+0.2% cases per week, p=0.032). This trend changed significantly after implementation of the first ban (-0.3% cases per week, p=0.025). This implies a 14.7% decrease in the number of SCA cases after one year of smoke-free legislation. No further decrease was observed after the second smoking ban.

Conclusions After introduction of a nationwide workplace smoking ban in 2004, the incidence of out-of- hospital SCA significantly decreased in South Limburg. The introduction of a public smoking ban in the catering, sports and cultural sectors in 2008 did not lead to a further decrease.

Implementation The findings of this study support the smoke-free legislation in the Netherlands. When we extrapolate our regional study results to the whole Dutch population, the workplace smoking ban prevented at least 33 persons to suffer from SCA in the first year after the ban came into effect.

Parallelsessions 1: March 28, 13.30-15.00 15 1D - Session Cessation clinics

1D.1: Predictors associated with success among smokers attending stop smoking clinics in Malaysia

L.H. Wee1, L. Shahab2, A.B. Bulgiba1, R. West2 1University of Malaya, P…TALING JAYA, Malaysia 2CRUK Health Behaviour Research Centre, University College London, LONDON, United Kingdom

Background A lot is known about predictors of success in quitting smoking but to date studies have almost exclusively focused on Western countries. More data are needed on the cross-cultural gen- eralisability of the findings.

Objectives This study aimed to assess predictors of short-term success in stopping in smokers attending Malaysian smokers’ clinics.

Method One hundred and ninety smokers attending five stop-smoking clinics in Malaysia were interviewed using a structured questionnaire prior to their quit attempt. Predictors included demographic variables, smoking patterns and dependence, past history of quitting, the ‘quitting rule’ (abrupt versus gradual) and motivation to quit.

Results 70 (36.8%) participants were abstinent at 3-month follow-up. In multiple logistic regression, participants were found to be more likely to be successful if they were married, did not pre-plan their quit attempts, were unhappy about being a smoker and more motivated to quit, described themselves as smoking more than other smokers at their age and did not indicate that smoking helped them to stay alert. The quit smoking clinic attended was also associated with successful quitting. No independent association was found between quit success and nicotine dependence.

Conclusions Predictors of successful smoking cessation do not appear to generalise in a straight forward manner from Western to Non-Western samples. In particular, nicotine dependence and motivational predictors appear to have divergent associations with smoking abstinence which may reflect the influence of different tobacco control environments.

Implementation Findings from this study suggest that since non-Western countries are at an earlier stage in the tobacco epidemic, exhibiting weaker tobacco control measures, pressure to stop may be less. Thus, quit success may be influenced to a greater extend by motivational than dependence measures because unlike in Western countries, the total pool of smokers in non-Western countries will comprise of fewer ‘hardcore smokers’ and more smokers who could stop if they wanted to. This study opens a novel perspective for future smoking cessation interventions in non-Western countries since motivational factors may be used more effectively here as traditionally clinic interventions tend to focus on highly addicted, ‘hardcore’ smokers and have not given high priority to those who are not motivated to quit based on the tenet of TTM.

Parallelsessions 1: March 28, 13.30-15.00 16 1D.2: Ten years developement of tobacco cessation clinics in France

B.D. Dautzenberg1, J.O. Osman2 1Pitie-Salpêtrière hospital APHP, PARIS, France 2Office Français de prévention du Tabagisme (OFT), PARIS, France

The French concept of tobacco cessation clinics “consultation de tabacologie”has been set in 1999 by Bernard Kouchner, Ministry of health and the first clinics were founded one year later.

Before 2000, there was no coordination between the anti smoking facilities created from 1970.

OFT has been maintaining the list for years and defined main characteristics of tobacco cessation clinics in France.

Method The database of characteristic of tobacco cessation clinics maintained online by OFT has been analyzed on the data base as it was on January 1st. 2010,

Results The number of tobacco cessation clinics has increased from 275 in 2001 up to 505 in 2004 and 670 in 2010 according the dates reported by tobacco cessation clinics. There is one tobacco cessation clinic for 100 000 inhabitants in France.

All 98 French departments (except 2) have from 1 to 48 tobacco cessation clinics. Among them, 398 tobacco cessation clinics are hospital based (59.5%) and 272 based in the community, mainly in non-profit sector. Tobacco cessation clinics are set in pulmonary units in 145 cases, addiction units in 143 cases, general medicine units in 110 cases, preventive units in 88 cases, in cardiology units in 35 cases, in maternity in 28 cases and in other specialties in 33 cases. In 88 cases the tobacco cessation clinics were independent from other medical units.

A CO analyzer is used for > 90% of smokers in 74% of tobacco cessation clinics. Urine cotinine is measured in routine in only 60 tobacco cessation clinics. The Fagerström test is used for > 95% of smokers, the HAD test is used by 81% of tobacco cessation clinics.

All tobacco cessation clinics use nicotine replacement therapy and other medications of prescription for smokers. Only 38 tobacco cessation clinics (6%) use occasionally acupuncture as adjuvant therapy for cessation.

Behavioral supports are used in 238 tobacco cessation clinics. Face to face consultation is associated with group session in 27% of tobacco cessation clinics. The 30 tobacco cessation centers with no prescription, but only behavioral support are not included in tobacco cessation clinics at this time. But all tobacco cessation services will be reclassified according to the eSCCAN definitions in 2011.

Conclusions Tobacco cessation clinic is available on near all French territory with one tobacco cessation clinic/100 000 hab. Constant improvement is observed but not all tobacco cessation clinics reach the standard level and > 90% of French smoker who quit don’t address tobacco cessation clinics to stop.

Parallelsessions 1: March 28, 13.30-15.00 17 1D.3: Who Will Take Over Tobacco Control in Russia: New Services - New Challenges?

M.G. Gambaryan, A. Deev, A. Kalinina National Research Centre for Preventive Medicine, MOSCOW, Russian Federation

Smoking is a big public health problem in Russia with the highest prevalence among men and increasing prevalence among women; Russia presents the highest prevalence of smoking attributable premature mortality in the European Region. Despite this public awareness is still low regarding smoking, and smoking related diseases remain greatly underestimated and underdiagnosed.

Our multi-centre population based study with 3771 randomly selected representative sample of men and women aged 35-64 in three regions of Russia revealed a prevalence of smoking in 54.5% of men and 14.3% women with high relation to cardiovascular (prevalent in 22.5% of men and 29.3% women) and respiratory diseases - 12.9% and 15.7% respectively - from whom only 50.9% were ever told to have any respiratory diagnosis(p<0.001).

In the context of confronting the problem of tobacco use and implementing key issues of FCTC, Ministry of Health of Russia has launched in September 2009 an initiative about “Organising Health Centres for Promoting Healthy lifestyle in citizens of Russian Federation including prevention of alcohol and tobacco use”The “Health Centres”(HC) should become new forms of pre-primary health service institutions meant for screening of “healthy people”. They are formed and equipped to identify risks and detect early stages of cardio-respiratory diseases, and particularly smoking as risk factor of those (spiromentry and CO-detection are mandatory examinations in the screening) and use the findings for health education (HE) and/or further investigation and treatment of the patients.

However this innovation presents many questions and new challenges for health system - like building up teams of professionals, dealing with the findings of the screening in HC, interconnections with primary health care and hospital sectors.

To confront some of those challenges we work towards 1)enhancing capacity of health professionals in HE and health promotion (HP) including smoking prevention/cessation and smoking related diseases prevention, 2)piloting the activities of HC in different organizational models like e.g. at the workplaces, regional or municipal policlinics, to identify the best models for smoking education/cessation and recommend the best HP implementation and evaluation strategies.

Our preliminary findings of pilot studies in National Media Company as a workplace model and municipal policlinics reveal: 1. Health screening may largely contribute to early risk detection in healthy people, particularly with regards Smoking Related Diseases; 2. workplaces are promising settings for HP programs implementation due to high cover age of working-age population, and high motivation of those for promoting own health, 3. smoking cessation may be best implemented in policlinic settings; 4)further investigation is needed to identify best cost-effective models for HP interventions.

“Health Centres for Promoting Healthy lifestyle”initiative is a big step forward raising awareness and enhancing knowledge of the population about health risks of smoking (including individual risks), which provides a sound ground for smoking cessation.

Parallelsessions 1: March 28, 13.30-15.00 18 1D.4: Standard Smoking Cessation Interventions in Denmark

N.T.K. Kjær Danish Cancer Society, COP…NHAG…N, Denmark

Background Health personnel have been systematic trained to run two standard smoking cessation interventions all over Denmark during the last 10 years: Smoking cessation in groups and individual counselling. During the same period of time the prevalence of smoking has fallen from 33 % to 26 %.

Objectives Half of the Danish smokers have plans to stop smoking. Standard smoking cessation interventions have been organised in order to secure easy access to effective methods to quit smoking.

Methods Two interventions are used. In the group format ten to twelve smokers meet with a cessation counsellor for five sessions and stop smoking between the second and third session. The individual counselling also consist of five sessions but this format is more flexible with regard to the participants’ readiness to stop. A highly motivated smoker can quit smoking after the first session, whereas a more ambivalent smoker can spend more sessions on contemplation and preparation.

The two standard smoking cessation intervention are run by nurses, midwifes and personnel at pharmacies. About 5000 of these so-called cessation counsellors have been trained from 2000 to 2010 at three-day courses. The counsellors have been trained in interviewing and advising smokers to quit assisted by a manual with guidelines for the five sessions. They have received basic therapeutic skills inspired by Motivational Interviewing and cognitive therapy.

Results A systematic follow-up has been made of 3628 adults who participated in smoking cessation groups or in individual counselling interventions in Denmark. With the most conservative way of measuring one in six of the smokers were smoke-free measured after twelve months. The rates of continued abstinence after twelve months were nearly 20% among those smokers who participated in four of the five sessions. Five determinants were identified which influenced continued abstinence: gender, age, the degree of nicotine dependence, the format and the setting of the cessation service.

Conclusions We believe that we have shown that it is possible to implement smoking cessation interventions across a country and to keep the rates of continued abstinence from clinical trials. The successful cessation interventions were run by nurses and equivalent staff that had received only three days of training and had no other particular therapeutic skills.

Implementation One or both standard smoking cessation interventions are today implemented in 97 of 99 municipalities in Denmark and free of charge for the smokers.

Parallelsessions 1: March 28, 13.30-15.00 19 1D.5: Smoking cessation counseling clinics in Estonia. Assessment and networking: Estonian experience

T.H. Harm …stonian Institute for Health Development, TALLINN, …stonia

All health care professionals should play a leading role in tobacco control. They should be role models as non-smokers, assess and address tobacco, educate about tobacco, advice on cessation and support tobacco-free environment.

Objective – Prevalence of smoking in Estonia. According to Health Behaviour Study among Estonian Adult Population, 2008, there are 26% of 16-64 years old population daily smokers (39% males and 17% females). In 2006 the precentage was 28 and in 2004 - 33. Smoking behaviour is strongly connected with the education level: 16% males with higher education are daily smokers, compared with 50% of males with basic education. Also 66% males and 33% female unemployees are daily smokers (2008). According to Estonian Medical Birth Registry 2008, 11% of pregnant women continue smoking during pregnancy (2006 - 10% and 2004 - 9%). According to Estonian school-based survey of students in 13-15 age (Estonian GYTS, 2007), there was 31% of students (32% boys and 30% girls) who currently smoke cigarettes or use some other tobacco products. 35% of them initiated smoking before age ten. 28% of never smokers are likely to initiate smoking next year. 43% live in homes where others smoke in their presence.

Methods – Smoking Cessation Clinic (SCC) assessment and networking: Estonian Network of Health Promoting Hospitals and Health Services was established in 2000. Estonian HPH Network joined the European Network of Smoke-free Health Care Services (ENSH) in 2005. Estonian HPH Network is a partner in e.SCCAN (European Smoking Cessation Clinic assessment and networking ) project (2010-2011). Estonian SCC country profile: 1 340 415 inhabitants, 34% smokers, total tobacco ban 2007. Density of SCC - 1 clinic for 60000 inhabitants. The tendency is to move from the hospital setting into community setting (primary health care). In the frame of National Strategy for CVD prevention (2005-2020) and National Strategy for Cancer (2007-2015) was established the network of 21 SCC (2005-2009), incl 3 SC centres for children and adolescents and 2 - for pregnant women. Since September 2010 SC clinics for 16-64 years old population are financed by European Social Foundation programme (2010-2011).

Results 240 healthcare professionals (medical doctors, nurses, midewives) passed 16 hours education and training programme on tobacco consumption and cessation. The smoking cessation counseling service is free of charge for patinets. On average, 16-19% of the quitters are staying as non-smokers after 1 year. The guidelines for smoking cessation and good practice exist. Accupuncture, hypnose, phytotherapy without any medication is excluded from SCC list.

Conclusions The HPH and ENSH networking process give to the health care organisations the opportunities to exchange experiences, good practices and to accelerate the know-how process. It is only through collaborative action that we can truly come to grip with smoking as killer No.1.

Parallelsessions 1: March 28, 13.30-15.00 20 1E - Session Lower socio economic status and effects of policy

1E.1: The re-shaping of life-worlds: Male UK Bangladeshi smokers and the English smoke-free legislation

D.D. Ritchie1, G. Highet1, S. Platt1, K. Hargreaves2, A. Amos1, C. Martin3, M. White4 1University of …dinburgh, …DINBURGH, United Kingdom 2Institute of …ducation, LONDON, United Kingdom 3Scottish Centre for Social Research, …DINBURGH, United Kingdom 4University of Newcastle, N…WCASTL…, United Kingdom

Objective To explore the role of smoking in creating and sustaining health disadvantage in the Bangladeshi community; and to improve understanding of the adaptation and adjustment of male British Bangladeshi smokers to the English smoke-free legislation.

Design We draw on data derived from the Evaluation of Smoke-free England (ESME), a qualitative, longitudinal study conducted between 2007 and 2008 in two English metropolitan areas. Methods included repeat interviews with panel informants and key stakeholders, focus groups with sampled communities, and observations in community venues. In this paper, we present data from repeat interviews (n=34) conducted before and after the legislation with 15 male Bangladeshi panel informants and from two focus groups, one with Bangladeshi men, the other with Bangladeshi women, the latter providing an additional valuable perspective on male Bangladeshi smoking behaviour.

Results Bangladeshi smokers in this study had largely accommodated to the smoke-free legislation and most had reduced their consumption of cigarettes, albeit to a modest degree. However, at the same time some Bangladeshi smokers appeared to have increased their use of shisha, a popular alternative method of smoking tobacco in this community. Smoke-free also had an impact on the social and cultural forces that shape smoking behaviour in this group. In particular, family homes continued to be a key space where tobacco is consumed, although the legislation may have helped to shift the balance in favour of forces that oppose smoking and the enduring cultural norms that continue to tolerate it. Smoking in public was also less socially acceptable, especially in the vicinity of the mosque and at community events. In some older groups, however, smoking remains a deeply embedded social habit which, in some instances, can undermine smokers’ efforts to quit.

Conclusion We conclude that, for maximum impact, tobacco control interventions aimed at whole populations may need to be supplemented by culturally sensitive measures in some local areas where there is a high concentration of Bangladeshi people.

Implementation • While Bangladeshi smokers have largely accommodated to smoke-free legislation, smoking remains a deeply embedded social habit in some older peer groups • Smoking in public appears to have become less socially acceptable in Bangladeshi

Parallelsessions 1: March 28, 13.30-15.00 21 communities • Smoking in family homes remains subject to competing forces, although smoke-free legislation may have helped to shift the balance against pro-smoking norms and cultural rules (e.g. respect for elders) which encourage tolerance towards smoking • Reduction in tobacco consumption in minority ethnic communities is best achieved by supplementing interventions aimed at whole populations with culturally sensitive measures which target particular sub-groups’

1E.2: Evaluating social and behavioural impacts of English smoke-free legislation in different ethnic and age groups A. Gilmore1, K. Lock2, E. Adams3, P. Pilkington4, K. Duckett2, C. Marston2 1University of Bath, BATH, United Kingdom 2London School of Hygiene & Tropical Medicine, LONDON, United Kingdom 3Oxford Brookes University, OXFORD, United Kingdom 4University West of …ngland, BRISTOL, United Kingdom

Objective To explore differences in the social and behavioural impacts of smoke-free legislation (SFL) in different ethnic and age groups.

Methods A longitudinal, qualitative panel study of smokers using in-depth interviews conducted before and after introduction of SFL. A purposive sample of 32 smokers selected from three ethnic groups (Turkish, Somali and White British) in deprived London neighbourhoods. Sixty five interviews were completed with approximately equal numbers of younger and older, male and female participants in each ethnic group.

Results SFL had positive impacts with half smoking less and three quitting. Although there were no apparent differences in smoking and quitting behaviours between groups, there were notable differences in the social impacts of SFL. The greatest negative impacts were in smokers aged over 60, potentially increasing their social isolation, and in young Somali women whose (largely shisha) smoking was driven more underground. In contrast, most other young adult smokers felt relatively unaffected, describing unexpected new social benefits of the legislation created by outside smoking areas making it ‘even more social to smoke’. Although there was a high degree of compliance, reports of illegal smoking were more frequent among young, ethnic minority smokers, with descriptions of venues involved suggesting they are ethnically distinct and well hidden from general public. Reported changes to smoking in the home after SFL were complex. Half of respondents reported stopping smoking in their own homes after SFL, but almost all were Somali or Turkish. White respondents tended to report increases in home smoking.

Conclusions Although our study suggests that SFL can lead to reductions in tobacco consumption, it also shows that legislation impacts vary by ethnicity, age and gender with implications for inequalities. In this English study, particular concerns include increasing social isolation in the elderly, the difficulties of denormalising smoking in the young with the danger that the opposite may occur, and, in groups where smoking was already stigmatised, such as Somali women, driving smoking further underground.

Parallelsessions 1: March 28, 13.30-15.00 22 Implementation This study highlights the importance of understanding the meaning of smoking in different social and ethnic contexts. Most evaluations of SFL have focused on impacts on the population as a whole, including impacts on air quality, smoking prevalence rates or health. Few studies have examined differences in compliance with, or social and behavioural impacts, of legislation between different age or ethnic groups. Research and evaluation needs to explicitly study the potential equity effects of tobacco control interventions so future policy can be developed to reduce health and social inequalities. Qualitative approaches have been previously used to gain important insight into issues of tobacco control including home smoking, but this study shows the relevance of such study designs to SFL evaluation.

1E.3: The effectiveness of cultural adaptations in interventions aimed at smoking cessation: a systematic review

V. Nierkens, C. Vissenberg, M. Nicolaou, I.G. Van Valkengoed, E.J. Beune, M.A. Hartman, K. Hosper, K. Stronks Academic Medical Center - University of Amsterdam, AMST…RDAM, The Netherlands

Objective The contribution in the effectiveness of specific cultural adaptations in lifestyle interventions, including smoking cessation interventions, has not been well established. This review aims: 1. to gain insight into the effectiveness of the specific cultural adaptation in interventions aimed at smoking cessation among non-Western ethnic minority groups by reviewing studies that only varied the specific cultural adaptation between intervention and control group; 2. to explore the features of specific cultural adaptations that may help to explain their potential utility.

Methods This review was part of a larger review of cultural adaptations in lifestyle interventions aimed at smoking cessation, diet and physical activity. A systematic review of English and non-English articles using MEDLINE, PSYCHINFO, EMBASE and the Cochrane Controlled Trials registers (1997 - 2009). Search terms were based on the OVID Mesh terms and included, among others, ‘ethnic’, ‘racial’, ‘religious groups’, ‘health education’ and / or ‘health promotion’ ‘smoking cessation’. Only studies that described the effect evaluation of a lifestyle intervention aimed at ethnic minority adult population, in which the intervention encompassed cultural adaptations, was aimed at smoking cessation as primary outcome and had a control group that enables the evaluation of the specific cultural adaptation were included. Independent extraction of articles by 2 authors using predefined data fields, including study quality indicators.

Results Regarding smoking cessation, we had more than 19000 hits. 6 studies met all inclusion criteria. The specific cultural adaptations tested by varied across the included studies and included both surface and deep structure adaptations, ranging from incorporating cultural values in written materials to the involvement of lay health advisors. Several studies incorporated more than one cultural adaptation. In contrast to diet and physical activity, specific cultural adaptations appeared to be effective on main outcomes in 5 out of 6 studies. Analysis of the features of the adaptations and interventions reveal a broad diversity in type of adaptations and results. We could not identify one type of adaptation that appeared more

Parallelsessions 1: March 28, 13.30-15.00 23 effective than others.

Conclusion Regarding smoking cessation, it appeared that cultural adaptations appeared to increase the effectiveness of interventions aimed at ethnic minorities, but we cannot explain why interventions regarding smoking cessation appeared to be more effective than the others. To gain more insight into the value of specific cultural adaptations, more systematic experiments aimed at testing a single cultural adaptation are necessary.

Implementation The information of this study will help to design future studies that may provide insight into which adaptations will be most promising for developing effective interventions for ethnic minority populations.

1E.4: Higher socioeconomic status and educational level are not associated with lower smoking prevalence in Greece

F.F. Filippidis, S.S. Schoretsaniti, Y.T. Tountas National and Kapodistrian University of Athens, ATH…NS, Greece

Objectives In most countries, significant differences in smoking prevalence between different socio- economic groups have been documented. The level of education has also been shown to affect the prevalence of smoking. The objective of the present study was to explore potential inequalities in smoking prevalence among the Greek adult population.

Methods Data were obtained from the national household survey Hellas Health I, conducted during 2006. Candidate respondents were selected by means of a three-stage, proportional to size sampling design. A representative sample of the Greek adult population, comprising of 1005 adults (483 men and 522 women, mean age 47.4 ± 18.2), was interviewed. Individuals who responded that they smoke daily or occasionally were classified as smokers. Smokers who smoke more than 20 cigarettes per day were classified as heavy smokers. The ESOMAR socioeconomic classification was used to determine socioeconomic status. The chi-square test was used to make comparisons between groups.

Results Among the general adult population, smoking prevalence was 43.1% (52.4% among men and 34.5% among women); 40.1% of the smokers were heavy smokers. Smoking prevalence did not differ significantly between the various socioeconomic groups, neither in men nor in women. The proportion of heavy smokers also did not differ significantly (p>0.05) between different socioeconomic groups. On the contrary, educational level was found to influence the prevalence of smoking, but not the proportion of heavy smokers. Surprisingly, people of low educational level tend to smoke less frequently than individuals who have completed more than 7 years of education. This association was statistically significant in both men (p<0.05) and women (p<0.001).

Conclusions Smoking prevalence among the Greek adult population is high among all socioeconomic and educational groups. In Greece, unlike most developed countries, higher educational level and socioeconomic status are not associated with lower prevalence of smoking.

Parallelsessions 1: March 28, 13.30-15.00 24 Implementation Clearly, education and socioeconomic status are not the major determinants of smoking in Greece. Therefore, anti-smoking campaigns and bans should target the whole Greek population and incorporate appropriate lifestyle-related messages.

Parallelsessions 1: March 28, 13.30-15.00 25 1F - Session Denormalising and effect of policy measures

1F.1: The end of the tobacco era: Tobacco-free Finland by 2040

M. Hara Finland’s ASH, H…LSINKI, Finland

Background In the 1920s, Finnish cigarette consumption was the highest in the world, and was far more than in other Nordic countries. At the beginning of the 1950s, some 76% of men and 13% of women smoked. The high smoking rate among men at that time was one of the side effects of the Second World War - the cigarettes smoked were generally of the Russian type that had a heavy tar content of 35-45 mg. Since then, there has been a sharp decline in daily smoking among men. By 2009, daily smoking among adults in the 15-64 year age group was 19%, 22% in men and 16% in women. The use of snus is minimal.

Among adolescents, the long-term decrease seen in daily smoking stopped in 2009, and turned to increase among 14-16-year-old boys over the past two years. In addition, the use of snus and smoking self-rolled cigarettes increased over the past two years.

Although our tobacco strategy was comprised of various tobacco control measures, it was obvious that there was a need for a new set of legislative actions to combat tobacco use. In 2010, the political aim of the Tobacco Act was defined to end tobacco use in Finland by 2040.

The objective is: 1. to describe the reasoning behind the amendment to the aim of the Finnish tobacco legislation 2. to describe the tobacco industry’s reaction and fight against the novel goal of a tobacco-free Finland 3. to evaluate the future progress towards a tobacco-free society

Discussion Tobacco products are one of the most toxic commodities in the consumer market. The principles and legal rules of health protection and consumer safety would call for a total ban on the manufacturing and sale of these products.

The fact that it is not yet possible to ban tobacco products is not a ground to consider them as ordinary commodities in general legislation and international agreements. The toxicity of these products makes them no ordinary commodities, of which the production and trade are to be reduced by all possible means.

Instead of aiming to reduce smoking and the health harm caused by smoking, the aim of the Finnish tobacco legislation is to end the use of tobacco products by 2040.

Conclusion The proposed aim to end the consumption of tobacco products describes the objective of the tobacco policy better than the previous legislation that sought to ‘reduce’ it. This means that we fully deny the harm reduction policy.

Parallelsessions 1: March 28, 13.30-15.00 26 1F.2: Time for a reality check? Misperception of smoking prevalence in Ireland

F.O. Howell Health Service …xecutive, NAVAN, Ireland

Introduction and Objectives Why people start and continue to smoke is a complex interplay between nicotine addiction and psychosocial factors such as social norms which refer to perceptions and beliefs as to what is “normal”behaviour. These beliefs are influential on behaviour. Overestimation of unhealthy behaviours increases these behaviours, and underestimations discourage them. The aim of this study was to quantify the extent of a misperception, if any, with respect to the perception of smoking prevalence in Ireland.

Methods The Office of Tobacco Control (OTC) monitors cigarette smoking prevalence on a monthly basis to gain a detailed picture of smoking patterns in Ireland using a monthly telephone omnibus quota survey of 1,000 individuals conducted by Ipsos MRBI using random digit dialing. As part of the March 2010 survey additional questions on perception of smoking were asked. Data were analysed using Epi-Info 2002.

Results The overall smoking prevalence was 23%, Just over three-quarters (76.4% of smokers and 75.4% of non-smokers) thought that more than 25% of the population smoked, with a third of smokers (32.3%) and a quarter of non smokers (25.6%) thinking that more than 50% of the population smoked. Smokers were significantly more likely to state that the smoking prevalence was >50% (Risk Ratio 1.3, 95% Confidence Interval 1.0 - 1.6, p<0.05). Overall the commonest category selected by both smokers (48, 21.0%) and non-smokers (144, 18.7%) was a population prevalence of 46-50%.

When asked about smoking prevalence in peer age groups smokers (150-65.5%) were significantly more likely than non-smokers (416-53.9%) to overstate smoking prevalence (Risk Ratio 1.2, 95% Confidence Interval 1.1 - 1.4, p<0.05). Moreover, for both smokers and non-smokers, more than 50% of each group overestimated smoking prevalence in their respective age group..

Conclusions This study shows that both smokers and non-smokers very much overestimate the prevalence of smoking in the population overall and within their own peer age group. As social norms impact on behaviour it may be worthwhile to correct that misperception. Opportunities exist to promote the positive message that more than 7 out of every 10 persons is smoke free and as such change the perception that smoking is normative behaviour.

Utilising libertarian paternalism in such a manner to change perception might encourage non-smokers not to engage in a minority activity and so prevent youth initiation, and it might “nudge”smokers to think about quitting. Getting them to actually quit and sustaining their quit attempt into the future will require additional strategies.

Parallelsessions 1: March 28, 13.30-15.00 27 1F.3: Consumption of tobacco products in Europe

L. Nguyen1, J. Pekurinen1, G. Rosenqvist2 1National Institute for Health and Welfare, H…LSINKI, Finland 2Hanken School of …conomics, H…LSINKI, Finland

Tobacco consumption is considered addictive and harmful to people’s health. Pricing policies are seen as the most important intervention in tobacco control to reduce smoking. The EU project “Pricing Policies and Control of Tobacco in Europe”(PPACTE) has involved developing econometric demand models to investigate the impact of prices on different tobacco products in selected European member states, including Finland, Germany, Ireland, Sweden, the Netherlands and the United Kingdom.

Time series data for each country are on national level including annual consumption per capita and real price of each tobacco product, real disposable income per capita, and information on tobacco control policy measures. The time series at best started in 1960. For most countries studied, cigarettes are the dominating tobacco product. For some of the countries, pipe and/or rolling tobacco and snus are the second product most used. Con- sumptions of these products are endogenous variables in the estimated models. Based on theory of demand and theory of addiction, conventional demand models, partial adjustment and rational addiction models are applied. As well known properties of time series, autocor- relation and cointegration have to be considered and taken into account, the time series are tested for stationarity. Thus, the error correction model is also applied. Models are estimated by instrumental variable methods (2SLS) and Engle-Granger two-step.

For cigarettes, the estimated short-run price elasticities of demand ranged from 0.21 to 1.05, and the long-run price elasticities from 0.35 to 1.87. For pipe tobacco, short-run price elasticities ranged from 0.26 to 1.51, and long-run price elasticities ranged from 0.42 to 1.23. For snus, short-run price elasticities ranged from 0.08 to 0.28, and long-run price elasticities ranged from 0.11 to 0.50. Pipe tobacco appeared to be a substitute for cigarettes in Finland and Germany, as did snus in Sweden. Disposable income was in most cases positively related to tobacco consumption. The estimated models highlighted the differing influence of anti-smoking measures on consumption of selected tobacco products.

In the empirical literature, price elasticity estimates of demand for cigarettes range from 0.14 to 1.23, but most of them are in the narrow range of 0.3 and 0.5. Since the PPACTE project is ongoing, we will continue to analyze possibly new coming data and thus will expect to produce more results to provide policy recommendations to European member states concerning reduction of smoking by means of demand price elasticities.

Parallelsessions 1: March 28, 13.30-15.00 28 1F.4: Does good knowledge of the illnesses caused by second-hand smoke (SHS) influence SHS-protective behaviours?

K.A. Evans, A. Gilmore, M. Sims, K.F. Judge University of Bath, BATH, United Kingdom

Objectives To explore over an 11-year period (1996-2007) in England: (1) respondents’ knowledge of the illnesses that can be caused by SHS (2) the factors influencing knowledge; (3) the relationship between knowledge and SHS-related behaviour, including whether homes are smokefree and if respondents smoke in the presence of children.

Methods Analyses of cross-sectional data from the smoking module of the nationally representative Omnibus Survey. Knowledge of 10 individual SHS-related illnesses were explored. A compos- ite knowledge score was created combining knowledge of 10 illnesses; <5 correct responses indicating poor knowledge and >=6 correct answers equating to good knowledge. Multivariate logistic regression was performed to elicit determinants of ‘good’ or ‘poor’ knowledge. Trends over time were examined and the relationship between knowledge and SHS-protective behaviours explored.

Results When all years were pooled (N= 30,745), over 80% of respondents knew that SHS causes respiratory illnesses such as, childhood asthma (84%), chest infections (90%), adult asthma (84%), lung cancer (86%) and bronchitis (85%). Respondents were less aware that SHS can cause child ear infection (33%) and cot death (55%), and coronary heart disease (71%) and coughs and colds in adults (68%). Respondent’s knowledge of respiratory illness remained high over the study period. There was a small increase over time in the knowledge that SHS causes cot death and ear infections in children and adult lung cancer and coronary heart disease. Age, social class, car ownership, smoking status, number of children in the household, age of the youngest child in the household and year all independently predicted levels of knowledge. Just 15% of respondents with poor knowledge reported having a smokefree home, compared to 34% of respondents with good knowledge. Similarly, 45% of smokers with poor knowledge smoked when in a room with a child compared to 27% of smokers with good knowledge. Knowledge independently predicted both outcomes. Measures of social class were also predictive of SHS protective behaviours, with those from higher social classes and a greater number of cars showing higher odds of having a SF home and abstinence when in a room with children and adults.

Conclusions Knowledge of the illnesses that SHS can cause is poor for particular illnesses and population subgroups. Individuals who smoke in the home, have lower occupational status, have no car and live in a home with a higher number of children or adults are independently less likely to have ‘good’ knowledge. There’s a relationship between level of knowledge and SHS-related behaviours. Although causality cannot be determined through cross-sectional data, the fact that knowledge is a key construct in many health behaviour change theories, suggests that improving knowledge in these sub-groups may be a useful step in securing further reductions in exposure to SHS.

Parallelsessions 1: March 28, 13.30-15.00 29 1G - Symposium: How to increase participation of young mokers in cessation interventions – the ACCESS project

Stephanie Floeter, Sibylle Fleitmann, Peter Dalum, Alexandra Kmetova, Hein de Vries

Introduction Youth generally start smoking around the age of 13 with highest smoking rates at the age of 18. According to the ESPAD1 study, 58% of 15-16 year old students have tried smoking a cigarette at least once, 29% have used cigarettes during the last 30 days. Tobacco dependence develops rapidly among youth smokers. Half of teen smokers who loose autonomy over tobacco do so by the time they are smoking seven cigarettes per month, half of those who meet the criteria for ICD-10-defined dependence do so by the time they are smoking one to two cigarettes a month.2 It has been found that the desire and attempts of youth smokers to quit develop soon after smoking onset3. Already within three months of starting to smoke, young people start to seriously think about quitting. Over the next two years, smokers gradually lose confidence in their quitting ability. After a smoking career of two and a half years youth become gradually aware of smoking as an addiction and how difficult it is to quit. International data shows that about 60% of adolescent smokers tried to quit during the last six months but that 90% of those who initially quit turned back to this risk behavior within a six months period4.

The development of effective youth smoking cessation interventions is therefore not only necessary from a public health point of view but also corresponds to a need experienced by adolescent smokers themselves. However, international experience has shown that adolescent smokers are generally not interested to participate in smoking cessation interventions5, even though these have been shown to be effective6. Still more than 80% believe that they can stop on their own. They expect interventions to be patronizing and think that seeking external support, except with their friends, is not necessary. On European as well as on international level this attitude is mirrored in low participation rates reported by intervention providers.

The ACCESS project The aim of the project ACCESS was to increase the impact of adolescent smoking cessation interventions and to support providers, developers, funding bodies and policy makers in the development of effective recruitment strategies. The objective was to gain knowledge on how to motivate young smokers to take part in smoking cessation interventions and to transform this knowledge into concrete recommendations for cessation practice. The project ran from September 2009 until October 2010 and has received co-funding from the European Union in the framework of the Public Health Programme. It consists of 11 partners across Europe and is coordinated by the IFT Institut für Therapieforschung in Germany. Partners are: • IFT - Institut für Therapieforschung München, Germany • Danish Cancer Society, Denmark • Maastricht University, The Netherlands • General University Hospital in Prague, Czech Republic

Parallelsessions 1: March 28, 13.30-15.00 30 • Stop smoking NGO, Slovak Republic • Agencia Formacion Investigacion y Estudos Sanitarios, Spain • Slovenian Coalition for Tobacco Control, Slovenia • Riga City Council Department of Welfare, Latvia • Foundation Against Respiratory Diseases, Belgium • Institut für Sozial und Gesundheitspsychologie, Austria • GABO:mi, Germany (project management)

Methods In the 10 partner countries, national stakeholders and experts relevant to the topic were identified and organized within national networks. Each participating country assessed good practice models based on the experiences of national providers of youth smoking cessation. These experiences as well as the results of an international literature review lead to the development of guiding principles for the motivation/recruitment of young people to participate in smoking cessation programmes. In order to discuss possible strategies for future implementations of the results and to gain practical knowledge for concrete actions, a European stakeholder conference drawing together national and international experts from 14 countries has been organized. In addition, a process evaluation was performed.

Results Nine principles have been identified to guide providers and policy makers in the development of comprehensive recruitment strategies. These principles address the need to establish non-smoking as a social norm and state that effective youth specific smoking cessation interventions must be available and that recruitment strategies should be evidence based. They further suggest that cessation interventions need to benefit from positive branding, need to be pro-active and to have a personal touch. It is necessary to choose the right language, incentives may be an option and partnership with stakeholders in youth health matters is an important asset.

Strategies that support these guiding principles were grouped into five categories – interpersonal communication, marketing, tailoring, behavioral learning techniques and structural change. A range of existing activities was identified according to settings where youth spend their time: • Health care services, social services/institutions • Schools and work places • Internet • Traditional media • Out of school/leisure settings • Specific access points for tobacco users

In this symposium the results of the project will be presented and discussed. Conclusions will be drawn for future practice and research.

The aim of the symposium is: • to draw the attention of health professionals and policy makers to the need of integrating recruitment strategies as an integral part of any smoking cessation interventions • to discuss practicability of recruitment strategies and implementation of guiding principles • to increase the network of smoking cessation experts and policy makers interested in youth smoking cessation recruitment

Parallelsessions 1: March 28, 13.30-15.00 31 Organisation of the symposium: • Overview of youth smoking and smoking cessation and introduction of the ACCESS project: Sibylle Fleitmann • Scientific evidence on the effectiveness of youth smoking cessation programmes and recruitment strategies: Peter Dalum • Access Strategies for Teen Smoking Cessation – Presentation of the developed recruitment principles, strategies and activities: Stephanie Floeter • “The Dream Project”: Creative, interactive work and discussion in small groups on recruitment principles and activities for youth smoking cessation programmes and their implementation on policy level (Peter Dalum, Hein de Vries, Alexandra Kmetova) • Presentation of results of group discussion and proposal of (policy) changes needed to successfully implement recruitment strategies with a view to increase cost effectiveness of youth smoking cessation interventions.

Statement concerning conflict of Interest The ACCESS project receives funding from the European Union in the frame of the Public Health Programme and is co-funded by the project partners listed above. The project partners do not receive funding from the Tobacco industry or related bodies.

Parallelsessions 1: March 28, 13.30-15.00 32 1H - Symposium: Nicotine Vaccination: a preview. The trial, the brain, societal context and the tobacco control community Chair and Co-chair: Anna Wolters and Onno van Schayck CAPHRI School for Public Health and Primary Care, Maastricht University, NL Presenters: Onno van Schayck, PhD, CAPHRI, Maastricht University, NL Anique Van Dorp, MD, CAPHRI, Maastricht University, NL Philippe Hoogsteder, MD, CAPHRI, Maastricht University, NL Erwin van Rijswoud, MSc, ISIS Institute for Science, Innovations and Society, Radboud University Nijmegen, NL Anna Wolters, MPhil, CAPHRI, Maastricht University, NL

Summary Most smokers are aware of the health consequences of their habit and want to quit smoking, but have difficulty doing so. Only 3-5 % of smokers who quit on their own are successful. Intensive individual or group behavioral modification therapy enhances success, but only about 15-30 % of smokers remain abstinent one year after therapy. Pharmacotherapy has had broad appeal, since it is considered to be more convenient than behavioral therapy. The aim is to affect the ‘biology of nicotine addiction’ by mimicking the reinforcing effects of nicotine and reducing withdrawal symptoms. Currently available are nicotine replacement therapy (such as nicotine gum) and psychotropic drugs (such as bupropion). The rate of abstinence using pharmacological treatments, with or without behavioral modification therapy, is still less than 50 % and is typically about 25%. Since the vast majority of those who attempt to quit will fail, the need for better approaches to smoking cessation is clear and urgent. In the domain of pharmacotherapy, a promising new treatment has been developed. It is a vaccine, that could be applied as an aid in quitting, in maintaining abstinence, and in preventing addiction in beginning smokers. The treatment is presently subjected to a trial in which 600 healthy smokers participate. The trial is part of a multidisciplinary NWO-funded project, carried out by research school CAPHRI (Maastricht University) and Maastricht University Medical Center+ (MUMC+).

The symposium includes contributions in the domain of experimental medicine, cognition sciences, sociology of science, and empirical ethics. Its aim is three-fold: to present the study of a vaccine for the therapy and prevention of smoking, to indicate that this innovation needs public support in order to work well, and to collect the views of the tobacco control community on the ethical issues surrounding its prospective introduction. The presentation consists of four lectures and an interactive dialogue with the audience. Professor Onno van Schayck elucidates the background and the technicalities of the vaccine and explains why it is fruitful to have a pharmacological innovation studied by a multidisciplinary team. Anique Van Dorp clarifies why a rising concentration of nicotine causes a ‘kick’ in smokers and how a vaccine may subdue this cognitive effect. Details of the double-blind trial with 600 tests persons are presented by Philippe Hoogsteder. Erwin van Rijswoud compares the strengths and weaknesses of recent immunization initiatives with the future introduction of nicotine vaccination. In the interactive final, moderated by Anna Wolters, the audience is asked to react on a number of ethical issues.

Parallelsessions 1: March 28, 13.30-15.00 33 Nicotine vaccination: how it works, why we need it, and what we expect from it

Onno van Schayck, CAPHRI, Maastricht University

Starting from the concept that nicotine is addictive, it would be of considerable interest to find a safe and effective means of blocking its effects. Nicotine is a small molecule that does not elicit an immune response in animals or humans. Vaccination is an attractive candidate for blocking the effects of nicotine because of its specificity. In order for the immune system to respond to this happen, nicotine can be combined or bound to a larger molecule in a unique manner, so that an immune response is mounted against the addictive agent. This method has already been used to create vaccines against many small molecules. Conceivable applications of nicotine vaccination are therapeutic and preventive: treating tobacco use, preventing relapse, and preventing nicotine addiction in future smokers. Vaccination would represent a unique addition to the available strategies for treating nicotine dependence. Indeed, smoking prevalence and incidence in the 21st century are much higher than was aimed for. A multidisciplinary research team covers all the relevant issues of this innovative treatment: next to safety, efficacy, and mechanism of nicotine vaccination, its ethical and societal implications are object of study.

Nicotine and dopamine: marriage or divorce? Expected cognitive effects of nicotine vaccination

Anique Van Dorp, CAPHRI, Maastricht University

A double blind parallel (treatment) group cross-over (challenge) placebo controlled fMRI- study will be conducted to test the hypothesis that a nicotine challenge given after vaccination with a vaccine stimulating the production of nicotine-specific antibodies will result in no or reduced effects of nicotine on the central nervous system (CNS). The primary aim is to show that these antibodies attenuate nicotine induced CNS effects on brain activation patterns and cognitive performance relative to placebo. The secondary aim is to evaluate how these changes in CNS stimulation alter subjective measures and the addictive properties of nicotine. Forty-eight smokers will be randomized in two parallel groups, receiving active vaccine or placebo over a period of 20 weeks. Both groups will be given a nicotine challenge, a chewing gum either containing nicotine (2 mg) or a placebo, on separate days just prior to fMRI-recording (Blood Oxygenation Level Dependent). The effects of treatment will be evaluated on a modified flanker task, an N-back task, a task for divided and selective attention, reactivity to smoking-related cues, and finally resting state brain activity. Questionnaires will be used to asses subjective mood, subjective alertness, withdrawal and smoking behaviour. These results could offer further support for the mechanism of action of the vaccine.

Trials and tribulations: the Dutch phase 2B trial of nicotine vaccination

Philippe Hoogsteder, CAPHRI, Maastricht University

Previous studies have proved both the safety and immunogenicity of the nicotine vaccine as an aid in smoking cessation. The present trial is a phase 2B, multi-center, randomized, double-blind, parallel-arm study. It is designed to evaluate the efficacy and safety of the nicotine vaccine. The vaccine is co-administered with varenicline in smokers who want to quit. In addition, the six hundred test persons who participate in the study receive a

Parallelsessions 1: March 28, 13.30-15.00 34 series of individual counselling sessions by trained nurses. Clinical data demonstrate that antibody titers and vaccine immunogenicity are dose-related. Active immunization will not interfere with the central nerve system (CNS) and is therefore likely to produce fewer side effects than for instance bupoprion and varenicline, smoking cessation aids that act on the neurotransmitters in the CNS. Besides these advantages, a nicotine vaccine is likely to have a better compliance. The possibility of relapse prevention is an important aim. Vaccinated ex-smokers who lapse are expected to have no or diminished reward from nicotine inhalation resulting in a considerable reduction of relapse rate.

Immunization and its allergic societal reactions

Erwin van Rijswoud, ISIS, Radboud University Nijmegen

The recent history of vaccine development tells a multifaceted technological and societal story on difficulties of both developing vaccines, as well as using them. After the successful and relatively uncontroversial eradication of smallpox in the 1970s, controversies over vaccination intensified. In some instances, such as HIV, the cry from patient groups for a vaccine was and still is immense. As hopes, hypes and disappointments followed up on each other in the last three decades, vaccine developers learned to be very cautious in communicating on the prospects of a HIV vaccine. In more recent years, the scientific and public controversies over MMR, HPV and H1N1 vaccines have demonstrated the opposite case from HIV: that the technological availability of a vaccine need not result in a smooth and undisputed public acceptance of these vaccines. In these instances, distrust in experts and governmental institutions outweighed the potential medical benefits of these vaccines. To the surprise of the experts involved, their authority waned, and not just for technical reasons. The successful introduction of a new vaccine relies not only on the technological feasibility, but also on the societal context in which it is to be used. So, what challenges may lie ahead for a nicotine vaccine and for immunization that aims not at infectious diseases but at behavior? Rather than providing answers and recommendations for a successful implementation, the focus will be on analyzing the possible socio-cultural responses to the introduction of this vaccine.

Ethical implications of nicotine vaccination: an interactive dialogue with the tobacco control community

Anna Wolters, CAPHRI, Maastricht University

Nicotine vaccination will increase clinical and public health options for interfering with smoking as an unhealthy lifestyle. It may well produce important shifts in notions of personal and social responsibility for health. Is nicotine vaccination morally justified as a strategy to combat and prevent smoking in adults and children? If so, under what conditions? To assess these questions, it is vital to take the normative intuitions and frameworks of stakeholders into consideration. For this part of the symposium, an ‘in vivo’ stakeholder study is designed. The moderator presents an ethical issue and asks the audience to react by means of showing a card of a certain color. Consequently, members of the public are invited to explain their choices. In function of the given answers, follow-up questions allow for an in-depth elaboration. For both the audience and the presenters, the interactive final increases awareness of implicit and explicit values within the tobacco control community. This contributes in grasping the normative consequences of the development and possible introduction of nicotine vaccination.

Parallelsessions 1: March 28, 13.30-15.00 35 1. ESPAD, 2009 The 2007 Espad Report, Substance among students in 35European countries. www.espad.org 2. Di Franza et al (2007). Symptoms of tobacco dependence after brief intermittent use. Arch Pediatr Adolesc Med, 161, 704-710. 3. O’Loughlin et al (2009). Milestones in the Process of Cessation Among Novice Adolescent Smokers, American Journal of Public Health, 99, 499-504 4. Bancej et al (2007). Smoking cessation attempts among adolescent smokers: a systematic review of prevalence studies. Tobcacco Control, 16, e8 5. P.Dalum, Events for Adolescent smoking cessation- the Development, Implementation and Evaluation of a Danish Adolescent Smoking Cessation Intervention. Danish Cancer Society, 2009 6. Sussman, S. & Sun, P. (2009). Youth tobacco use cessation: 2008 update. Tobacco Induced Diseases, 5(1), 3.

Parallelsessions 1: March 28, 13.30-15.00 36 1I: Workshop FCTC/FCA What exactly is it, why should you join FCA and what can you do? – a practical lecture

What The WHO Framework Convention on Tobacco Control (WHO FCTC) is the first treaty negotiated under the auspices of the World Health Organization. It was adopted by the World Health Assembly in 2003 and entered into force since February 2005. The Framework Convention Alliance (FCA) was founded in 1999 and is made up of over 350 organizations from more than 100 countries working on the development, ratification and implementation of the FCTC. The Conference of the Parties (COP) is the governing body of the WHO Framework Convention on Tobacco Control (WHO FCTC) and is comprised of all Parties to the Convention as well as observers, including members of the civil society. The FCA is the umbrella organization of many NGOs involved in global tobacco control. Unfortunately not so many European organizations are members of FCA and are attending the Conference of the parties.

Who Speakers: Cornel Loghin Radu & Nick K. Schneider

How In this session the ins & outs about FCTC and FCA are presented. The two speakers attended earlier Conferences of the Parties and where involved in the development of the FCTC instruments – on governmental and NGO levels. Presentations will include background information on the FCTC and the FCA as well as the processes in which the FCTC instruments, e.g. the implementation guidelines, are developed and how members of civil society contributed. It will give you reasons why membership of FCA is important; what you can do ensure that the FCTC is globally ratified and implemented. This workshop will discuss the newest developments with regard to the decisions adopted at the 4th Conference of the Parties in November 2010 and the role of civil society in current and future work related to the FCTC. This really is a must-attend session!

Parallelsessions 1: March 28, 13.30-15.00 37 Parallelsessions 2 Monday March 28, 15.30-17.00

2A - Session Success and failure of smoking ban in bars and restaurants

2A.1: Monitoring of smokefree legislation in German hospitality venues: Improvements and failures

M.P.L. Poetschke-Langer, U.M. Mons German Cancer Research Center, H…ID…LB…RG, Germany

Objectives After a highly emotional debate on secondhandsmoke 2005 - 2007 one federal law and 16 state laws were implemented in Germany in 2007 -2008 . The legislation varies from state to state especially in hospitality venues. Against the background of substantial differences the German Cancer Research Center conducted an evaluation before and after the introduction of the laws to demonstrate improvements and failures and to ask citizens about their attitude and behaviour regarding secondhandsmoke and smokefree legislation.

Methods Two well established methodologies for the evaluation of smokefree legislation were used: One evaluation quantified exposure to secondhandsmoke in German restaurants, bars and entertainment venues by determining the concentration of respirable suspended particles measuring 2.5um or less (PM 2,5) in indoor air , for a minimum of 30 minutes per visit. The concentration of particulate matter in the indoor air was measured in 39 restaurants, 20 cafés, 12 bars, 9 discotheques and 20 restaurant cars in trains. Pre-legislation measurements were performed between 30 September and 31 October 2005 and post-implementation measurements in the same period and venues in 2009. Additionally annual polls were conducted between 2005 and 2010 using consistent questions and time periods.

Results Exposure to secondhandsmoke decresed by about 80 percent between 2005 and 2009. However this is only true when smoking is completely banned. If there were smoking rooms, tobacco smoke penetrated into smokefree rooms polluting them four times as much as venues without smoking rooms. Particularly high levels of tobacco smoke were found in venues with smoking rooms or in pubs and bars without regulation. The German population is in favour of smokefree hospitality venues - the acceptance rates increased from 53% in 2005 to 74% in 2010. Even among smokers, two thirds of the occational smokers and 41% of regular smokers favored smokefree bars and restaurants. And while it is less permitted to smoke in public places, fewer and fewer smokers tolerate smoking in their own homes: In 2007, 30% of smokers had a completely smoke-free home, in 2009, it was already 41%.

Parallelsessions 2: March 28, 15.30-17.00 38 Conclusions Exceptions such as the approval of smoking rooms or smoking pubs prevent a complete protection of nonsmokers, and diverging regulations in hospitality venues in the different German states lead to injustice and health risks for hospitality workers and guests.

Implementation There is no alternative to a complete smokefree legislation covering all public venues.

2A.2: The failure of partial smoking bans in hospitality venues: The example of Spain and Germany

N.K.S. Schneider1, E.F.M. Fernandez Muñoz2, E.M.S. Sebrié3 1German Cancer Research Center, H…ID…LB…RG, Germany 2Institut Català d’Oncologia-IDIB…LL , Universitat de Barcelona, BARC…LONA, Spain 3Roswell Park Cancer Institute, BUFFALO, United States of America

Objectives After the ratification of the WHO Framework Convention on Tobacco Control (FCTC) in 2003 and the adoption of guidelines on Article 8, FCTC several EU Member introduced comprehensive smoking bans in public places. However, some countries, such as Spain and Germany, decided to introduce partial smoking bans, which only cover some hospitality venues.

Methods Analysis of national legislation, state regulations, as well as peer reviewed literature, tobacco industry documents and media reports. We assessed the contents of the legislation, its implementation on state level and the evaluation by experts in both countries.

Results The Spanish tobacco control law implemented in 2006 has striking similarity to the ‘Cour- tesy of Choice’ and ‘Traditional Hospitality’ programs promoted by Philip Morris in the 1990s. It included several exceptions and vague definitions, leading to differences in regional inter- pretation 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. Given the widely accepted failure of the law, the Spanish government decided to revise the law in 2010.

Between 2007 and 2008 Germany’s 16 states introduced partial smoking bans in restaurants, bars, and pubs. In July 2008, following legal challenges by small venue owners as well as claims by tobacco industry and the German hospitality association calling for the introduction of the so-called ‘Spanish Model’, the Federal Constitutional Court introduced an interim regulation allowing owners of venues under 75 m2 to decide if they want to allow smoking or not, under the condition, that no access is granted to minors and that no prepared food is served. Although the Court ruled that a complete ban on smoking in public places would have been constitutional, the vast majority of state legislatures decided to include the interim regulations in the revised state laws. In July 2010 the Bavarian population overruled its legislature and forced the re-introduction of a comprehensive smokefree law.

Conclusion The two case studies on Spain and Germany, demonstrate that the Spanish Law implemented in 2006 included elements propagated by the tobacco industry and was used to propose

Parallelsessions 2: March 28, 15.30-17.00 39 these programmes as an alternative to comprehensive smoking bans in Europe. Several countries, such as Germany, adopted similar legislation and also failed in protecting non- smokers against exposure to tobacco smoke in hospitality venues.

Implementation National policy makers, advocates and researchers should be aware of the ‘Spanish model’ and its successor the ‘German model’ and its use by tobacco industry front groups. Both models should not be considered as alternatives to comprehensive smoking bans in hospitality venues.

2A.3: Extending Smokefree Laws to the Hospitality Industry in the Netherlands: Misperception and Policy Failure

M. Gonzalez, A. Glantz UCSF, SAN FRANCISCO, United States of America

In July 2008 the Netherlands extended smokefree laws into the hospitality industry (Horeca).

We analyzed the implementation of smokefree laws in the Netherlands through interviews with advocates and the Ministry of Health. We triangulated these with other source materials, such government documents, news articles, explanatory pamphlets, scientific papers, statistical reports, and other media that were either publically accessible or were made available to the author.

There was strong compliance in all Horeca sectors except for bars and nightclubs. The Ministry of Health’s implementation campaign did not lay strong groundwork for a smokefree hospitality industry by promoting the law to the (nonsmoking) general public, including stressing the benefits for hospitality workers or delegitimizing tobacco company claims. Instead, it only targeted smokers, stressing the fact that they would have to leave their “friend”the cigarette, outside Horeca venues. The fact that the law allowed smoking rooms created an opening to take advantage of the tobacco industry-promoted (and untrue) claim that such laws hurt business to create an economic wedge between large and small venues. The Minister of Health undermined implementation when he participated in a ribbon-cutting ceremony for a smoking room.

Opponents of the smokefree law, with support from tobacco companies, were able to create the misperception that the law was damaging small bars, and compliance among all bars decreased. Small bar owners without employees sued to be exempted from the law. In 2009 the Dutch Supreme Court ruled that the law applied to these venues. Despite this ruling, advocates have not been able to effectively combat the misperception that smokefree laws lead to economic loss in small bars, and after 2010 Parliamentary elections the minority government’s agenda included partially repealing smokefree laws.

Despite a strong tobacco-control advocate coalition and strong initial enforcement, tobacco- industry backed third parties succeeded in encouraging widespread non-compliance with the law. when challenged by industry front groups, public health officials and activists lost the “war of perceptions”over the link between smoking and bars, and were unable to counter the economic loss argument. The Netherlands illustrates that the passage of nominally strong policies is not enough to provide comprehensive protection for nonsmokers (and the positive secondary effect of decreasing the use of tobacco). This case underscores the importance of implementing smokefree campaigns with a broad educational campaign that targets the general public and addresses industry interference.

Parallelsessions 2: March 28, 15.30-17.00 40 2A.4: Tobacco control and direct democracy. Conclusions from the Bavarian referendum for smokefree bars and restaurants

D.J. Jazbinsek1, F.J.W. Wiebel2 1Dieter-Mennekes-Umweltstiftung, B…RLIN, Germany 2German Medical Action Group Smoking or Health, MUNICH, Germany

By the end of 2009, more than 1.3 Million Bavarian voters signed a petition for a complete smoking ban in all hospitality venues. Never before in Europe had so many people actively engaged in a tobacco control issue. Although the necessary quota of agreement of 10% was by far exceeded, the Bavarian Government refused to change legislation and set a referendum for July 4th 2010. It ended with a clear vote of 61% in favor of smokefree hospitality venues - at a voter participation of 38%. Since August 1st 2010 smoking is forbidden in all bars, discotheques, pubs, restaurants and gaming halls in Bavaria, one of the major federal states in Germany. In the end of September, more than six million visitors attended the first smoke- free Oktoberfest in Munich, the world’s largest fair. The success of the Bavarian referendum has given similar initiatives in Austria and Switzerland a boost.This historic success of tobacco control is the result of a hard fight. Months before the election day, the tobacco industry decided to counter the referendum with a massive PR-campaign. A strategic alliance was set up, consisting of tobacco companies, breweries, bar owners, advertising agencies and slot-machine operators. On the other side a coalition was formed out of opposition parties, health organizations, non-smokers initiatives and sports associations. In our presentation we analyze the efforts of both sides to gain public support. For example, one decisive factor for the outcome of the referendum was the use of Facebook. Finally we discuss the implications of the Bavarian experience for possible national or Europe wide citizens’ initiatives on tobacco control.

2A.5: The ‘Spanish model’ does not work: mid-term assessment of Spanish smoking Law in hospitality workers

J.M.M.S. Martinez Sanchez1, E. Fernández1, M. Fu1, J.A. Pascual2, M.J. López3, M. Perez-Rios4, A. Schiaffino5, C. Ariza3, E. Salto6, M. Nebot3 1Institut Català d’Oncologia, L’HOSPITAL…T D… LLOBR…GAT, Spain 2IMIM-Hospital del Mar, BARC…LONA, Spain 3Agència de Salut Pública de Barcelona, BARC…LONA, Spain 4Consejería de Salud, SANTIAGO D… COMPOST…LA, Spain 5Servei de Salut Comunitària, Ajuntament de Terrassa., T…RRASSA, Spain 6Departament de Salut, BARC…LONA, Spain

Objectives A smoke-free law came into effect in Spain on 1st January 2006, affecting all enclosed workplaces except hospitality venues. This type of partial ban also known as the “Spanish model”has been used by the tobacco industry to undermine the development of complete smoke-free policies worldwide. The objective of this study was to evaluate the impact of the law among non-smoker and smoker hospitality workers 6, 12, and 24 months after the ban.

Methods We recruited 431 hospitality workers in the baseline survey (2005) and 170 (39.4%, 106 non-smokers and 64 smokers) were followed up 2 years later. We assessed salivary cotinine concentrations as a marker of secondhand smoke (SHS) exposure and tobacco consumption

Parallelsessions 2: March 28, 15.30-17.00 41 at baseline and 6, 12, and 24 months after the ban.

Results Among non-smokers, salivary cotinine concentration (-70.6%; p<0.01) and self-perceived exposure to SHS (-4 h; p<0.05) decreased in hospitality workers in venues where smoking was totally banned. There was no reduction in cotinine concentrations but an increase in self-reported SHS exposure in venues where smoking continued to be permitted. Among smokers, salivary cotinine concentration increased at 2-year follow-up (p<0.05), regardless the type of ban in the venue.

Conclusions The 2005 Spanish smoking law has not protected non-smoker hospitality workers from SHS exposure nor has reduced tobacco consumption among smokers.

Implications On 2nd January 2011, an amendment to the Law extends the ban to all hospitality venues with no exemptions. Hopefully, the “new Spanish model”will be considered a good example of smoke-free policy.

Parallelsessions 2: March 28, 15.30-17.00 42 2B - Determinants of cessation effects

2B.1: Can perceived risk and benefit of quitting predict smoking cessation outcome?: Malaysian experience

S.M.Y. Munira Yasin1, R.M. Masilamani2, M.F.M. Foong Ming2, D.K. Koh3 1University Technology MARA, KUALA LUMPUR, Malaysia 2University Malaya, KUALA LUMPUR, Malaysia 3University of Singapore, SINGAPOR…, Singapore

Perceived risk and benefit of quitting may be an important barrier to successful treatment. This study examined the association between initial perceived risk and benefit of quitting and cessation outcome during a two month smoking cessation attempt. Participants (n= 185) were treatment-seeking smokers from two smoking cessation clinics in the Klang Valley, Malaysia. They received structured behaviour therapy and free Nicotine Replacement Therapy (NRT). Prior to treatment, a 12 sub-item Perceived Risk and Benefit Questionnaire (PRBQ) was administered. This was used to assess a smoker’s initial perception during the quit attempt. Participants were re-contacted at the end of two months to determine their smoking status. Results showed that, participants intending to quit demonstrated a higher perception on the benefits of quitting compared to the risks of quitting. Those with a higher education level had a higher perception of the benefit of quitting (p=0.02). PRBQ items such as Perceived risks of quitting (i.e. weight gain, negative affect, social ostracism, loss of enjoy- ment and craving) were not associated with abstinence at two months. However, those who perceived a benefit of higher physical attraction post cessation were less likely to have stopped smoking at two months (OR= 0.18; 95% CI: 0.08; 0.45). Other perceived benefits at baseline, such as health, general well-being, self-esteem, finance and social approval were not associated with smoking cessation at two months. The results suggest that in our study population, smokers’ baseline perception of the benefit of quitting prior to therapy can barely predict their quit results at two months. Counseling patients with respect to the advantages and disadvantages of quitting may have changed their perception, which is associated with better cessation outcome.

Keywords: Perceived risk and benefit; Smoking cessation; Malaysian; Behavior therapy

2B.2: Action Planning Theory for Improving Quitting Behavior in Smokers

H. De Vries1, M. Eggers1, C. Bolman2 1Maastricht University, MAASTRICHT, The Netherlands 2Open University Heerlen, H……RL…N, The Netherlands

Objective Many smokers intent to smoke but do not make a successfull quit attempt. Action planning theory suggests the development and execution of action plans. This study analyzed the role of action plans and action execution in smoking cessation.

Methods We used a sample of 1005 smokers who were extracted from the control group of a smoking cessation study. Only respondents willing to quit within a year were eligible for recruitment. Participants were asked to fill in an online questionnaire based on the I-Change Model and

Parallelsessions 2: March 28, 15.30-17.00 43 Action Planning Theory one and six months after baseline.

Results Planning specific quit steps and executing them predicted successful quitting. First, the results of the study show clearly that participants who planned to quit smoking within one month made more action plans than those willing to quit after 6 months. Second, action planning and execution of the intended actions (goal actions) were related to succesful quitting: After 6 months, 27% of the smokers who executed less than the average of seven action plans had quit successfully versus 61% of the smokers who completed more than the average. Regression analysis assessing the contribution of action planning and action planning execution (goal actions) shows that the amount of action plans formulated one month after baseline was not signficant after controlling for execution of these plan. Yet, a significant predictor was the amount of realized actions one month after baseline for predicting later quitting after six months.

Conclusion Planning and execution of action plans is iimportant. Realization of intended action plans is an important final step towards successful quitting and needs more attention in future cessation programs.

2B.3: Can we better predict smoking cessation? An approach to analyse dynamic predictors

R. Prenger, M.E. Pieterse, L.M.A. Braakman-Jansen, R.H. Klein Entink, E.R. Seydel University of Twente, …NSCH…D…, The Netherlands

Objectives Behaviour change is a gradual process including cognitive changes. Most studies reporting prediction analyses of cognitive parameters are logistic regression analyses limited to baseline predictors, thus failing to incorporate dynamic changes in cognitive parameters during follow-up. Repeated measures analyses include these effects, but do not consider the smoking status at time of measurement. The present study examined the dynamic nature of the psychological processes that result in smoking cessation.

Methods Data were used from the SMOKE study in which two smoking cessation interventions were compared for COPD outpatients. The cognitive parameters self-efficacy, social norm, attitude and descriptive norm were measured at baseline, 6 and 12 months and validated point prevalence abstinence rates were measured at 6 and 12 months follow-up. To compare baseline analyses with dynamic predictors, two different Cox proportional hazards models were estimated in this study: 1) A Cox model using baseline estimates of the covariates predicting abstinence at 12 month follow-up and 2) a Cox model with time varying covariates including abstinence rates at 6 and 12 months follow-up. In this second model, variables were entered in Cox regression analysis with time varying covariates, in which the dynamic nature of the cognitive parameters was explored, adjusted for changes in smoking status. Using this method, two different time periods were analysed separately adjusted for the fact that the time periods within one patient are interdependent.

Results Attitude and descriptive norms appeared to be significant baseline predictors with an explained variance of 7.6% for the first model. However, the second model with time vary-

Parallelsessions 2: March 28, 15.30-17.00 44 ing predictors showed that positive changes in self-efficacy and descriptive norm strongly increased the chance of smoking cessation, implying that it contributed significantly to the prediction of smoking cessation over time accounting for changes in smoking status. The explained variance of these covariates was 39.6%.

Conclusions This study showed strong predictive effects in the time varying model during the course of one year on actual smoking cessation. However, both models differed on predictors found significant for smoking cessation. Attitude appeared to be a baseline predictor but its effects diminished with time varying analysis which found that self-efficacy was significant in the course of achieving smoking cessation. This outcome is largely consistent with recent meta- analyses, according to which self-efficacy is generally considered to be the strongest predictor of smoking cessation. Furthermore, the magnitude of the predictive effect as expressed in the model R square is remarkably high compared to earlier research. This suggests that, even when using just two time periods, a dynamic Cox regression analysis can improve our insight in the quitting processes and effective intervention components, whereas analysis using baseline predictors mainly shows how an intervention can be targeted to specific patient characteristics.

2B.4: Predictors of quit attempts and quit attempt success in general population samples: a systematic review

E.V. Vangeli1, J.S. Stapleton1, E.S. Smit2, R.B. Borland3, R.W. West1 1University College London, LONDON, United Kingdom 2Maastricht University, AMST…RDAM, The Netherlands 3VicHealth Centre for Tobacco Control, CARLTON, Australia

Objective A systematic review was conducted to identify the predictors of quit attempts and the success of quit attempts in adult general population samples.

Methods We performed an electronic search of EMBASE, PubMed, Web of Science, PsychINFO and the Cochrane Tobacco Addiction Group specialised register for studies that specifically examined predictors of smoking quit attempts and/or quit attempt success prospectively in adult general population samples. The review was limited to studies written in English and excluded studies involving interventions. A hand-search of the reference lists of included studies and conference abstracts was also carried out and leading researchers in the field contacted. Nine observational studies met the inclusion criteria and data were extracted independently by two researchers.

Results There was a high level of methodological heterogeneity between studies examining predictors. Through comparison of conceptually similar variables, this review found that motivational factors dominated prediction of quit attempts whereas dependence consistently predicted success. Social grade also predicted success but was only examined in two studies. None of the other socio-demographic factors predicted making a quit attempt or quit attempt success.

Conclusions Motivation to stop smoking and dependence are associated with different stages of the quitting process and many assumptions about predictors of quit attempts are not supported by the

Parallelsessions 2: March 28, 15.30-17.00 45 evidence. The findings of the review are limited to simple associations of predictors as it was not possible to systematically adjust for potential confounders due to covariate heterogeneity.

Implementation There is a need for a common standard in the definition of quit attempts and quit attempt success to be reached. Similarly, achieving some uniformity in predictor measures and the covariates adjusted for is necessary to enable identification of predictors via the pooling of results across studies through formal meta-analysis.

2B.5: Smoking cessation among cardiac patients with and without a Type D personality: a 6-month follow-up.

Authors: Berndt, N.C.B., Open University of the Netherlands, Heerlen, The Netherlands (Presenting author)

Bolman, C.B., Heerlen, Open University of the Netherlands Lechner, L.L., Heerlen, Open University of the Netherlands Mudde, A.M., Heerlen, Open University of the Netherlands De Vries, H.V., Maastricht, Department of Health Promotion, Maastricht University

Objectives A poor psychological and social cognitive profile has been associated with an increased risk of smoking in patients with cardiac disease. Recent studies have investigated the role of the Type D personality among this patient group, describing its relation to poor prognosis. Little is known about the moderating effect of the Type D personality on smoking as regards psychological and social cognitive risk factors. This study focuses on the effects of anxiety, depression, self-efficacy expectations and social influences on smoking cessation in cardiac patients and the possible moderating role of the Type D personality on these relationships.

Methods Eight comparable cardiac wards of Dutch hospitals agreed to participate. From these wards, 244 cardiac patients completed a questionnaire at the time of hospital admission. Six months after discharge patients were interviewed to ascertain their smoking status. To date, 145 cardiac patients completed the follow-up interview (60%). Quitters (n=78) and smokers (n=67) were compared on risk factors of smoking by use of independent sample t-tests. Regression analysis was used to identify potential predictors to smoking cessation.

Preliminary results Patients had a mean age of 56 years and three-quarter were male. First results indicated that the prevalence of Type D patients was 25%. These patients were more frequently depressed and had higher levels of anxiety compared to non-type D patients. Smoking cardiac patients scored significantly lower on self-efficacy, social modelling and support. A regression analysis ran in two steps indicated that the inclusion of Type D did not lead to an improvement in the level of prediction of smoking cessation and beyond a model that included anxiety, depression, self-efficacy, and social influences. Social modelling, indicating few smokers in the social environment, was significantly associated with an increased chance to quit smoking (OR=1.64; 95% CI 1.09-2.46). Social support and self-efficacy expectations showed substantial associations with smoking cessation, respectively (OR=1.52; 95% CI 0.99-2.32; OR=1.45; 95% CI 0.94-2.24).

Parallelsessions 2: March 28, 15.30-17.00 46 Preliminary conclusions Cardiac patients are at high risk to continue smoking after hospital discharge when experiencing many smokers in the environment, few social support and weak self-efficacy expectations. Our findings indicate that Type D personality is not an impediment to smoking cessation and does not moderate the effect of social cognitions.

Implementation Cardiac patients are not a homogenous group and subgroups may benefit from specific interventions. These should be offered in-hospital to support patients to quit smoking as early as possible and aim to reduce the perceived influence of smokers in the social environment. Particular attention should be paid to enhance social support and self-efficacy expectations.

Parallelsessions 2: March 28, 15.30-17.00 47 2C - Session ETS at home

2C.1: The motivators and barriers to a smoke-free home: identifying the positive levers for change.

L. Jones, O.A. Atkinson, T.C. Coleman, A.M. McNeill, S.L. Lewis University of Nottingham, NOTTINGHAM, United Kingdom

Objectives One of the most effective ways to reduce second hand smoke exposure in children is to encourage parents and other adults (caregivers) to make their homes completely smoke- free. However, this may require substantial behaviour change and there is evidence to suggest that some caregivers may face significant barriers when trying to implement and maintain a smoke-free home. Therefore, the aims of this study are to explore, in detail, home smoking behaviours and the motivators and barriers to smoke-free homes, among a group of disadvantaged caregivers, and to identify the positive levers

Methods In-depth interviews were conducted between July and September 2009, with 22 smoking caregivers, accessing Children’s Centre Services in Nottingham, UK. Interviews were audio- recorded and transcribed verbatim. Data were coded and analysed thematically to identify emergent main and sub themes.

Results Caregivers had some general understanding of the dangers of second hand smoke, but their knowledge appeared incomplete and confused. All interviewees described rules around smoking in the home, however, these tended to be transient and fluid. Caregivers were often living in difficult and complex circumstances and experienced significant barriers to creating a smoke-free home. The motivators for change were more strongly linked to house decor and smell, than their children’s health, although many caregivers expressed a desire to quit smoking.

Conclusions Whilst some attempts were being made to restrict smoking at home, the fluidity of these home smoking rules appears unlikely to offer appropriate protection for smokers’ children. The motivators to introducing smoke-free homes were home decor, children’s health and the possibility that making a successful change in home smoking behaviour might be a stepping stone to quitting completely. Our findings suggest that targeted education on SHS exposure is necessary, but in order to instigate caregiver behaviour change, providing demonstrable evidence of the impact of smoking on their children’s’ health is more likely to be effective.

Implementation This study extends our knowledge of the attitudes, beliefs and behaviour of disadvantaged caregivers, for whom smoking in the home is still common. In addition, it identifies a number of positive levers that can be utilised by health care professionals to increase the likelihood of significant and sustained smoking behaviour change for caregivers who cannot or will not quit smoking.

Parallelsessions 2: March 28, 15.30-17.00 48 2C.2: Changes in smoking in the presence of young children in the Netherlands (2003 - 2009).

M.R. Crone1, G.E. Nagelhout2, I. Van den Burg3, R.A. Hirasing4, B.J.C. Middelkoop1 1Leiden University Medical Center, L…ID…N, The Netherlands 2Maastricht University, CAPHRI, MAASTRICHT, The Netherlands 3STIVORO, the Dutch expertise centre for Tobacco Control for a Smokefree Future, TH… HAGU…, The Netherlands 4VU University Medical Centre, Social Medicine, AMST…RDAM, The Netherlands

Objectives Passive smoking can have harmful consequences for young children. In the Netherlands, education programs, media campaigns and smoking bans have been implemented to decrease passive smoking and, in particular, passive smoking among children. The present study examines the changes in passive smoking in children over the last decennium.

Methods Yearly from 2003 to 2009, a nationally representative sample of 500-800 parents of children aged 0-4 years were asked to complete a web questionnaire on passive smoking and several background characteristics.

Results Passive smoking has decreased sharply in the last six years. In 2009, 19% of the households reported smoking at home and 10% at home in the presence of their child, compared with 53% and 37%, respectively, in 2003. In households with a higher socio-economic status and/ or with a child aged 1 year or younger, passive smoking at home was reported by 5% of the respondents. Child passive smoking is more prevalent among children living in households with older children (14%), among children with parents with a lower socio-economic status (29%), and among children with parents who are heavy smokers (38%). Directly after the implementation of the smoking ban in the hospitality industry in July 2008, there was a sharper decrease in passive smoking than in the preceding years. Child passive smoking outside the home decreased considerably in 2007-2009.

Conclusions Despite the decrease in passive smoking, some children are still more often exposed to tobacco smoke: older children, children with parents with a lower socio-economic status, and children with smoking parents, in particular heavy smoking parents.

Implementation Preventive programs should be optimized and smoking bans should be enforced to continue this decrease in passive smoking especially in vulnerable groups of children.

Parallelsessions 2: March 28, 15.30-17.00 49 2C.3: Kosova Tobacco Law: Do parents know how to protect their children?

A.B. Baraku1, M.B. Berisha2, B.M. Merovci3, E.B. Baraku3 1Iliria College, PRISHTIN…, Kosovo 2National Institute of Public Health, PRISHTINA, Kosovo 3Iliria College, Medical Sciences-Rezonanca, PRISHTINA, Kosovo

Objectives One third of primary school children in Kosova have lit cigarette before the age of 10. Parental influence helps to prevent this occurrence. This study explored parental knowledge in year 2009 about the Kosova Tobacco Law (promulgated in year 2007) comparing to gender, age, marital status, education, earnings and smoking habit. The purpose of this research was to identify parental knowledge level and recommend interventions toward providing children with smoke free environment, reducing social acceptance of smoking behavior, and decrease numbers of future smokers.

Methods Anonymous multiple-choice questionnaires were distributed to the children of the 6th grades of the 17 primary schools of Prishtina, for their parents to complete. One class per school was randomly selected. 405 (67.5%) families responded to the questionnaires. Answers were analyzed for individuals, parental couples and single parents. Statistical parameters used were proportion, average, standard deviation while statistical significance was tested with T-test of proportions and Chi square test, p<0.05. Education rate was codified by numbers 0-6, while income rate was calculated by mean value of the given interval. The permission was obtained by the municipal education authorities to visit schools, while the education process was minimally interrupted.

Results From 779 respondents, 36.8% were smokers, with statistically significant difference in prevalence of smoking between males (47%) and females (27.3%), p<0.01. 72.9% of respondents answered correctly to all inquired articles of the law. In general, smokers, males, elders, higher educated, lower income, and couple parents had slightly higher accuracy than their corresponding categories, with no statistically significant difference.

By articles of the law: a) 86.3% of respondents identified the right of children for protection from detrimental actions for their health. Accuracy of answers was statistically significant for higher educated parents comparing to less educated parents, and those with higher average monthly income comparing to lower average monthly income - for both p<0.05; b) 68.6% of respondents knew about the prohibition of selling tobacco products to underage persons, with 48.1 % of smokers asking their children to purchase them; c) 90 % of respondents were aware that smoking is not allowed in schools, hospitals, sports and cultural facilities; d) Only 46.7% of respondents recognized that smoking in restaurants is allowed up to 30% of the area. There was no significant difference of the results between the corresponding categories for each of b) to d) above.

Conclusions and Implementation Parental knowledge of legal means to protect children from tobacco influence varied. There is a need of parent advocacy to exercise children rights for protection from tobacco related health impact. Mass medium advertisements, discussions during parental meetings in schools and education of children, would serve the purpose. Municipal educational and health authorities should be informed and included in the process.

Parallelsessions 2: March 28, 15.30-17.00 50 2C.4: Exposure to tobacco smoke in home, worksite and public places in Poland – a multi-dimensional evaluation

K. Przewozniak, J. Lobaszewski, J. Gumkowski, W.A. Zatonski The Maria-Sklodowska Curie Cancer Center and Institute of Oncology, WARSAW, Poland

Background In 2002, over 8,700 adult Poles, including 1,800 non-smokers die prematurely from SHS-related diseases.

Objective To evaluate the magnitude, patterns and trends in exposure to tobacco smoke in home, worksite and public places in Poland.

Methods (1) Nationwide face-to-face questionnaire surveys conducted on random samples of adult (15+) Polish population; (2) nationwide self-administered surveys of schoolchildren aged 13-15 conducted within the GYTS research project; (3) assessment of cotinine content in saliva samples in nationwide randomized survey of Polish adult (15+) population; (4) assessment of air-borne nicotine content in 40 Polish households as well as nicotine level in hair samples of non-smoking women and children from smoking and smoke-free homes; (5) assessment of nicotine content in air and hair samples of employees from 10 bars and night clubs; (6) assessment of air-borne nicotine content in 36 public places of 4 Polish towns; (7) assessment of tobacco smoke pollution (PM<2.5µ) in 74 public places of 4 Polish towns;

Results National surveys show that SHS exposure tends to substantially decrease in last decade. In adult non-smoking population, the home exposure decreased in men from 39% in 1996 to 19% in 2009 and in women from 47% to 26%, respectively. In worksite, SHS exposure decreased from 47% to 19% in non-smoking men and from 37% to 12% in non-smoking women. Comparison of the 2003 and 2009 GYTS results show also big decline in exposure of children to tobacco smoke at home and in public places (from 87% to 53% in home and from 90% to 71% in public places). However, all studies show that the level of SHS exposure is still high both in home and public places among smokers and in some public places, especially bus stops and public transport objects (44% exposed) and gastronomic venues (39% exposed in bars and pubs and 26% in restaurants). Self-reports on SHS exposure might be even underestimated as it was shown by assessment of cotinine level in saliva samples of adult respondents. In addition, tobacco smoke pollution in public places is extremely high, exceeding over 15 times the US EPA public health norm. Children and non-smoking women from smoking homes have much higher concentration of nicotine in hair samples than those from smoke-free homes. Non-smoking workers of most polluted bars and night clubs have comparable level of nicotine in their hair samples when compared with smoking employees.

Conclusion Multi-dimensional evaluation of SHS exposure in home and public places indicates high risk of passive smoking in Poland.

Implementation This situation calls for more comprehensive tobacco control measures, including effective enforcement of complete ban of smoking in all public places and worksites and preventive educational programs oriented on home environment.

Parallelsessions 2: March 28, 15.30-17.00 51 2D - Symposium: Removal of POS dispays of cigarettes – does it help?

Chair: Luke Clancy, TobaccoFree Research Institute Ireland, Dublin, Ireland Co-chair: Ann McNeill, UK Centre for Tobacco Control Studies, Nottingham University, …ngland, UK

Presenters: Gerard Hastings, CRUK Centre for Tobacco Control Research, Stirling University, Scotland Richard Edwards, Department of Public Health, University of Otago, Wellington, New Zealand Maurice Mulcahy, Health Services …xecutive, Galway, Ireland Randi Lavik, National Institute for Consumer Research (SIFO), Oslo, Norway Ann McNeill, UK Centre for Tobacco Control Studies Nottingham University, UK David Hammond, University of Waterloo, Waterloo, Ontario, Canada N2L3G1

Summary The aims of this symposium are: 1. To review the rationale for banning the display of Tobacco Products at the Point of Sale (POS) 2. To consider the practicalities of the approach to introduction of such bans internationally 3. To assess the outcomes from legislation in terms of implementation, compliance, effects on sales and contribution to Tobacco Control (TC).

The importance of POS display has greatly increased where there is a ban on other types of advertising and marketing. This is confirmed by examination of the Tobacco industry documents. Both survey and experimental research has clearly shown that POS display increases the susceptibility to uptake of smoking among youth and makes smoking more acceptable. While these negative realities on the impact of POS on smoking are established there is little experience on the effects of the removal of POS display. This leads to a dearth of published peer reviewed literature on the topic available at present. This symposium will review the evidence regarding the significance of POS display to the Tobacco industry in a world context and address the deficiency of knowledge regarding the effects of removal of POS by reporting on the recent successful implementation of POS display bans from two European countries Ireland and Norway and longer established Canadian Provincial bans.

1st Presentation: Prof Gerard Hastings discusses the principles of marketing and how these apply to POS display. He concludes that that POS display is very important to the marketing of Tobacco and that it is imperative to ban POS and uses the same reasoning and principles to demand the introduction of Plain Packaging.

2nd Presentation: The Tobacco industry and their clients oppose the introduction of POS bans and Prof Richard Edwards examines the arguments offered internationally by the industry, its agents and scrutinises the evidence- base for their arguments and contrasts these with the evidential, moral and ethical case for regulatory and legislative measures.

3rd Presentation: There are two speakers during this presentation. Monitoring and compliance of the POS legislation introduced on 1st July 2009 in Ireland is

Parallelsessions 2: March 28, 15.30-17.00 52 reported by Dr Maurice Mulcahy showing successful implementation in terms of signage, countertop materials and tobacco products in a variety of retail settings. Data was acquired by direct observation and by questionnaire. Dr Randi Lavik from Norway describes the methods used to assess attitudes and impact of the Norwegian POS law of 1st Dec 2010 including pre and post Web surveys, focus groups, POS surveys of smoking habits, attitudes and observations of a representative sample of premises. TC changes in relation to the introduction of the law are explored by means of observation of 3 years sales statistics of Tobacco.

4th Presentation: Prof Ann Mcneill looks at the details of the laws enacted in Iceland, Ireland and Norway as revealed by document research and reports on the in depth analysis carried out using aspects of a logic model developed to comprehensively characterise the Irish POS law. This involved historical datasets, specially added POS questions in the monthly tracker surveys of prevalence and attitudes, retail audits, a cohort of adolescents and sales data. The results of the one year post implementation study showed a positive effect on attitudes consistent with enhanced TC

5th Presentation POS bans exist in 9 Canadian provinces from Saskatchewan (2002) to New Brunswick (2009).Dr David Hammond reveals that extensive data suggests that POS bans influence prevalence, level of consumption and age of initiation. The data also suggests that the influence of the bans increases with time. He stresses the need to account for the role of other TC interventions in the observed improvement in smoking.

1st presentation: POS Display and the Marketing of Tobacco

Authors: Gerard Hastings, Crawford Moodie and Allison Ford CRUK Centre for Tobacco Control Research, Stirling University, Scotland

Marketing is the art of getting the right product in the right place at the right price – and promoting it in the right way. ‘Right’ in this context has, of course no moral meaning, it refers simply to that which will succeed with consumers and potential consumers. These four Ps of marketing are sometimes referred to as the marketing mix, a name which reflects a collective purpose: they are brought together to form an offering that exceeds the sum of its parts – and in particular converts a utilitarian product into an evocative brand. Point of Sale display is important to the tobacco marketing effort for three reasons: 1. It facilitates both the place and promotion elements of the marketing mix. More specifically it also works with pack design to communicate crucial messages about style and to deceive the customer with illusions of reduced harm. 2. It delivers its punch precisely at the point that a purchase decision is being made, whether by a teen to buy for the first time, an equivocal smoker to relinquish their quit attempt, or the committed smoker to restock. 3. In ‘dark markets’, where other forms of advertising has been banned, it enables the retention of a crucial high street presence.

The lessons for tobacco control are that we should and indeed must ban display at point of sale and recognise the logical link this makes to plain packaging. In addition, however, we should note that the fundamental problem here is marketing and the continued freedom of tobacco corporations to make a profit out of such a lethal product.

Parallelsessions 2: March 28, 15.30-17.00 53 2nd presentation: International overview: the evidence base for removing point of sale tobacco product displays

Author: Richard Edwards Department of Public Health, University of Otago, Wellington, New Zealand

This presentation will review three lines of evidence: 1. the evidence that point of sale displays influence smoking behaviours – particularly uptake of smoking by children and quitting-related behaviours among smokers; 2. the evidence that removing point of sale displays is an effective tobacco control intervention 3. Arguments used by the tobacco industry and its allies to oppose removing point of sale displays, and the degree to which these arguments are supported by the evidence. The review will build on previous systematic reviews of the evidence, and also recent arguments made by tobacco industry funded consultants to government review processes. The presentation will finish by summarising the evidential and moral and ethical case for regulatory and legislative measures to remove point of sale displays.

3rd presentation: 1. Monitoring and compliance of POS legislation in Ireland.

Authors: Maurice Mulcahy, Health Service …xecutive, Ireland Manpreet Bains, University of Nottingham UK Ann Mc Neil , Gerard Hastings, Richard Edwards and Luke Clancy

Objective To identify changes in POS displays following a national ban implemented on 1st July 2009

Methods A before and after survey of a cross section of retail outlets

Results Over 200 retail outlets including retail groups (20 %), garages (10%), grocers (18 %), tobac- conists/newsagents (16 %) and off- licences (8 %) were surveyed using structured questionnaires administered by volunteers. 70 % of retail outlets surveyed were within 1 km of a school with 20% within 100m of a school. After the implementation of the ban there were significant reductions in the display of tobacco signage, countertop materials and tobacco products (p <0.001).

Conclusions High rates of compliance with the POS ban have been observed which ensure reduced exposure to tobacco advertising in the retail environment. 2. Monitoring and compliance of POS legislation in Norway.

Author: Randi Lavik National Institute for Consumer Research (SIFO), Oslo, Norway

1st of January 2010 the ban against point of sale promotional displays was implemented in Norway. SIFO is currently evaluating this legislation on behalf of the government. The data we shall present are as follows: WEB-surveys A national representative sample of respondents between 15 and 54 years,

Parallelsessions 2: March 28, 15.30-17.00 54 plus extra sample of smokers (representative of smokers). These data are collected at three points in time: November 2009, January 2010 and November 2010. All surveys look at smoking habits and attitudes, and will provide information about the degree to which the 2010 ban has led to any changes. Focus groups, before and after the ban was implemented among young people. Qualitative data. What do they think about the regulation? Observations in shops, before and after the legislations were implemented. Qualitative data. What do they think about the law and how do they behave in the shops? Sales statistics (volume) of tobacco products in Norway over the last three years. These data can tell us the extent to which changes have taken place. A challenge is that about 40 percent of all tobacco products are bought abroad (cross border shopping). Observations in a representative sample of grocery shops at the end of January 2010, in order to identify if the shops had implemented systems to hide tobacco and snuff, and if so, which ones were chosen? As s whole, these data – at least to a certain extent – can tell whether the ban has had any effect on smoking habits and attitudes towards smoking.

4th presentation: Point of Sale legislation in Europe – attitudes and economic impacts

Author: Ann McNeill, UK Centre for Tobacco Control Studies Co-authors of Irish research: Casey Quinn, Sarah Lewis, Luke Clancy, Richard Edwards, Maurice Mulcahy, Gerard Hastings

Objectives Points of sale laws are introduced primarily to protect children from the pernicious effects of tobacco marketing and promotion. This presentation will discuss point of sale laws across Europe and their impact. In particular it will examine the impact of the point of sale law in Ireland, introduced July 2009.

Methods A review of legislation across Europe using documents research. The Irish evaluation involved the development of a logic model to assess the effects of the Irish point of sale law. Results from the first year of implementation involved analysis of existing datasets, augmented where feasible. A monthly prevalence tracker of adults was utilized with specific questions asked about point of sale; retail audits; a small cohort of 13-15 year old adolescents; and sales data from AC Nielson.

Results Point of sale legislation has been introduced in Iceland, Norway and Ireland, and is due to be introduced in other countries across Europe. In Ireland, compliance with the law was excellent, recall of displays dropped significantly among adults and adolescents, and the law was popular among adults, including smokers. Changes in adolescents’ attitudes indicated that the law had helped to denormalise smoking. Sales and prevalence data showed no sudden change with implementation of the law over and above underlying trends and seasonal patterns.

Conclusions Point of sale legislation has very high compliance and reduces recall of tobacco displays. The law is popular and appears to help to denormalise smoking among youths and adults. There is no immediate impact on sales allowing retailers to adjust to the impact of the law.

Implementation Point of sale laws should be introduced in other countries as soon as possible.

Parallelsessions 2: March 28, 15.30-17.00 55 5th presentation: Cigarette display bans in Canada: changes in smoking prevalence and age of initiation.

Authors: David Hammond1, Rashid Ahmed2, Jessica Reid2, Robin Burkhalter2, K. Steven Brown3 Affiliations: 1Department of Health Studies, University of Waterloo, Canada 2Propel Centre for Population Health Impact, University of Waterloo Canada 3Department of Statistics, University of Waterloo, Canada

Objective To examine changes in smoking behaviour following the implementation of cigarette display bans (Display Bans) in nine Canadian provinces for which data was available: Saskatchewan (2002), Manitoba (2004), Prince Edward Island (2006), Nova Scotia (2007), British Columbia (2008), Ontario (2008), Quebec (2008), Alberta (2008), and New Brunswick (2009).

Methods Analyses were conducted using data between 1999 and 2009 from the Canadian Tobacco Use Monitoring Survey (CTUMS), conducted annually with a sample of 20,000 Canadian respondents (2,000 in each province).Three primary outcomes were examined: prevalence of daily smoking, daily cigarette consumption (CPD) among smokers, and mean age of initiation for 15 to 19 year-olds. Changes were examined within each province by comparing across “Pre” and “Post-ban” time periods, which were balanced in length to ensure an equivalent amount of time on either side of the Display Ban implementation. A “pooled effect” of Display Bans was estimated using linear regression analysis in which data from all provinces was combined.

Results Daily smoking prevalence among 15-19 year-olds and 15-24 year-olds decreased significantly post-Display Ban in four provinces: Manitoba, Saskatchewan, PEI, and Alberta. Among the 18+ age group, mean daily smoking prevalence decreased significantly post-Display Ban in three provinces: Manitoba, Saskatchewan, and PEI. Mean cigarettes per day decreased significantly post-Display Ban among smokers aged 15-19 in two provinces (Saskatchewan, and Alberta) and in four provinces among 15-24 year olds and those aged 18+ (Manitoba, Saskatchewan, PEI, and Alberta.) Mean age of initiation among youth aged 15-19 years increased significantly post-Display Ban in four provinces: Manitoba, Saskatchewan, PEI, and Nova Scotia. In the pooled-analysis including all provinces, smoking prevalence and CPD decreased significantly following bans among all age groups, and mean age of initiation increased significantly following bans.

Conclusion In Canada, smoking prevalence and consumption levels among daily smokers significantly declined following provincial Display Ban among all age groups, while age of smoking initiation increased (i.e., smoking initiation was delayed).

Implications Changes observed in smoking prevalence cannot necessarily be attributed to the Display Bans alone; however, the evidence is consistent with a decline in smoking behaviour following Display Bans. The impact of Display Bans was greatest in jurisdictions in which Bans had been implemented the longest: Manitoba (2004), Saskatchewan (2005), and PEI (2006). This suggests that the impact of Display Bans may build over time.

Parallelsessions 2: March 28, 15.30-17.00 56 2E - Session Lower socio economic status and cessation/smoking

2E.1: Disadvantaged women’s experiences of smoking cessation and the UK stop smoking services.

F.E. Beck1, L. Bauld1, A. Amos2 1University of Bath, BATH, United Kingdom 2University of …dinburgh, …DINBURGH, United Kingdom

Objective The FCTC states that the impact of tobacco control interventions on gender should be considered and, where appropriate, gender based strategies should be implemented. There is some evidence that women may be less successful at quitting smoking than men. The aim of this research was to explore disadvantaged women’s experiences of quitting smoking and of using the UK’s national stop smoking service in order to determine whether these services are meeting women’s needs.

Methods This study was qualitative and semi-structured interviews with 17 service-using women from 2 areas within the UK (Dudley and Bath) were conducted. Data were analysed using thematic analysis.

Results The results explore how the changing social context in the UK surrounding smoking has influenced women’s opinions about the acceptability of their smoking behaviour. Women’s experiences of smoking and addiction are also explored to highlight how it fits into their lives. Finally their experience of attempting cessation, pharmacotherapy and using the UK’s stop smoking services are explored in depth.

Conclusions The results highlight that, for the most part, women feel the existing services in the UK are effectively meeting their needs. However, a number of changes to the services were discussed including increased tailoring of service provision and increased promotion of different access routes. Changing social norms around smoking have been helpful in prompting women to quit.

Implementation The study highlights how the services could be improved to further meet women’s needs

Parallelsessions 2: March 28, 15.30-17.00 57 2E.2: Socioeconomic inequalities in smoking in 50 low and mid income countries around the world

A.E. Kunst, M.I. Witvliet, S. Mehmedovic AMC, University of Amsterdam, AMST…RDAM, The Netherlands

Objective In high-income countries, cigarette smoking was once more prevalent in higher socioeconomic groups, but later it became more prevalent in lower socioeconomic groups. If low and mid income countries were to follow the same development, smoking in these countries may still be more prevalent in higher socioeconomic groups, especially among women. The aim of this paper is to assess, for 50 low and mid income countries across the world, whether smoking is more prevalent in higher or lower socioeconomic groups.

Methods We used data of the World Health Survey of 2002-2005. Multilevel logistic regression was used to assess associations between socioeconomic indicators (educational level, occupational level) and smoking in 50 countries. The models accounted for country-level socioeconomic development, measured by gross domestic product (GDP) and female literacy rate (FLR). Inequalities in smoking were assessed for broad regions, for individual countries, and for groups of countries with similar national income or FLR.

Results In all countries combined, men and women in lower socioeconomic groups smoked more than those in higher groups. Across the world, smoking prevalence is related to lower occupational class and especially to lower educational level. Socioeconomic inequalities in smoking were generally largest in Asian regions. Smoking inequalities were about equally large, in relative terms, in Latin America, Middle East, Sub-Saharan Africa and Eastern Europe. There is no evidence for inequalities in smoking to be smaller in countries with lower GDP or FLR. When results were stratified by age, smoking was found to be more prevalent among higher socioeconomic groups among older women. These “positive”inequalities were most marked in the Eastern European region and nearby countries.

Conclusions and implementation For most of the world, inequalities in smoking epidemic do not follow the patterns to be expected on the basis of the historical experience of Europe and other high income countries. Instead, in most low and mid income countries, smoking is a problem of lower socioeconomic groups, both among men and women. Around the world, tobacco control policies should pay particular attention to the poor and to people with low education.

2E.3: Single mothers - a vulnerable group with a high smoking prevalence

U.R. Reulbach1, H.M.A. McAvoy2, Z.K. Kabir3, J.W. Wilde2, L.C. Clancy3 1Trinity College Dublin, DUBLIN, Ireland 2Institute of Public Health in Ireland, DUBLIN, Ireland 3Research Institute For a Tobacco Free Society, DUBLIN, Ireland

Objective To assess smoking prevalence among single mothers using a nationally representative data base that has not been previously analysed from a smoking perspective beyond basic frequencies.

Parallelsessions 2: March 28, 15.30-17.00 58 Methods Data from 2003-2008 was extracted from the survey of Income and Living Conditions (EU-SILC) which is a EU-wide, survey conducted in Ireland by the Central Statistics Office, as part of a programme to obtain information on the income and living conditions of different types of households. Commencing in 2003, the EU-SILC draws annually a random nationally representative sample of households. In this analysis, all household members aged at least 15 years old and with reported smoking status were included (N=61,679; females N=32,352). Single mothers were considered as women aged 15 or over resident in households comprising one adult with at least one child. A household and individual weight was applied for the calculation of prevalence rates to compensate for differential non-response. Furthermore, a logistic regression model was computed which adjusted for highest education achieved, household income, general medical card status and in consistent poverty (income < 60% of median income and deprived on a number of indicators). Rates and odds ratios are expressed with 95% Confidence Intervals (CIs).

Results Single mothers had on average a 144% higher smoking prevalence when compared with other women. The average smoking prevalence for single mothers was 56.2% (95% CI: 53.4- 59.0%) in the time period between 2003 and 2008 (the average smoking prevalence for mothers in a non-single adult household was 26.5%; 95% CI: 25.3-27.7%). The odds ratio of being a smoker was 4.7 (95% CI: 4.0-5.4; p<0.001) for single mothers when compared with other females in a socio-economically adjusted logistic regression.

Conclusions and Implementation Mothers in single adult households with a child or children (lone parent households) are at high risk of poverty and very high smoking rate are recorded in this group. This group must form a specific focus within efforts to tackle socio-economic inequalities in smoking and tobacco-related harm. Tobacco control and smoking cessation approaches must develop and deliver appropriate support to single mothers to quit smoking. Such target intervention would serve to reduce social inequalities in women’s health and would also have important implications for child health.

2E.4: SES-specific cost-effectiveness analysis of tobacco control: modeling tax increases and reimbursement policies

E.A.B. Over, B.M. Van Gelder, R.T. Hoogenveen, T.L. Feenstra RIVM, BILTHOV…N, The Netherlands

Objectives To develop a model that enables socio-economic status (SES)-specific evaluation of the long term effect of tobacco control regulation. To use this model for evaluation of costs and effects of tobacco tax increases and reimbursement of cessation support. Literature often reports that lower-SES groups are more sensitive to tax increases and profit more from reimbursement policy than higher-SES groups. Therefore these interventions could reduce the SES gradient in smoking and support a more equal distribution of health in the population.

Methods Four SES categories were distinguished based on education. The RIVM Chronic Disease Model (CDM) was extended to accommodate SES-specific input and produce SES specific outcomes. Model outcomes are life years gained, QALYs gained, healthcare costs and intervention costs. The model thus allows evaluating costs and long term health benefits

Parallelsessions 2: March 28, 15.30-17.00 59 of interventions that change start and/or quit rates of smoking. Effects of tax increases were modeled by using published SES-specific price elasticity of smoking cessation and initiation rates. Effects of reimbursement policy were modeled based on a large pilot study (N=1754) of reimbursement of cessation support, performed in 2009 among Agis policy- holders in the Province of Utrecht, the Netherlands. From this pilot, we obtained SES-specific reimbursement participation rates for a range of cessation support interventions. These were then combined with effect sizes obtained from systematic reviews and added to the baseline cessation rates in the CDM.

Results The model now allows evaluating SES specific long term effects of various policy options, thus supporting evidence based tobacco control interventions targeting low SES groups and helping to reduce the strong SES gradient in smoking and public health. Preliminary results show a progressive effect on that SES gradient. Final results for modeling tax increases and reimbursement policies will be presented at the conference.

Conclusions Cost-effectiveness of tobacco tax increases and reimbursement policies for cessation support can now be modeled and compared based on SES-specific data. This allows achieving a more nuanced picture of which tobacco control measure is most cost-effective.

2E.5: Smokers with Low Socio-economic Status: Are Traditional Smoking Cessation Systems Effective?

E. Di Sante1, R.S. Schwartz1, A.P. Philipneri1, N.M. Minian2, A.S. Srikandarajah1, A.B. Babayan1 1University of Toronto, TORONTO, Canada 2…CHO: Improving Women’s Health in Ontario, TORONTO, Canada

Objectives In Ontario, Canada, an evaluation was completed to assess the effectiveness of a traditional smoking cessation system for smokers with low-socio-economic status (low SES smokers). Low SES was defined as adult smokers with secondary education or less. This presentation will explore the smoking habits of low SES smokers and examine strategies to reach and support their cessation attempts.

Methods The Ontario smoking cessation system includes a helpline, quit contest, cessation services for hospitalized smokers, a program that provided free NRT and psychosocial counselling. Using a mixed methods approach, this assessment synthesizes information from four sources: the longitudinal Ontario Tobacco Survey (OTS) (n=4,501), an environmental scan, key in- formant interviews (n=19), a street intercept survey with current smokers and recent smokers (n=100). Analysis of the OTS adjusted for differences in age, sex, and smoking status.

Results The environmental scan showed that the current smoking cessation system is reaching less than 5% of low SES smokers, even though 12% report they want to quit in the next month. After adjusting for confounders, low SES smokers have higher adjusted odds ratio (AOR) for smoking daily (AOR=2.5; 95% Confidence Interval (CI): 1.81-3.34) and for being heavily addicted (AOR: 1.6; 95% CI: 1.23 to 2.12) compared to smokers with higher education. Low SES respondents smoke more cigarettes per day (mean=17) than other smokers (mean =

Parallelsessions 2: March 28, 15.30-17.00 60 13) (p-value<0.001). Despite their desire to quit, low SES smokers have limited awareness of services to help them quit or reduce their smoking. Data from the interviews show that most low SES smokers (n=59, street intercept survey) did not know where to go for help. Compared to other smokers, low SES smokers were significantly less likely to have used an evidence-based therapy six months prior to the OTS (AOR=0.66; 95% CI=0.48-0.91) and were 27% less likely to attempt to quit within one year (AOR=0.7; 95% CI; 0.53-0.99). Low SES smokers were 43% less likely to successfully quit (AOR=0.6; 95% CI; 0.35-0.92) compared to other smokers. Despite their desire to quit, most low SES smokers are not interested in using many of the services offered in their current form.

Conclusions Low SES smokers are a unique group that needs tailored programs and services; they should be consulted when cessation services are developed. A centralized system where low SES smokers can access information about programs and services would be helpful. Results from the evaluation show that programs and services should have increased availability in areas where low SES smokers work and reside.

Implementation Changes to existing smoking cessation services in Ontario are needed to more effectively reduce the smoking prevalence of low SES smokers. Conclusions from Ontario can be adapted for other jurisdictions.

Funding Ontario Ministry of Health Promotion and Sport, Canada

Parallelsessions 2: March 28, 15.30-17.00 61 2F - Symposium: Assessment of Tobacco Cessation Services in Europe – The e.SCCAN project

Chair: Bertrand Dautzenberg France and Sibylle Fleitmann Germany

Set up of the session 30 minutes Tobacco cessation services in Europe inventory and first year development of the e.SCCAN project by Bertand Dautzenberg, France

60 minutes Round table: good and bad practices in tobacco cessation services – lessons to take home from Denmark, Finland, France, Italy and Romania by Hanna Tonnensen, Denmark; Patrick Sandstrom, Finland; Bertrand Dautzenberg, France; Cinzia de Marco, Italy; Florin Mihaltan, Romania

Background Article 14 of the Framework Convention on Tobacco Control (FCTC) http://www.who.int/fctc/ en requires signatory Parties to take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence. Detailed provisions include the obligation to establish in health care facilities and rehabilitation centres programmes for diagnosing, counselling, preventing and treating tobacco dependence (Art. 14 c). Furthermore, there is an obligation of collaboration with other Parties to facilitate accessibility and affordability for treatment of tobacco dependence. Tobacco cessation services are key actors of the tobacco dependence treatment in many EU country, but urge heterogeneity exist. In order to clarify best and bad practice in Europe and to improve the consensus of health professional and advise national governments on how to fulfil the FCTC art. 14 obligations, it is of utmost importance to gain knowledge about current tobacco cessation service practice in each country.

The eSCCAN project Tobacco cessation services have an important role in promoting and supporting tobacco dependence treatment in the general medical practice and in the general population. Therefore, the collection of information on infrastructure of tobacco cessation services, their organisation, definition, and good practice in each of the 27 EU Member States is essential. Based on the collected evidence, expert consensus must be developed among leading health professionals to facilitate practical implementation of smoking cessation services in each EU country and disseminate result outside EU. The Office Français de Prévention du Tabagisme (OFT) in France has initiated a European project to assess the current tobacco cessation practice in Europe and to reach expert consensus on definitions of tobacco cessation services in order to create a common base line for action. The project is initially plan to run from end of 2009 to 2011. French experience of setting up a database on tobacco cessation services and the development of expert consensus on national level on definition of good/bad practice is the basis for this research project. The European network consensus on organisation of Tobacco cessation services will take in account international literature on smoking cessation, treatment programmes and guidelines available in Europe and internationally.

Parallelsessions 2: March 28, 15.30-17.00 62 The ECTOH eSCCAN symposium will be the first public presentation of this ongoing project and was build to be interactive with the international tobacco control community.

The aim of the symposium is to confront eSCCAN project with health professionals active in smoking cessation services and other stakeholders and to receive feed back to improve the project and developed the networking. The eSCCAN project will be presented focusing on organisation of service specifically dedicated to tobacco cessation that are only a small part of organisation of tobacco cessation in all EU countries. We will precise that good practice for tobacco cessation in general practice, organisation of general health service in EU countries, smoke free health service and the thematic of passive smoking will be take in account as they exist but that is not the subject of reflexion of eSCCAN experts group. The reason to split Tobacco cessation service in 3 categories will be presented and discussed. A global presentation of countries profiles and a presentation of who really work in tobacco cessation services across Europe will be presented (Doctor, Nurse, Psychotherapist, other health professional, and non health professions)

Some typical country profiles will be presented. Then a round table will be organized with the presentation of expert’s à 4 courtiers • Denmark, a country with a bad tobacco law will present good practice example and his country profiles with a focus on the data collection of individual data on tobacco cessation of tobacco users reaching tobacco cessation service. • Finland, a country with a good tobacco law will present his country profile and provide example of poor implementation of good practice and remaining bad practice. • Italy (or Span or Portugal) a country with a good law and a regional organization will present his country profile and one example of good practice and one example of bad practice • Romania (or Estonia Poland) will presented country profile and example of good and bad practice.

Declaration of conflict of interest There is no conflict of interest between the project partners and the tobacco industry. No funds from the Tobacco Industry or related bodies are accepted. The project receives co- funding from Pfizer Ltd in the frame of an unlimited educational grant. A memorandum of understanding will be signed with Pfizer ltd. guaranteeing that: • Their role is strictly confined to one of a supportive funder. • They will not influence directly or indirectly neither the strategic and scientific development nor the decision making process in any way or with any means at their disposal. • The financial contribution of Pfizer Ltd. will be acknowledged on the documents published in the course of the project.

Parallelsessions 2: March 28, 15.30-17.00 63 2G - Symposium: New insights in Preoperative smoking cessation: why and how?

Chair: Jean-Paul Humair MD MPH, Department of Community and Primary Care Medi- cine, University Hospitals of Geneva, Geneva, Switzerland Co-chair: Rodrigo Tango MD, Department of Community and Primary Care Medicine, University Hospitals of Geneva, Geneva, Switzerland

Presenters: Jean-Paul Humair, Rodrigo Tango

Background Smoking cessation before surgery is a major public health issue. Studies show that preoperative counseling and pharmacological therapy are effective interventions to promote smoking cessation and reduce perioperative complication rates. However, preoperative smoking cessation interventions are not part of standard care in most hospitals.

Aims and objectives This workshop, which is directed to all groups of health professionals, aims to: 1. Raise awareness about the link between smoking cessation and reduced perioperative complications. 2. Know the characteristics and content of effective preoperative smoking cessation interventions regarding the intensity, timing, professionals, counseling, and pharmaco logical therapy. 3. Promote implementation of preoperative interventions for smoking cessation to reduce the gap between recommendations and current practices.

Design This symposium is designed as a workshop including the most recent evidence on preoperative smoking cessation. It will be presented by two physicians with expertise in tobacco cessation. It will alternate work in small groups, plenary discussions, and presentations by the authors. The workshop is centered on two case studies featuring smokers with scheduled elective surgery. First, participants will be split in small groups for case discussion to identify the health risks of smoking and the benefits of smoking cessation before surgery. Then, they will discuss key elements for the implementation of the interventions for smoking cessation in hospitals. Groups will briefly present their responses in plenary. Then, authors will comment the presentations and provide a review of evidence on preoperative tobacco cessation interventions.

Content In this workshop authors will present the results of a literature review which can be summarized as follows: • Tobacco use increases 2 to 3-fold perioperative overall complication rates which are between 41 and 52% among smokers receiving usual care in the largest studies. • Smoking cessation 4 weeks before surgery reduces the overall surgical complication rates from 41 to 21% (49% less complications). A similar preoperative intervention performed 6-8 weeks decreases this rate from 52 to 18% (65% less complications). Complication rates are lower for abstainers than for smokers who reduced their

Parallelsessions 2: March 28, 15.30-17.00 64 consumption. • Smoking cessation interventions before surgery are effective as abstinence rates are higher at 4 weeks (36 vs. 2%) and at 1 year (33 vs. 15%). • The most effective smoking cessation interventions have the following characteristics: initiation at 6-8 weeks before surgery, intensive counseling and follow-up, pharmacological therapy tailored to patient and delivery by trained health professionals

In the last part of the workshop, participants will discuss the main obstacles to implementation of preoperative smoking cessation interventions: e.g. patients’ and health professionals’ lack of awareness of benefits of preoperative smoking cessation, surgeons’ reluctance to use nicotine replacement therapy, coordination of care between surgeons and tobacco specialists, exposure to tobacco smoke at home. Participants will brainstorm potential solutions to overcome these obstacles.

Implications for practice This workshop is highly relevant for health professionals involved in smoking cessation, regardless of their level of expertise in preoperative care. After the workshop, participants who are not familiar with this issue will know the evidence on health benefits of smoking cessation before surgery. Those already familiar with the topic will gain new insights to design implementation strategies of preoperative smoking cessation interventions in their healthcare settings.

Parallelsessions 2: March 28, 15.30-17.00 65 2H - Session Cessation interventions trials

2H.1: Validation and Dissemination of a Self-Help Approach to Smoking Relapse-Prevention

H. Brandon1, N.S.M. Marquinez1, M.A.K. Kovacs1, V.N.S. Simmons2, M.U. Unrod2, C.D.M. Meade2, S.K.S. Sutton2 1University of South Florida, TAMPA, United States of America 2H. Lee Moffitt Cancer Center & Research Institute, TAMPA, United States of America

Objectives Up to 95% of smokers relapse following a given smoking cessation attempt. Although relapse- prevention therapies have been developed, they have received mixed empirical support, and they have suffered from limited dissemination and usage. The goal of our research over the past 15 years has been to develop and test relapse-prevention interventions that are easier to disseminate and more attractive to smokers, compared to traditional face-to-face counseling approaches.

Method and Results With this goal, we developed the Forever Free relapse-prevention program, a series of booklets based on relapse theory and empirical smoking cessation findings. In two randomized controlled trials, these booklets were found to significantly reduce smoking relapse among recent quitters through up to two years of follow-up (Brandon et al., 2000, 2004). Moreover, they were found to be highly cost-effective in terms of predicted life-years saved (Chirikos et al., 2004).

Recently, these booklets were adapted for use by pregnant women, a population with exceptionally high rates of smoking relapse following childbirth. Because previous research identified level of partner support as a key outcome predictor, we developed one booklet specifically for the partner, with guidance on providing support for smoking abstinence. Results indicated overall benefits of the Forever Free for Baby and Me booklets through 8 months postpartum. However, efficacy was moderated by the women’s perceived level of partner support at baseline, such that those with generally supportive partners benefited the most from the intervention, compared to a usual care condition.

An ongoing effectiveness trial is testing the added value of the Forever Free booklets when provided to callers to a telephone quitline service (New York State), compared to usual care. Finally, another ongoing study is examining whether a modified set of booklets is efficacious for promoting both initial smoking cessation as well as maintenance of abstinence” as opposed to solely preventing relapse, as was their original intended purpose. Preliminary studies suggested that they were much more effective for smoking cessation than typical self-help interventions, perhaps because of their greater content.

Conclusions Research to date indicates that self-help is an effective and cost-effective approach to reducing smoking relapse. This presentation will summarize the Forever Free line of research, including published, recently completed, and ongoing studies.

Parallelsessions 2: March 28, 15.30-17.00 66 Implementation The Forever Free booklets have been disseminated by the US National Cancer Institute via the Internet, and they have been adopted by health departments, hospitals, and other organizations throughout the US. Both the original booklets and the pregnancy-specific ones have been “transcreated”into Spanish, with attention to both linguistic and cultural appropriateness across Hispanic groups. Similar self-help approaches may be viable throughout Europe.

2H.2: Quit smoking with text messages: an experience sampling approach in self-quitters

M.B. Bachmann, J.B. Brodbeck, H.J.Z. Znoj University of Berne/ Psychology, B…RN, Switzerland

Background and aim of the study Research shows that many smokers are motivated to quit smoking or have attempted to stop within the previous 12 months. Such attempts typically occur without the utilization of professional support (self-quitters). The success rate of these attempts, however, is very limited. Thus the question arises as to how smokers can be supported in maintaining their abstinence after quitting. The aim of this study is to develop a new approach to assist self-quitters in overcoming the urge to smoke and, in the event of lapses, to identify coping strategies that help prevent further progression of the relapse process.

Methods The sample consists of individuals between 20 and 40 years of age (N=200) who wish to give up smoking in the next 30 days without professional help and who have smoked at least 10 cigarettes a day for over a year. During 30 days after quitting participants record their experiences and situational conditions as they occur using an experience sampling method. A combined strategy of time and event sampling by text messages on mobile telephones is used. Pre- and post-assessments, as well as three- and six-month follow-ups, will be conducted using questionnaires on the World Wide Web. At the moment 140 participants have finished post-assessment.

Results Preliminary results of all participants who reached post-assessment will be presented. We expect that successful quitters differ in their coping strategies, in emotion regulation and self-control compared to relapsers.

Conclusions, Implications Preliminary results will be discussed.

Significance of the study The results will provide an empirical basis for recommendations about how people who want to quit can be supported. This study is innovative in two respects, it focuses on self-quitters and it uses the experience sampling methods for the smoking cessation process.

Parallelsessions 2: March 28, 15.30-17.00 67 2H.3: Comparing abrupt and gradual smoking cessation: a randomized trial

J.F.E. Etter University of Geneva, G…N…VA, Switzerland

Aims To compare abrupt and gradual smoking cessation.

Design Randomized trial and observational study (Internet, 2007-2010).

Participants Daily smokers who had no strong preference for either abrupt or gradual cessation were randomly assigned to receiving the instruction of either quitting immediately (n=375), or of gradually reducing their cigarette consumption by half over the next 2 weeks and then quit (n=375). Daily smokers who strongly preferred to quit abruptly were instructed to do so immediately (n=1758), those who strongly preferred gradual were instructed to reduce their cigarette consumption by half over the next 2 weeks and then quit (n=1236). Follow-up was conducted after 2, 4 and 6 weeks.

Findings Those who preferred abrupt were the most motivated to quit and the most confident in their ability to quit. After 4 weeks, quit rates were 16% in those who preferred abrupt, 8% in those who preferred gradual and 10% in those who had no preference (p<.001). In the latter group, abrupt was as effective as gradual (9% of those randomized to abrupt had quit vs. 11% of those randomized to gradual, p=0.2). Interactions were found with motivation to quit and confidence in ability to quit: the abrupt method was associated with better outcomes in those who were least motivated and least confident in their ability to quit.

Conclusions Preference for the abrupt method was associated with higher motivation to quit, higher self- efficacy and higher quit rates at follow-up. Those with low motivation and low confidence were more successful with the abrupt method. In those who had no strong preference for either method, abrupt and gradual produced similar results. Offering gradual may attract smokers who previously failed with abrupt.

2H.4: Efficacy of web-assisted tailored smoking cessation support: the value of stimulating action planning.

Author: Bolman, C.A.W., Open university of the Netherlands, Heerlen, The Netherlands (Presenting author)

Objectives The aim of the study was to examine the efficacy of a web-assisted tailored smoking cessation intervention in which potential quitters were explicitly stimulated to form action plans (e.g., plan a quit date, plan to remove ashtrays when quitting) and realize them (e.g. actually remove ashtrays) (AP intervention). In addition it was studied whether the AP intervention resulted in more planning and realization of planning and was appreciated more compared to a similar intervention without this Action planning add-on (control intervention). The latter

Parallelsessions 2: March 28, 15.30-17.00 68 intervention is currently offered to the Dutch general public.

Methods In a randomized control trial smokers in the AP intervention (N=977) were compared with smokers in the control intervention (N=1005) on several smoking outcomes six months after baseline. Intended action planning as well as demographic and smoking related characteristics were measured at baseline. Study participants’ appreciation, intended- and realized action planning were measured one month after baseline, while smoking outcomes were measured six months after. Both interventions consisted of one seven-to-nine page computer-tailored e-mail-delivered letter.

Results Complete cases logistic regression analysis showed a significant effect of the AP intervention on prolonged abstinence six months after baseline (OR=2.01; CI 1.08-3.84, p=.02), while the intention-to-treat analysis showed a borderline significant effect (OR=1.68; CI .96-2.92, p=.07). Sixteen percent of participants in the AP intervention were prolonged abstinent against 10% of those in the control intervention. No effects were found on point prevalence abstinence and continued abstinence. Participants in the AP intervention group showed significantly more intended action planning and action realization after one month. The AP intervention was also appreciated more than the control intervention in terms of interest, personal relevance, understandability, credibility, trust and relationship with the participants’ situation.

Conclusions Although there is no unequivocal evidence for the efficacy of the AP intervention compared to currently offered tailoring intervention, results are encouraging. Stimulating action planning results in more planning and realization of planning and is appreciated. Since the AP intervention may not have been intensive enough, efforts should be made to improve it e.g. by a more active engagement approach and by multiple tailoring AP feedback.

Implementation It is recommended to improve the AP intervention before implementation. It might however already be useful in practice since it is definitely as effective as the existing web-assisted tailored smoking cessation intervention, is appreciated more and results in more planning and realization of planning.

Parallelsessions 2: March 28, 15.30-17.00 69 2I - Workshop: How to deal with the tobacco industry in realizing a smoke free workplace & hospitality industry

WHAT Smoke free work places and a smoke free hospitality industry are getting more common in Western Europe. In Eastern Europe some countries have to go along this road. In this process, it’s quite possible that they will encounter obstacles, initiated, organised or endorsed by the tobacco industry, open or hidden. In this workshop the most used tactics by the tobacco industry are briefly presented; you will be provided by strategies to counter this in an effective way.

WHO Speakers: Norma Cronin, Antonella Cardone and Sam Villiers

HOW This workshops will provide a aractical approach in countering the hospitality industries opposition to smoke free legislation. Industry’s most used tactics to prevent or delay smoke free workplaces will be shown. And the Irish Cancer Society approach of setting up a pro health lobby group will also be explained. After this introduction you will work in small groups to discuss for about 30-40 minutes what you can do to counter these tactics. Each group will present in an elevator-pitch-method the solutions they think what should be done. After theses pitches feedback will be given by all participants, followed by a plenary discussion about the pro’s and con’s of the chosen strategies. Feedback of all strategies will be given by the speakers.

Parallelsessions 2: March 28, 15.30-17.00 70 Parallelsessions 3 Tuesday March 29, 11.15-12.45

3A - Symposium: Smoking in Movies: What can be done?

Chair: Prof. Dr. Fabrizio Faggiano, University of Avogadro, Novara, Italy Co-chair: Dr. Lies van Gennip, STIVORO, Den Hague, The Netherlands

Presenters: Prof. Dr. Stanton A. Glantz, University of California, San Francisco, USA Prof. Dr. James D. Sargent, Dartmouth Medical School, Lebanon, New Hampshire, USA Prof. Dr. Reiner Hanewinkel, Institute for Therapy and Health Research, Kiel, Germany Mr. Marcel Boulogne, …uropean Commission, Directorate General for Information Society and Media, Audiovisual and Media Policies Unit, Brussels, Belgium Dr. Terje Peetso, …uropean Commission, Health and Consumers Directorate-General, Unit C6 – Health Law and International, Brussels, Belgium Mrs. Barbara Zolty, Tobacco Free Initiative, World Health Organization. Geneva, Switzerland

Summary: This symposium aims at presenting various policy options on local, regional, national, EU, as well as international level on the topic of smoking in movies. Smoking in movies has been identified as a causal risk factor for youth smoking by several authorities, including WHO, the US National Cancer Institute, and the Centers for Disease Control and Prevention (CDC). The empirical evidence of these conclusions will be summarized, with an emphasis on prevalence of movie smoking and effects on youth in European countries.

Five policy options will be discussed: 1. Requiring an adult classification for any film that shows or implies tobacco, 2. Requiring studios and theatres to run a proven-effective anti-smoking ad before any film with any tobacco presence, in any distribution channel, 3. Certification in the closing credits that nobody on the production received anything of value (cash money, free cigarettes or other gifts, free publicity, interest-free loans or anything else) from anyone in exchange for using or displaying tobacco, 4. Eliminating tobacco brand identification and the presence of tobacco brand imagery (such as billboards) in the background of any movie scene, and 5. No subsidies of films with tobacco portrayals from European taxpayers.

A round table discussion will try to identify ways to incorporate smoking in movies into the European anti-tobacco strategy within the broader frame of the WHO Framework Convention on Tobacco Control (FCTC) treaty.

Course of the symposium This symposium has the format of a round table discussion. Thus, most of the 90 minutes time should be directed to a discussion among the presenters which is guided by the two

Parallelsessions 3: March 29, 11.15-12.45 71 chairs of the symposium.

Nevertheless, there should be a max of five minutes of presentation for each of the presenters. Please restrict your slides (if you choose to use slides) to a maximum of five slides. In order to avoid duplications of the presented material, we suggest that presenters should address the following topics in their statements:

1. Dr Sargent: Smoking in movies: One cause of adolescent smoking. 2. Dr Hanewinkel: Identifying the movie smoking vector: Sources of exposure for EU adolescents. 3. Dr Glantz: Limiting youth exposure: The four component solution. 4. Mrs Zolty: Disseminating evidence-based policy on movie smoking: World Health Organi- zation Framework Convention on Tobacco Control 5. Dr Peetso: Movie smoking on the European health agenda: The contribution of the Euro- pean Union 6. Mr Boulogne: Movie smoking and media policies in Europe: How can EU policies promote the reduction of movie smoking?

Parallelsessions 3: March 29, 11.15-12.45 72 3B - Session Harm reduction

3B.1: Tobacco Harm Reduction - the role of snus in smoking cessation. Empirical findings from Scandinavia

E. Lund Norway Institute for Alcohol and Drug Research, OSLO, Norway

‘In the EU, with Sweden as the only exception, snus has been banned since 1992. However, with regard to health, there is disagreement about whether the ban is appropriate. The main argument against the ban, raised by bodies such as the Royal College of Physicians of London and the European Respiratory Society, is that the ban deprives smokers, who are seriously addicted to nicotine, a harm-reducing alternative to cigarettes. In the USA, the American Association of Public Health Physicians and a series of eminent tobacco researchers are in favour of including snus within the arsenal of harm-reducing nicotine products. Their recommendations are based on the conviction that use of snus can contribute to cessation of, or a dramatic reduction in, smoking - the most harmful form of nicotine intake.

However, few randomized controlled trials (RCT) have been carried out to assess the use of snus on smoking cessation, and health authorities in the EU have used the absence of evidence from RCTs as a reason for warning against use of snus as a method for quitting smoking. However, in the absence of experimental studies, observational data from Sweden and Norway have been accumulated to illuminate this issue.

The presentation aims to present recent research on the transition between ciagrettes and snus from countries where snus is legal to sell. Will snus come in addition to or instead of cigarettes? Do snus have a role in smoking cessation? Is snus a gateway to cigarettes? What will be the impact on public health if the ban on snus were to be lifted in the EU? ‘

3B.2: The association between the use of NRT for harm reduction and cessation: A prospective analysis

E.V. Beard, R. West University College London, LONDON, United Kingdom

Objectives It is important to know how far smokers’ attempts at ‘harm reduction’ are associated with increased or reduced quitting activity. This study aimed to assess the stability of ‘harm reduction’ activities overtime, and the association of smoking reduction (SR) and the use of NRT for SR and temporary abstinence (TA) at baseline, with reports of attempts to quit smoking, smoking status and cigarettes per day at 3 and 6 months follow-up.

Method Data from 2,472 current smokers involved in the Smoking Toolkit Study, a series of monthly surveys of adults aged 16+, were used. At baseline participants were asked (1) whether they were attempting SR, if so, whether they used NRT, and (2) whether they regularly used NRT for periods of enforced temporary abstinence. They were also asked about their demographic characteristics and daily cigarette consumption. At 3 and 6 months follow-up, data on attempts to quit smoking and smoking status (4-week point prevalence cessation) was also collected.

Parallelsessions 3: March 29, 11.15-12.45 73 Results Fifty-one percent of smokers reported that they were reducing their cigarette consumption at baseline and 13% using NRT for SR. Thirteen percent of smokers reported using NRT for TA. Those reporting that they were using NRT for SR (OR 2.07, CI 1.05-4.07) and TA (OR 2.15, CI 1.16-3.98) at baseline, were more likely to report using it for such purposes at follow-up. NRT use for SR was positively associated with attempts to quit smoking (OR 1.42, CI 1.09-1.85) and smoking status (OR 1.84, CI 1.18-2.85) at 6 months follow-up. The use of NRT for TA was also associated with attempts to quit smoking (OR 1.5, CI 1.28-.13) and smoking status (OR 2.37, CI 1.0-3.53) at 6 months follow-up. No association with attempts to quit or smoking status was reported for TA, after controlling for the use of NRT for SR. The number of cigarettes smoked per day among those using NRT for TA increased over time from baseline to 6 months follow-up (F=99.85 (2, 2410), p<.05). Cigarette consumption was similar for those using and not using NRT for SR and TA at all time points.

Conclusion Stability in harm reduction activities was reported over time. While the use of NRT for SR was found to be positively associated with subsequent attempts to quit smoking and smoking status, the use of NRT for TA was not associated with either quit attempts or smoking status after excluding those using NRT for SR.

Implications These findings suggest that the use of NRT for harm reduction does not undermine cessation, and that the use of NRT for SR may promote it. Consideration should be given as to whether the use of NRT in these ways is provided alongside traditional tobacco control policies.

3B.3 : Smokeless tobacco and coronary heart disease: risks among non-smokers in Bangladesh

M.A. Rahman1, N. Spurrier1, M.A. Mahmood1, M. Rahman2, S.R. Choudhury3, S. Leeder4 1The University of Adelaide, AD…LAID…, Australia 2I…DCR (Institute of …pidemiology, Disease Control and Research), DHAKA, Bangladesh 3NHFH&RI (National Heart Foundation Hospital & Research Institute), DHAKA, Bangladesh 4The Menzies Centre for Health Policy, The University of Sydney, SYDN…Y, Australia

Objectives To determine the association between smokeless tobacco (SLT) use and coronary heart disease (CHD) among non-smoking adults in Bangladesh.

Methods A case-control study of non-smoking adults aged 40-75 years, residing within Dhaka City Corporation areas, was conducted in 2010. Cases of CHD were selected from two cardiac hospitals; controls were selected from both hospital and community settings. Cases were classified as incident cases (diagnosed within last one-year) of CHD if diagnosed as such by the hospital cardiologists. Neighbourhood residents of the CHD cases not known to have any cardiac disease were selected as community controls. Hospital controls were those patients who attended the cardiac outpatient departments but on examinations were declared as not suffering from CHD by the hospital cardiologists. Four community controls were matched to each case on age (±5years), gender, residential area and socioeconomic status; one hospital control was matched to each case on age and gender. Data were collected through structured interviews. Analyses of association were adjusted for age, hypertension, diabetes, family history of heart disease, physical activities and acute psycho-social stress.

Parallelsessions 3: March 29, 11.15-12.45 74 Results The sample comprised 302 CHD cases, 1208 community controls and 302 hospital controls (male: female 50:50 mean age 53±8.5years). Forty percent of the study subjects were current users of or had used SLT in the past. Defining current SLT use as any use in last one-year, 36% of the subjects were current users. Current use of SLT was similar among cases (33%), community controls (33%) and hospital controls (32%). The majority of SLT users were heavy users (used at least once a day) and long term users (duration >10years). Current use of SLT was not associated with increased risk of CHD when community controls were used (adjusted OR 0.87, 95% CI 0.63-1.19, p>0.05), or hospital controls were used (adjusted OR 1.00, 95% CI 0.63-1.60, p>0.05), or when both controls were combined (adjusted OR 1.00, 95% CI 0.74-1.34, p>0.05) in analyses. Similarly, when we analysed the data specifically focusing on individuals who had quit SLT (no use for >1year), quitting was not associated with increased risk of CHD. Risk of CHD did not increase with use of individual type, frequency and duration of each SLT product.

Conclusions In this study, there was no statistically significant association between SLT use and CHD among non-smoking adults in Bangladesh.

Implementation Because of the vulnerability of case-control studies, others should test whether what we have found can be replicated in prospective studies. If our findings are confirmed, it may well be that the strategic focus for reducing CHD in Bangladesh should be upon smoking control rather than SLT.

3B.4 : Does use of smokeless tobacco among adolescent cigarette smokers predict cigarette use in the future?

M. O’Hegarty1, L.L.P. Pederson2, A.M.M. Malarcher1, K.A. Asman3, S.A.M. Mirza1 1Centers for Disease Control and Prevention, ATLANTA, United States of America 2McKing Consulting Corporation, ATLANTA, United States of America 3RTI International, ATLANTA, United States of America

Objective To examine whether current use of smokeless tobacco in addition to current use of cigarettes is related to continuing smoking one year later among adolescents.

Methods Data came from Waves I and II of the National Longitudinal Study of Adolescent Health, using information from 3,284 current smokers (grades 7-11, 169 grade 12 students were interviewed at Wave II). There is one year between Wave I and Wave II. Multivariate models were used to assess whether use of smokeless tobacco at Wave I was associated with continuation of cigarette smoking at Wave II, controlling for possible confounders.

Parallelsessions 3: March 29, 11.15-12.45 75 smokeless tobacco-only at Wave II, and 17.9% quit both cigarettes and smokeless tobacco at Wave II. Among cigarette-only users at Wave I, 73.4% used cigarettes-only at Wave II, 1.6% used smokeless tobacco-only at Wave II, 5.0% used both smokeless tobacco and cigarettes at Wave II, and 20.0% quit cigarettes at Wave II. Smokers who also used smokeless tobacco at Wave I were less likely to continue smoking at Wave II (adjOR =0.71 [95% CI 0.52-0.98]) than cigarette-only users at Wave I.

Conclusions Combined use of cigarette and smokeless tobacco does not appear to be related to continued smoking one year later. Longer term follow-ups are needed to determine the stability of this relationship for > 1 year.

Interventions The results from this study provide information to refute the idea that adolescent cigarette smokers who also use smokeless tobacco are at greater risk of continued tobacco use than cigarette-only smokers. The 2008 Update to the Public Health Services guidelines for Treating Tobacco Use and Dependence concluded that counseling for smoking cessation is effective in treatment of adolescent smokers. Therefore, adolescent smokers should be provided with counseling interventions to aid them in quitting smoking. Clinicians should identify smokeless tobacco users, strongly urge them to quit, and provide counseling cessation interventions. Clinicians delivering dental health services should provide brief counseling interventions to all smokeless tobacco users.

3B.5 : Electronic cigarettes: utilization, satisfaction and perceived efficacy

J.F.E. Etter1, C.B. Bullen2 1University of Geneva, G…N…VA 4, Switzerland 2University of Auckland, AUCKLAND, New Zealand

Background Little is known about e-cigarette users, about how they use this product and about their opinions and satisfaction.

Aims To assess use, satisfaction and perceived efficacy with electronic cigarettes.

Methods Internet survey (English/French, 2010).

Results There were 3587 participants (70% former smokers, 61% men). On average, the median duration of e-cigarette use was 3 months, users drew 120 puffs/day on their e-cig and used 5 refills/day. Most respondents (97%) used e-cigarettes containing nicotine and users spent $33 per month on their e-cigarettes (incl. refills, components). Most (88%) said the e-cigarette helped them quit smoking or reduce their smoking (92%). Respondents used the e-cigarette becausethey perceived it was less toxic than tobacco (84%), to deal with craving for tobacco (79%) to quit smoking or avoid relapsing (77%), because it was cheaper than smoking (57%) and to deal with smokefree situations (39%). Most (83%) feared that e-cigarettes might be banned by authorities.

Parallelsessions 3: March 29, 11.15-12.45 76 Conclusions This study provided a description of real world users of electronic cigarettes. E-cigarettes were used mainly by former smokers, as an aid to quit smoking and to avoid relapse, much as people would use NRT products. E-cigarettes were perceived as satisfactory, useful and efficacious.

Parallelsessions 3: March 29, 11.15-12.45 77 3C - Symposium Tobacco industry tactics: understanding continuity and change

Chair: Jeff Collin Director, Global Public Health Unit, Social Policy, School of Social & Political Science University of Edinburgh, United Kingdom

Presenters: Pascal Diethelm Gary Fooks Deborah Arnott

This symposium will show examples of the tactics of the tobacco industry in various ways. Whether it is through denial of the harmful effects of (passive) smoking, Corporate Social Responsibility of the industry and the result of that focus or lobbying against point of sales bans.

After an introduction by Jeff Collin 3 presentations will be given:

1st: Tobacco denialism: what it is and how to respond

Pascal Diethelm

Objective To provide means of identifying public communication and campaign by adversaries of tobacco control when they are the expression of a more general ‘tobacco denialism’ phenomenon, with a view of knowing how to respond.

Methods Review of internal tobacco industry documents, publication by notable tobacco denialists, and review of media coverage of tobacco ‘controversies’, putting this material in the context of current knowledge about denialism obtained from research work and publications in non- tobacco contexts.

Result As is stated in the WHO Framework Convention on Tobacco Control, ‘scientific evidence has unequivocally established that … exposure to tobacco smoke cause[s] death, disease and disability’. Genuine scientific controversy may still exist on some specific aspects (such as, for example, whether exposure to SHS causes breast cancer), but the general issue has reached (and for quite some time) the status of scientific fact, in the same way as the causal link between lung cancer and active smoking. Denial of the health effects of either active or passive smoking has been initially engineered by the tobacco industry, on a global scale and using a wide array of methods ranging from the corruption of science to the launch of massive public relations campaigns aimed at influencing public opinion and political leaders (this was an early manifestation of ‘corporate denialism’). The industry, having been found guilty of conspiracy by courts in the USA for such denial, is now under close scrutiny and is subjected to the provisions of the WHO/FCTC.

Parallelsessions 3: March 29, 11.15-12.45 78 However, denial continues today but has morphed into a new form: a ‘tobacco denialism’ movement has emerged, which share many characteristics of other denialist movements, such as HIV-AIDS denial, vaccine denial, climate denial, evolution denial and holocaust denial. Denialist movements use, to various degrees, the following six tactics: conspiracy theories, the use of fake experts, cherry picking the evidence, creation of impossible standards, logical fallacies, and manufacture of doubt. Each of these tactics is described and illustrated with examples.

Conclusion The above tactics characterize tobacco denial, and, as such, they provide a means for recognizing tobacco denialism and distinguishing it from genuine scepticism, a distinc- tion that the media often does not make. Once denialism is recognized, the next stage is to decide how to respond. Entering into a scientific debate with a denialist is not possible, since ground rules, such as scientific honesty, are not usually obeyed. Censorship is clearly not an option. The best way is to shift the debate and expose the deniers’ tactics to public scrutiny, while refraining from fallacious ad hominem arguments against the deniers themselves.

Reference 1. Diethelm P, McKee M ‘Denialism: what it is and how should scientists respond’ European Journal of Public Health, Vol. 19, No. 1, 2-4

2nd: Tobacco industry lobbying on display ban – a present day case study from the UK

Deborah Arnott, Action on Smoking and Health in the UK

In 2008 the UK government put legislation before parliament to prohibit the display of tobacco in shops. The tobacco industry, recognising that it is no longer effective lobbying politicians in its own name, has used a succession of front groups purporting to represent the interests of small shopkeepers to lobby against the legislation. In the first case the “Save Our Shop” campaign carried the logo “Responsible Retailers”, but did not explain that this was a brand of the Tobacco Retailers Alliance, nor that the TRA was little more than a subsidi- ary of the Tobacco Manufacturers Association (TMA) based in TMA offices and that the TMA itself was a club for the UK’s big three tobacco companies, Imperial, BAT and Gallaher. Mirror- ing the campaign against smokefree public places, the front groups created a “myth of lost profits” to scare small businesses into opposing the law. Once ASH revealed the industry links the TRA became dormant and the legislation passed into law. However, when the government changed and the Conservatives came into power in May 2010 industry lobbying started again, hopeful that a government which appeared to be committed to a “bonfire of the regulations” would repeal the display legislation. Lobbying this time was in the name of the National Federation of Retail Newsagents, by a firm of lobbyists called Hume Brophy. Hume Brophy’s links with BAT have now been revealed to the horror of members of the NFRN – to quote a former president “The federation is a puppet of the tobacco industry”. The fight continues to prevent the legislation being repealed. By the time the ECTOH meets we should know whether the tobacco industry or the health lobby have won this battle.

Reference 1. The smoke-filled room: How Big Tobacco influences health policy in the UK. London, ASH, 2010 www.ash.org.uk/SmokeFilledRoom 2. Observer 27th February Tobacco firms accused of funding campaign to keep cigarettes on display: National Federation of Retail Newsagents’ campaign is being influenced by the tobacco industry, says trade body’s ex-leader Parallelsessions 3: March 29, 11.15-12.45 79 http://www.guardian.co.uk/business/2011/feb/26/tobacco-firms-campaign-cigarettes-display http://www.guardian.co.uk/commentisfree/2011/feb/27/observer-editorial-ban-cigarette-displays

3rd: From Lobbying to Corporate Social Responsibility: the Evolution of Tobacco Industry Political Activity

Gary Fooks and Anna Gilmore

Objectives Existing research suggests that tobacco companies first developed Corporate Social Responsi- bility (CSR) programmes to restore their declining political influence. This political dimension of tobacco industry CSR is reflected in the guidelines for implementation of article 5.3 of the WHO Framework Convention of Tobacco Control (FCTC), which identifies corporate social responsibility (CSR) as a practice used by tobacco companies to influence public health policymaking. Despite this, the political aims and effects of CSR remain underexplored. This paper aims to fill this gap by presenting a model of CSR that illustrates how CSR practices work politically. Specifi- cally, the paper uses existing models of corporate political activity as a basis for categorising the ways in which British American tobacco (BAT) and other tobacco companies have used their CSR programmes to maintain and, potentially, revitalise their political influence.

Methods Analysis of: BAT’s internal documents made publicly available as a result of U.S. litigation; existing studies of CSR in the tobacco industry focusing on Philip Morris; BAT’s social and annual reports; and CSR related web-based material.

Results Industry documents suggest that CSR provides tobacco companies with a platform for a wide range of strategies which correspond to traditional techniques of corporate political activity. These include: constituency building; constituency destabilisation; the provision of information both to policy élites and the general public; and the provision of financial incentives to policy makers. In addition to this, CSR has been used as a platform to facilitate the pre-emption of legally enforceable national and international regulation with voluntary forms of corporate governance and tobacco regulation. Each of these broad strategies comprises a large number of discrete tactics aimed, for example, at securing access to policymakers and gathering intelligence on policymakers and public health advocates. These strategies and attendant tactics are designed to work at a number of different, mutually reinforcing levels to: provide third party advocacy; reduce the political influence of more radical and politically active public health advocates; reshape perceptions of the tobacco industry as a credible source of policy relevant data; shape perceptions of what constitute the most effective approaches to tobacco regulation; and shape the priorities of policy élites.

Conclusion and Implementation Tobacco company CSR programs have, in the first instance, to be understood as a political practice – an innovative form of corporate political activity that aims to produce public policy outcomes favourable to the firm’s continued economic survival and success. In this sense, CSR is essentially no different in its objectives than traditional lobbying or political contributions. In addition to providing an important framework of analysis for tobacco industry research, our findings are potentially useful for tobacco control advocates and policymakers interested in ensuring compliance with the FCTC by national governments.

Parallelsessions 3: March 29, 11.15-12.45 80 3D - Symposium: Effectiveness of Tax and Price Policies for Tobacco Control: IARC Handbook Volume 14

Chair: Frank Chaloupka University of Illinois, Chicago, USA Co-chair: Maria Leon IARC, Lyon, France

Presenters: Sophia Delipalla, University of Macedonia, Thessaloniki, Greece Katherine Smith, University of Bath, Bath, UK Carlo La Vecchia, Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy Silvano Gallus, Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy Esteve Fernandez, Institut Català d’Oncologia-IDIB…LL, Barcelona, Spain Hana Ross, American Cancer Society, Atlanta, USA Frank Chaloupka, University of Illinois, Chicago, USA Luk Joossens, Fondation contre le Cancer, Brussels, Belgium David Levy, Pacific Institute and University of Baltimore, Baltimore, USA Luke Clancy, Tobacco Free Research Institute, Dublin, Ireland

Summary of Symposium As the WHO Framework Convention on Tobacco Control (FCTC) comes into effect in an increasing number of countries, policy-formulated tobacco control initiatives including increases in tobacco tax and price will proliferate, driving changes in tobacco use. It is therefore crucial to complete an evidence-based assessment of the effectiveness of these interventions. In volume 14 of the IARC Handbooks on Cancer Prevention, the evidence was gathered, presented, critically discussed and synthesized by a group of 21 experts from 12 countries from October 2009 to May 2010. This work was subject to further review and evaluated during a one-week meeting at IARC (17-22 May 2010).

The aim of this symposium is to disseminate widely the evidence on the impact of tobacco tax policies in changing tobacco use. Including the significant moderator effect the tobacco industry and organized tobacco tax evasion can have in these policies.

Presentations Tobacco companies have engaged in marketing activities to lower the price of their products and have influenced tax policy through lobbying efforts. Reduced number and geographic coverage of empirical studies have included industry pricing strategies and have so far focused exclusively on cigarettes. Most existing research on industry efforts to prevent large tax increases or earmarking of taxes and to reduce current taxes focuses on North America. Research on industry efforts to influence tax structures currently involves only a small number of country-specific case studies. Almost no empirical evidence exists on the impact of minimum tobacco pricing policies or on bans on tobacco company price-related marketing efforts. Surveys conducted both in high and low to middle income countries indicate that the overall price elasticity of adult smoking ranges between -0.2 and -0.6, with half of the effect of price impacting smoking prevalence and the other half influencing smoking intensity. These findings are consistent with those from a vast number of studies using aggregated data, the price elasticity being around -0.4 for developed countries and ranging between -0.2 and -0.8 for most of low to middle income countries. Surveys conducted in high income countries indicate support among the general population for tobacco tax in-

Parallelsessions 3: March 29, 11.15-12.45 81 creases. Higher tobacco prices/taxes lead to lower smoking prevalence, lower smoking intensity and higher rates of smoking cessation among youth and the poor, as well as reduced initiation among youth. In many countries tobacco excise taxes are disproportionately collected from people with lower income, therefore are regressive. However, given that the poor are more price/tax responsive compared to the rich, a tax increase is progressive and helps the poor to reduce their tobacco tax payment in the majority of the cases. The primary determinant of tax avoidance and small-scale bootlegging is the disparity in taxes and prices across jurisdictions. There are multiple determinants of tax evasion including corruption level, informal distribution networks, the presence of organised crime, others. Studies show that tax avoidance and tax evasion reduce but do not eliminate the effectiveness of tobacco tax increases in reducing tobacco use and raising revenues, and undermine other tobacco control measures. Tax evasion adds to health disparities between socioeconomic groups. Abundant literature examines the effect of smoking on health care expenditures and other health care outcomes, and finds that reduced smoking through increased taxes not only increases the life of the smoker, but also reduces medical costs. Further health gains can be expected through reductions in secondhand smoke exposure and fewer adverse birth outcomes. In addition, reductions in tobacco use through price increases have been associated with reduced alcohol and illicit drug use. Taxes may also serve as a source of government revenue that can be directed back into tobacco control.

1st presentation: Tobacco Industry Pricing, Price-Related Marketing, and Lobbying Strategies

Authors: Sophia Delipalla University of Macedonia and Katherine Smith University of Bath

Objective To review and identify factors informing the effectiveness of tobacco tax and pricing policies.

Methods A systematic approach was taken to searching for literature in 13 electronic databases. Relevant studies were then reviewed by an inter-disciplinary team, including economists and experts on tobacco industry research.

Results The extent to which tobacco product prices rise, following a tax increase, depends mainly on market and tax structures. Given that tobacco product markets are highly concentrated, recent empirical evidence indicates that tobacco taxes are generally over-shifted. Higher and uniform specific excise taxes result in higher tobacco-product prices. Tobacco companies can engage in a variety of marketing activities that lower the price or otherwise add value to their products. From the tobacco companies’ perspective, such price-reducing marketing efforts have advantages over direct pricing strategies as they can be more specifically targeted to particular population segments. The tobacco industry also tries to influence tax policy. Evidence, almost entirely from North America, shows that industry lobbying has been successful at keeping taxes low, particularly at the federal level, and at combating earmarking at the sub-national level. In addition, case study evidence suggests tobacco companies have attempted to influence tobacco excise tax structures, favouring those that will benefit their brands at the expense of their competitors. Governments can influence tobacco product prices through higher tobacco taxes. Some have implemented minimum pricing policies (where this is legal) and others have included bans on price-reducing marketing within comprehensive bans on industry marketing.

Parallelsessions 3: March 29, 11.15-12.45 82 Conclusions Empirical studies on industry pricing are limited in number and geographic coverage, and have so far focused exclusively on cigarettes. Most existing research on industry efforts to prevent large tax increases or earmarking of taxes and to reduce current taxes focuses on North America. Research on industry efforts to influence tax structures currently involves only a small number of countryspecific case studies. Almost no empirical evidence exists on the impact of minimum tobacco pricing policies or on bans on tobacco company price-related marketing efforts.

Implementation More research is needed to explore the following: (i) the impact of tobacco tax structure on prices and industry short- and long-term pricing strategies, particularly for products other than cigarettes; (ii) tobacco companies’ use of pricerelated marketing techniques; (iii) industry efforts to influence tax levels and avoid earmarking in regions beyond North Ameri- can; (iv) industry efforts to influence tax structures in areas other than the few existing; (v) the effectiveness of minimum tobacco pricing policies and bans on tobacco company price-related marketing efforts.

2nd presentation: Tax, price and aggregated and adult individual-level demand of tobacco products

Authors Silvano Gallus, Carlo La Vecchia Istituto di Ricerche Farmacologiche Mario Negri and Esteve Fernandez Institut Català d’Oncologia-IDIB…LL

Objectives To review and discuss price and taxation of cigarettes and other tobacco products and their implications on tobacco use.

Methods Two systematic literature reviews were conducted to identify all publications providing data on price or tax elasticity on demand for tobacco products, using individual-level data on adults and aggregated data respectively. PubMed searches up to February 2010 were completed and later on updated up to May 2010 along the consultation of additional databases. Retrieved publications from the World Bank and from the list of references of originally identified studies were also considered. Attention was paid to studies reporting the total price elasticity of demand, price elasticity of smoking prevalence and price elasticity of smoking intensity and to the evidence from low, middle, and high-income countries.

Results Overall, 76 original papers or reports from studies using individual data on adults and over 100 studies with aggregated demand estimates were examined. Surveys conducted both in high and low to middle income countries indicate that the overall price elasticity of adult smoking ranges between -0.2 and -0.6, with half effect of price on smoking prevalence and half on intensity. These findings are consistent with those from a vast number of studies using aggregated data, the price elasticity being around -0.4 for developed countries and ranging between -0.2 and -0.8 for most of low to middle income countries. The wider range in these settings is probably related to differences in affordability and availability of different tobacco products. Increased taxation has a measurable effect on smoking cessation. Higher cigarette taxes tend to be associated with switch towards cheaper brands or other tobacco products. Surveys conducted in high income countries indicate support among the general population for tobacco tax increases, and such support becomes appreciably greater whenever

Parallelsessions 3: March 29, 11.15-12.45 83 a portion of the new tax revenues are devoted to measures for tobacco control.

Conclusion Price and tax measures are an effective, feasible and important means of reducing the prevalence of tobacco use and tobacco consumption among adults.

Implementation Increases in tobacco product taxation and price are required in high, middle, and low-income countries to reduce tobacco use in the population.

3rd presentation: Review of demand studies among young people and among the poor

Authors Hana Ross American Cancer Society and Frank Chaloupka University of Illinois at Chicago

Objective To examine the characteristics of the demand for tobacco products among young people and the poor, and their implications for the responsiveness to changes in tobacco prices and taxes among these two population subgroups.

Methods An overview of studies on the effects of prices/taxes on the demand for tobacco among youth and the economically disadvantaged was conducted. The special attention was paid to studies reporting the total price elasticity of demand, price elasticity of smoking prevalence and price elasticity of smoking intensity. These results are compared to and contrasted with similar estimates obtained from data on the older and more affluent population subgroups. A review of the research evidence on the effects of price on youth smoking uptake, smoking initiation, smoking cessation and on demand for tobacco products other than cigarettes was conducted as well. The evidence from low, middle, and high-income countries, along with the factors that influence the extent of differences in price elasticity across different socioeconomic groups within these country groups is analyzed.

Results In general, tobacco use among young and poor people is more responsive to changes in tobacco prices and taxes compared to older and more affluent adults. This is primarily due to lower disposable income. In addition, youth are more price/tax responsive, because of the lower level of addiction due to their shorter smoking history, their greater focus on the present, and because of peer influences. The general rule of higher price responsiveness among the poor may not apply to some countries where there is ready access to low or untaxed and inexpensive tobacco products, therefore the cost of substitution is low.

Conclusion Higher tobacco prices/taxes lead to lower smoking prevalence, lower smoking intensity and higher rates of smoking cessation among youth and the poor, as well as reduced initiation among youth. There are multiple links between tobacco use and poverty. In many countries tobacco excise taxes are disproportionately collected from people with lower income, therefore are regressive. However, given that the poor are more price/tax responsive compared to the rich, a tax increase is progressive and helps the poor to reduce their tobacco tax payment in the majority of the cases.

Parallelsessions 3: March 29, 11.15-12.45 84 Implementation Future research should focus on stages of youth smoking uptake, and on peer and family influences on tobacco use among youth people. The issue of tax regressivity and the related issue of smoking cessation among the poor warrant further investigation.

4th presentation: Tax avoidance and tax evasion of tobacco products

Author: Luk Joossens, Belgian Foundation against Cancer

Objective To assess the impact of tax avoidance and tax evasion on tax policies. Tax avoidance and tax evasion can decrease the economic welfare by making tobacco products more affordable and available, thus exacerbating the negative health consequences associated with tobacco use and secondhand smoking. Moreover, illicit tobacco trade can channel sales proceeds to organized crime and lead to a loss in government tax revenues.

Methods The presentation reviews and summarizes the research findings related to tobacco tax avoidance and tobacco tax evasion from published literature and empirical evidence. First, the difference between tax avoidance and tax evasion is explained. Second, the motivation for tax avoidance and tax evasion are presented. Third, the most recent estimates of the extent of tax evasion globally, regionally and also in some mselected countries are provided. Fourth, the review of the literature on the impact of tax avoidance and tax evasion on public health measures is summarized. Finally, the impact of policies attempting to curb illicit tobacco trade is reviewed and the lessons learned form the implementation of those policies are offered.

Results Studies show that tax avoidance and tax evasion reduce but do not eliminate the effectiveness of tobacco tax increases in reducing tobacco use and raising revenues. Tobacco tax avoidance and evasion undermine other tobacco control measures. Tax evasion adds to health disparities between socioeconomic groups.

Conclusions The primary determinant of tax avoidance and small-scale bootlegging is differentials in taxes and prices across jurisdictions. There are multiple determinants of tax evasion. These include the level of corruption, informal distribution networks, the presence of organised crime, the extent of cross-border trade and strength of border controls, insufficient penalties, weak tax administration and enforcement, differential treatment of domestically-produced and imported products, the pre-tax price of tobacco products, and the strategies of tobacco companies, as well as price and tax levels.

Implementation Research on the effectiveness of strategies aimed at reducing tax avoidance and evasion is limited and difficult. The modus operandi for the supply of illegal tobacco products may change over time as illicit traders adapt their practises in response to government actions. Tax evasion can be reduced via a combination of various strategies such as international cooperation, legislative measures to control the supply chain, increased enforcement and strong penalties, as shown by evidence largely from case studies.

Parallelsessions 3: March 29, 11.15-12.45 85 5th presentation: Health, revenue and economic impact of taxes

Authors David Levy Pacific Institute and University of Baltimore and Luke Clancy Tobacco Free Research Institute, Dublin

Objective To examine the impact of tobacco product taxes on population health (through the impact on lives saved and disease incidence (in smokers and secondhand smokers)) and on health care cost savings, and to examine the effects of tobacco tax increases on tobacco industry employment (and farming) as well as on non-tobacco industry employment, on government revenue, on tobacco tax revenue, and on the Consumer Price Index.

Methods A brief discussion of the conceptual framework is presented followed by a review of the evidence for health effects, employment effects, tax revenue and the consumer price index. Empirical/statistical studies as well as simulation models were considered. The evidence from low, middle, and high-income countries is considered to the extent available.

Results A large literature examines the effect of smoking on health care expenditures and other health care outcomes, and finds that reduced smoking through increased taxes not only increases the life of the smoker, but also reduces medical costs. Further health gains can be expected through reductions in secondhand smoke exposure and fewer adverse birth outcomes. In addition, reductions in tobacco use through price increases have been associated with reduced alcohol and illicit drug use. The effects of reduced smoking on obesity are less clear. Economic studies of a cigarette tax increase have also been considered. Studies generally have found that reduced tobacco consumption and employment leads to employment in other economic sectors, often leading to a more productive use of economic resources. Taxes may also serve as a source of government revenue that can be directed back into tobacco control to provide further benefits from reduced smoking. Finally, increased tobacco taxes have been shown to have minimal, if any effect on general price inflation.

Conclusion Cigarette taxes can be expected to have a large impact on society through a number of different channels. The effects of a tax increase can be expected to improve the health of a country and its economy. These studies, especially those on health effects, provide strong justification for tax increases. Arguments against taxes increases based on their effects on the economy can generally be shown to be weak.

Implementation The literature is vast, but further study is needed for low and middle income nations. Nevertheless, although the magnitude of effects may differ, the same types of benefits may be expected in these countries.

Funding: The EC FP7 Grant Agreement HEALTH-F2-2009-223323 “Pricing Policies and Control of Tobacco in Europe (PPACTE)” funded IARC Handbook volume 14.

Parallelsessions 3: March 29, 11.15-12.45 86 3E - Session Monitoring systems

3E.1 : Tobacco Monitoring Switzerland

T.R. Radtke1, R.K. Keller1, H.K. Krebs2, R.H. Hornung1 1University of Zurich, ZURICH, Switzerland 2Kommunikation und Publikumsforschung, ZURICH, Switzerland

Objectives Based on recommendations by the World Health Organization, the Federal Council in Switzer- land passed a package of measures designed to reduce the harmful effects of tobacco on health. As a decision-making basis for implementation of these measures, a continuous survey of tobacco use was needed. Therefore, a research system, called Tobacco Monitoring Switzerland [TMS], was developed and implemented in 2000. The TMS is a representative, continuous survey of tobacco consumption among 14- to 65-year-olds in Switzerland.

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 We will present latest results of tobacco consumption, smoking habits of adolescents and second-hand smoke for 2010. In 2009, the smoking prevalence in Switzerland is still very high (18% daily and 8% occasional smokers) and it is higher among men than women (31% vs. 24%). 20-to 24 year-olds have the highest smoking prevalence with 39%. Concerning second-hand smoke 15% of the 14- to 65-year-olds were exposed to second-hand smoke for at least seven hours per week in 2009.

Conclusions The TMS provides up-to-date data on tobacco consumption for various target groups (the public, the media, political decision-makers, or prevention specialists) reliably, quickly, and in a user-friendly way. In addition, it fulfils high methodological requirements.

Implementation The TMS builds a basis for prevention and intervention measures in Switzer- land. Furthermore it ensures a continuous survey of tobacco consumption in Switzerland and due to this fact builds a basis for implementation of these measures

Parallelsessions 3: March 29, 11.15-12.45 87 3E.2 : The pattern of smoking uptake and cessation across the lifespan in England

J.A. Fidler, R. West University College London, LONDON, United Kingdom

Objective To assess the pattern of smoking uptake and cessation across ages using data from an English population representative survey

Methods Data were taken from the Smoking Toolkit Study, a series of monthly cross-sectional surveys of a representative sample of the English population. Between November 2006 and August 2010 a total of 82,698 respondents reported their smoking status with the following response options; I smoke cigarettes (including hand-rolled) every day, I smoke cigarettes (including hand-rolled), but not every day, I do not smoke cigarettes at all, but I do smoke tobacco of some kind (e.g. pipe or cigar), I have stopped smoking completely in the last year, I stopped smoking completely more than a year ago, I have never been a smoker (i.e. smoked for a year or more). Age in years was also established and used to calculate a) the change in smoking prevalence and b) the change in quit ratio (ex-smokers divided by ever smokers) with each age increase.

Results Smoking uptake was still occurring up to at least age 21. Two periods of successful quitting were apparent; late twenties and early thirties, and after age 50. Between age 35 and 50 the pattern of smoking behaviour remained stable and very little successful quitting occurred.

Conclusion Despite a previous focus on uptake of smoking among children, the results show that young adults in England continue to be at risk of becoming smokers. There are clear times when cessation occurs, but middle age emerged as a period of relative constancy of smoking behaviour in this population.

Implementation These findings provide evidence for targeted intervention at particular ages, notably prevention of uptake in early adulthood and improvement of cessation rates in middle age.

3E.3: Validity of Measuring Current Smoking Prevalence in a Specific Population by Using Different Surveillance Tools

O.Y.S. El Shahawy Virginia Commonwealth University, RICHMOND, United States of America

Background Tobacco use surveillance is essential in monitoring the tobacco control progress. Scientists follow up on that using estimates provided from different survey tools in most occasions. Up to date, there was no cross validity test of the outcome measure of different tools, partly because of impracticality or difficulty.

Objectives To assess the difference in current smoking prevalence estimates according to the same

Parallelsessions 3: March 29, 11.15-12.45 88 question in the same population using different surveys to detect sources of bias if any.

Methods Global Youth Tobacco Survey (GYTS) and Global School Health Survey (GSHS) share the same methodology within all steps of sampling and survey administration. Eight countries co-implemented the surveys at the same point of time and populations using the same research teams. A two stage cluster sampling procedure was followed, same output was used for the first stage at school level and then there was random selection at classrooms level within the same school in the second level. Countries were Guyana and Namibia in 2004, Libya, Philippines, Saint Lucia, Saint Vincent & the Grenadines, Trinidad & Tobago and Uruguay in 2007. Data were analyzed to compare the findings of both surveys regarding the current use of cigarettes as it had the same wording across both surveys in all countries.

Results GYTS consistently reported higher prevalence among all 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 Philippines where GSHS recorded 9.7% (7.7-11.7) while GYTS recorded 17.3% (14.7-20.4) and Saint Lucia where GSHS recorded 7.8% (5.7-9.9) while GYTS recorded 12.7% (10.4-15.3)

Conclusions GYTS recorded consistently a higher trend than GSHS in the same population. This shows that different surveillance tools give different outcomes of the same risk factor within the same population which is a potential form of bias in measurement. One possible reason would be the ‘Framing Effects’ as GYTS could be more sensitive to detect consumption since it is specific to tobacco. Another reason would be the ‘Response Fatigue’ as in GSHS the question ranged from being the 33rd question to the 54th question, while in GYTS it was always the 1st question to be asked.

Implementation Same surveillance tools should be used to monitor the trend of tobacco use over time because using different tools even with minimal variation can produce different outcomes. This could give false impression on the tobacco control activities effectiveness within a given population.

3E.4: Patterns of smoking prevalence and attitudes in Poland: GATS Poland 2009-2010

Zatonski1, A. Fronczak2, P. Bilinski3, B. Samolinski4, P. Miskiewicz5, F. Raciborski4, D. Kaleta6, A. Koziel5, J. Lobaszewski1 1The Maria-Sklodowska Curie Cancer Center and Institute of Oncology, WARSAW, Poland 2Ministry of Health, WARSAW, Poland 3Chief Sanitary Inspectorate, WARSAW, Poland 4Medical University of Warsaw, WARSAW, Poland 5WHO Country Office in Poland, WARSAW, Poland 6Medical University of Lodz, LODZ, Poland

Objectives To determine the smoking patterns of Polish adult population and its attitudes toward smoking and tobacco control policies.

Parallelsessions 3: March 29, 11.15-12.45 89 Methods Nationally representative survey based on the global standardized GATS methodology. A multi-stage, geographically clustered sample design was used for the study purposes. 14,000 households were sampled from the Central Statistical Office household address database and one individual (aged 15+) was randomly chosen from each participating household. Eventually, 7,840 adults were interviewed.

Results GATS Poland study results show that 33% of adult men (5.2 million), 21% of adult women (3.5 million), and 27% overall (8.7 million) are daily smokers. 30.3% of adult Polish population (9.8 million) currently smoke cigarettes (both daily and occasionally). 5 in 10 current smokers are willing to quit and one out of three declared a quit attempt during last 12 months preceding the study. 34% of respondents were exposed to SHS at workplace and 44% in their home. High percentage of non-smokers (88%) was exposed to tobacco smoke in bars, pubs or night-clubs. 25% of survey participants have noticed any form of cigarette marketing, mostly at points of sale, while 62% of adults have met anti-cigarette smoking information in media. 18% of current smokers thought about quitting after seeing the warning labels on cigarette packs and “Your doctor or pharmacist will help you quit smoking” was most remembered warning. Majority (93%) of Poles believes that smoking causes lung cancer, however nearly 40% are not aware of the fact that smoking causes a stroke and 20% does not know about causal relation of smoking to heart attack. Almost half (48%) of adults supports raising taxes on tobacco products and 65% would favor a complete ban on smoking in all worksites. 47% supports banning smoking in gastronomic venues and 41% of Poles favors a complete ban on manufacturing and sale of smoking tobacco products.

Conclusions GATS Poland results confirm observations made over last three decades in other national tobacco surveys. While the prevalence rates of daily smoking continue to drop among all adult men, there is no substantial decline observed in overall adult female population. Study results also show high levels of SHS exposure in non-smoking population and a gap in knowledge of adult Poles on health effects of smoking.

Implementation On the basis of GATS Poland study, several policy recommendations were made. Although many comprehensive tobacco control policies were developed in Poland over last 20 years, current situation still brings new challenges, especially related to protection of non-smokers from tobacco smoke in worksites and public places, effective enforcement of existing tobacco control measures, progressive tax and price policy regarding tobacco and urgent introducing pictorial health warnings.

Parallelsessions 3: March 29, 11.15-12.45 90 3E.5: Results at Your Fingertips: The Tobacco Informatics Monitoring System (TIMS)

S.O.C. O’Connor, A. Philipneri, R. Schwartz University of Toronto, TORONTO, Canada

Objectives The Tobacco Informatics Monitoring System (TIMS) is a dynamic database-driven website housing key tobacco control indicators detailing progress of a complex, multi-level government smoke-free program. This presentation will describe the development of this initiative and demonstrate TIMS’s user friendly and easy-to-navigate interface, which we argue will facilitate stakeholders’ use of tobacco-related data in program planning, decision making, surveillance and evaluation.

Methods Technical requirements for TIMS were developed by reviewing existing tobacco-related data portals (Center for Disease Control’s STATE system, World Health Organization’s Core Health Indicators, California’s C-STAT) and financial sites (Yahoo Finance, MSN Money Central, Globefund). Site design included several iterations, with the process being informed by an advisory group (comprising practitioners, policy-makers, advocates, and researchers); user testing; and an expert heuristic evaluation, which compared the site to web-design standards including ergonomics and usability.

Results Currently, TIMS contains over 140 indicators relating to demographics, tobacco use, smoking cessation, prevention, protection, and public opinion. Users are able to navigate through the site to access millions of unique data points including obtaining results by population (age, sex, education, occupation, and income), geography (national, provincial, and sub-provincial), and multiple surveys spanning multiple years. Display options include table, chart, and map, with dynamic capabilities to sort, group, print, and download.

Conclusions By providing ready access to analysed data, the TIMS website has the potential to enable new insights into emerging issues and trends. It is expected that the site will facilitate links between health-outcome results and the decision-making process such as consideration of health equity issues focusing on priority sub-populations and high-risk areas. This information has the potential to inform program planning, decision making, and evaluation.

Implementation TIMS will provide a variety of stakeholders (public health professionals, policy makers/analysts) with easy to access, timely, and robust information on key tobacco control indicators. TIMS addresses the need for acquiring this information for: decision making, program planning, and evaluation.

Parallelsessions 3: March 29, 11.15-12.45 91 3F - Session Youth prevention predictors

3F.1: Seeing is doing: Adolescent smoking due to peer mimicry, not peer pressure

Z. Harakeh, W.A.M. Vollebergh Utrecht University, UTR…CHT, The Netherlands

Objectives We examined whether implicit (mimicry) and/or explicit (pressure) peer influence affect adolescent smoking.

Methods Two experiments were conducted among daily-smoking adolescents aged 16-24 in the Netherlands. The first study consisted of a 2- factorial design (smoking condition), testing whether adolescents mimicked smoking without smelling the cigarette of the other, i.e. while interacting with a confederate through the internet with webcam. The second experiment consisted of a 2 (smoking condition) by 2 (pressure condition) factorial design, testing whether adolescents smoked because of mimicry and/or peer pressure. Primary outcomes were tested in these analyses: the total number of cigarettes, and heavy smoking (≥ three cigarettes).

Results The first study consisted of two conditions: no smoking condition (N = 17), and smoking condition (N = 19). Adolescents smoked more cigarettes in the presence of a heavy-smoking model than in a non-smoking model (exp B=2.57, 95%CI=1.43-4.61). Smoking behaviour of the confederate (exp B=20.68, 95%CI=1.18-363.72) and CO-level (exp B=1.30, 95%CI=1.01- 1.66) both increased participant’s likelihood for heavy smoking. The second study consisted of four conditions: the no pressure and no smoking condition (N = 15), the smoking and no pressure condition (N = 16), the pressure and no smoking condition (N = 20), the pressure and smoking condition (N = 17). Peer pressure (exp B=1.19, 95%CI=0.86-1.64) did not affect the total number of cigarettes smoked while mimicry (exp B=1.65, 95%CI=1.18-2.31) did. The findings were similar with respect to heavy smoking (exp B=3.24, 95%CI=0.79-13.28, and exp B=38.29, 95%CI=7.96-184.12 respectively).

Conclusion Smoking peers affect adolescent smoking due to peer mimicry, not peer pressure.

Implementation Smoking cessation programs and policy should aim at preventing the mere interaction with smoking peers and raise awareness about the impact of this process; 1) by preventing smoking models in smoking cessation ads and campaigns, 2) by banning smoking at schoolyards, and 3) by increasing awareness of mimicking smoking others.

Parallelsessions 3: March 29, 11.15-12.45 92 3F.2: Self-Efficacy in Adolescent Smoking: A Four-Year Longitudinal Study

J.M. Hiemstra, R. Otten, R.C.M.E. Engels Radboud University Nijmegen, NIJM…G…N, The Netherlands

Objectives Smoking onset takes place during adolescence. It is important to prevent young adolescents from smoking, because people who initiate smoking early in life are more likely to develop a long enduring smoking habit. One way to prevent adolescent smoking is by strengthening individual skills to reduce the likelihood that adolescents will start experimenting. One important individual factor is refusal self-efficacy, which refers to adolescents’ confidence in their ability to stay a non-smoker and the confidence to refuse a cigarette.

The aim of this study was twofold First, we looked at the changing role of self-efficacy in adolescent smoking over time while controlling for parental, sibling, and friends’ smoking. Second, we looked at the timing of adolescent smoking onset during adolescence and how this is affected by the time-varying effects of self-efficacy, smoking behavior of parents, friends and best friend and parental smoking specific communication.

Methods This study was based on data of five waves of the ‘Family and Health’ project. At baseline, 428 adolescents (mean age = 13.3 years; SD = .48) and their parents participated. Only never smokers at baseline (n = 272) were included to measure smoking onset.

For the first aim, latent growth curves analyses calculated general trends of self-efficacy, parental, sibling, and friends’ smoking behavior across ages 13 through 18 years, and we tested whether these growth parameters were predictive of growth of adolescent smoking. For the second aim, life tables and Kaplan Meier survival curves were used to describe event occurrence data. Next, discrete-time survival analyses were used to examine the relation between smoking onset, and self-efficacy, parental smoking, friends’ smoking and smoking specific parenting. Finally, the moderating effects between self-efficacy and environmental smoking, smoking-specific parenting on smoking onset were tested.

Results Latent growth curve parameters showed that a decrease in self-efficacy, an increase in proportion of smoking friends, and an increase in sibling smoking over time were related to an increase in adolescent smoking. Initial levels of sibling and friends’ smoking moderated the link between self-efficacy and adolescent smoking over time.

Findings revealed that 49% of all non-smoking respondents at baseline did start smoking within 4 years. The period of greatest risk for smoking onset was the first 2 year-period (age 13 to 16). Discrete-time survival analyses showed that low self-efficacy, high frequency of communication and high friends smoking were associated with smoking onset. No interaction effects were found.

Conclusion This study showed that self-efficacy is an important predictor of adolescent smoking behavior during adolescence (even after controlling for environmental smoking and smoking-specific communication).

Parallelsessions 3: March 29, 11.15-12.45 93 Implementation The results imply the importance of prevention programs focusing on self-efficacy skills and prevention of smoking friends.

Grant Dutch Cancer Society (2006-3464) and the Dutch Organization of Scientific Research (016-005-029; 400-05-051).

3F.3: Potential reach of smoking prevention programs in Dutch vocational schools; determinants of school directors’ intention

J. Veldwijk1, C. Hoving2, B.M. Van Gelder1, T.L. Feenstra1 1National Institute for Public Health and the …nvironment, BILTHOV…N, The Netherlands 2Maastricht University, MAASTRICHT, The Netherlands

Objectives This study investigated the current, intended and potential reach of smoking prevention programs in Dutch vocational schools and analyzed determinants of school directors’ intention to adopt two effective programs.

Methods Two questionnaires, based on the Diffusion of Innovation theory and the I-Change model, were developed and distributed amongst all Dutch vocational school directors (n = 452) of which 34% completed the questionnaire. The questionnaires focussed on either the ‘Healthy School and Stimulants program’ (HSS-program) or the ‘Out-of-school Computer Tailoring program’ (CT-program). Both these programs were proven to be effective among vocational school students. The potential reach of these programs was calculated by adding the percentages of current and intended users. Determinants of school director’s intention to adopt either program were identified use multivariate linear regression analyses.

Results The current and potential reach of the HSS-program was respectively 14% and 29% whereas the current and potential reach of the CT-program was respectively 0% and 5%. Being female, perceiving a higher percentage of smoking students in school, having a personality more open towards change, perceiving fewer cons of the program, a higher level of self efficacy towards adopting the program and a more positive social norm towards adopting a smoking prevention program from other school directors resulted in a positive intention towards adopting either program.

Conclusion The present study showed that the reach of these two effective smoking prevention programs is fairly low, with many schools using non evidence based programs.

Implications School-based smoking prevention efforts are likely to improve if schools choose to use programs that are proven to be effective, which can be encouraged by adapting existing and newly designed programs to school directors’ characteristics and providing easy access to reliable information regarding available programs.

Parallelsessions 3: March 29, 11.15-12.45 94 3F.4: Parental influences in relation to the effectiveness of school-based smoking prevention

M.R. Galanti1, M.P. Caria1, F.F. Faggiano2 1Karolinska Institutet, STOCKHOLM, Sweden 2Università del Piemonte Orientale „A. Avogadro„, NOVARA, Italy

Objective To clarify whether and in which direction parental influences on adolescents smoking modify the effect of a school-based prevention program.

Methods Secondary analyses of the EU-DAP study, a multi-centric controlled randomized study in seven European Countries evaluating the effectiveness of a school curriculum against tobacco, alcohol and other drugs based on a Comprehensive Social Influence approach. The association between the school curriculum and adolescents’ current smoking 18 months after baseline was evaluated in separate strata of: a. parents’ smoking behavior b. perceived parents’ allowance of child’s smoking c. perceived parental monitoring d. perceived parental support. Adjusted odds ratios (OR) and corresponding 95% Confidence Interval (CI) were calculated by means of multilevel logistic regression.

Results In the whole sample, there was no association between receiving the experimental curriculum and current smoking at follow-up. On the other hand, all variables related to parental influences significantly predicted adolescents’ smoking, both at baseline and at follow-up, in the hypothesized direction, i.e. increased risk of smoking in offspring with parental smoking and perceived tolerance, decreased risk with high parental monitoring and support. Parents’ smoking behavior did not modify the effect of the intervention. Among boys who perceived some degree of parental tolerance towards smoking there was a protective effect of the intervention relative to daily smoking (OR=0.54 , CI=0.31-0.94). The same pattern was seen among boys perceiving high parental support (OR=0.72, CI=0.49-1.05) or high parental monitoring (OR=0.63, CI=0.42-0.94). The results for girls did not differ from those of the whole sample.

Conclusions Parental influences do not interact with smoking prevention programs in school in a straightforward way. General parenting styles may potentiate the beneficial effects of a program, if any, to a larger extent than smoking-specific behaviors or attitudes.

Implementation The role of parents in monitoring and supporting their children during adolescence should be emphasized in school-based preventive programs against cigarette smoking and the use of other substances.

Parallelsessions 3: March 29, 11.15-12.45 95 3F.5: Adolescent’s perceptions and expectations of parental action on children’s tobacco use; three decades national data

G. Nilsson Umeå University, UM…Å, Sweden

Objectives The overall objective of this study was to explore adolescents’ perceptions and expectations of parental action regarding children’s tobacco use, and whether they had changed over time. To see if there were differences whether the adolescent was a tobacco user or not the adolescents’ tobacco use was followed and described.

Methods The study used a repeated cross-sectional design, reporting Swedish national data from three decades. Data were collected in 1987, 1994 and 2003 by a questionnaire mailed to homes, in total to 13500 persons. The annual samples, which were random and national representative, consisted of 4500 young people aged 13, 15 and 17 yr, 1500 individuals per age group. The sampling and data collection procedures were done the same way during each survey. Chi2 tests were used to calculate differences in distributions. The study was repeated 2009- 2010 and preliminary findings from the study will be presented during the seminar.

Results Adolescents in all age groups became more positive toward parental action over time. In 2003, more than 86% of the adolescents, including both smokers and non-smokers, strongly supported parental action on their children’s smoking by trying to persuade them not to smoke (94%), by not smoking themselves (87%) and by not allowing their children to smoke at home (86%). Both non-smokers and smokers supported the idea of parental action in a similar way. Eighty-nine percent of the adolescents expected their parents to act against smoking and 85% against snus-use.

Smoking was stable at 8% in 1987 and 1994 but decreased to 4% in 2003. In 1987 the snus-use prevalence was 4% and in 2003 it was 3%. Snus-users were mostly boys while few girls had done more than tried snus. More young people in all age groups had never tried smoking compared to the previous studies. In 2003 57% stated that they had never tried smoking.

Conclusions Adolescent smoking has decreased and the proportion who never tried smoking has increased.

The results of this study contradict the perception often expressed by parents that their teenage children do not want them to intervene and that they have lost the possibility of influencing their children’s lifestyles, including the use of tobacco. This study shows that a majority of adolescents strongly support that their parents should intervene to help them refrain from tobacco, but preferably not in a punitive manner. This support includes both non-tobacco and tobacco using adolescents. The finding rejects the notion that adolescents ignore or even despise parental practices concerning tobacco.

Implementation Prevention strategies and interventions addressing adolescent tobacco use that involve parents can be improved by using these findings to motivate and encourage parents to be active and to intervene against their children’s use of tobacco.

Parallelsessions 3: March 29, 11.15-12.45 96 3G - Session Youth Empowerment

3G.1: Empowering youth in tobacco control: the EU-Help Youth Network 2005-2010

N.K.S. Schneider, K.D. Deibert German Cancer Research Center, H…ID…LB…RG, Germany

Objectives The EU Help campaign is the biggest awareness raising campaign in Europe tackling smoking prevention, cessation and exposure to tobacco smoke. To empower youth in tobacco control and to have the voice of youth heard in EU policy making, the campaign increasingly involved youths and youth organisations in its activities. In 2005-2006 the European Commission and European Youth Forum developed a European youth manifesto. In 2008 the German Cancer Research Center and the European Commission established an informal youth network to coordinate youth participation in the EU Help-campaign, to build a trans- disciplinary tobacco control network by students for students and to establish peer lead capacity building for students in Europe.

Methods Internet based research to identify relevant student and youth organisations, presentation of the campaign at international youth meetings, coordination of EU funded youth projects as well as organisation of capacity building events, including three Youth Network Meetings on Tobacco Control. Guidance and oversight was provided by the scientific advisory board.

Results In 2005-2006, over 10.000 youth participated in the youth manifesto process and 200 delegates from 25 EU member states adopted the European youth manifesto “Youth: For a Life without Tobacco!”, which was widely circulated to ministries and through press conferences in all EU member states. In 2010, 87 delegates from 59 youth organisations participated in the EC Help Student Network Meeting in Riga and adopted the “Youth Declaration on Tobacco Control”, in May 2010. Building on the declaration, 69 youth delegates representing 54 youth organisations developed a “Commitment Paper”in October 2010, in which they committed themselves to create a youth network and remain active in tobacco control.

In addition to the network activities, technical support and funding were provided to projects run by youth organisations. In 2009 a total of 15 national and 1 transnational youth project were coordinated in 13 EU member states. In 2010 a total of 24 national and 4 transnational youth projects were coordinated in 24 EU member states 2010.

Conclusion Youth organisations are committed to actively contribute to tobacco control activities on national and transnational level. Investment in youth lead tobacco control projects and networks offer a targeted approach to a relevant target group and cost-effective capacity building opportunities.

Implementation The creation of a formal European Youth Network on Tobacco Control should be promoted and widely supported on national and European level.

Parallelsessions 3: March 29, 11.15-12.45 97 3G.2: Successful Slovenian youth example on tobacco control

M.B. Bizjak, J.P. Peloza Youth Association No …xcuse Slovenia, S…VNICA, Slovenia

Youth Association No Excuse Slovenia is a non-profit making organization of about 70 young people aged 15 to 25 and “O2 belongs to you« is one of their projects working on the field of a tobacco-awarness raising and tobacco policy making. Becoming young experts in anti- tobacco advocacy, we widened our activities and developed aditional projects dealing with alcohol policy and sustainable development. We learned that being young is not the same as being unexperienced, while at the same time it is often a priority rather than on obstacle when advocating for our views, reaching an agreement with the law-makers and informing the society about other crucial issues. Moreover, there are so many oppurtunities for youth organizations at the moment in the European Union.

Each year our organization accepts 15 to 20 new, unexperienced but motivated 15 years olds and educates them into being good anti-tobacco advocates by inviting various experts to lecture, organizing rhetoric, debate and advocacy courses and later even stimulate them to attend and organize anti-tobacco and other health-related conferences/events.

Our financial supporters are the Slovenian Ministry of Health, Slovenian Ministry for Education and Sports, Student Organization of the University of Ljubljana and the HELP campaign, but we also hand in hand cooperate with some other health and youth organizations, dealing with active youth involvment in tobacco policy.

At the local level we organize over 300 peer-to-peer worshops for about 7000 youngsters yearly, pointing out the’cool’ aspects of non-smoking, immoral methods of tobacco industry manipulation with youth, as well as health and cost effects of smoking on society. We take an interactive informal approach, based on discussion and consultation. From our experience only health-risk approach is not efficient for young people, whereas making them realize that they are victims of the industry, stimulating them to think with their own head and not be manipulated by industry and media, works well!

The »O2 belongs to you« project was developed hand-in-hand with the European Commission’s HELP campaign, starting with co-writing the European Youth Manifesto on Tobacco in 2005. We took this oppurtunity as our starting point and are since then the biggest and most active youth organization in Slovenia, dealing with tobacco issues. We actively attended all the HELP youth conferences and took part in creating the campaign as well.

Among the interective possibilities of this presentation there is sharing approaches of participants in peer-to-peer workshops and obstacles that they, as members of different organizations and institutions, Health Professionals or polititians, face in a dialogue with youth. I can show a 6 minute movie, made by us for our peer-to-peer workshops, showing the global aspect of the tobacco problem, health issues and tobacco Industry approach to atract young people.

Parallelsessions 3: March 29, 11.15-12.45 98 3G.3: Youth Participation and Advocacy in Tobacco Control

A. Crossfield, C. Lunt Smokefree North West, MANCH…ST…R, United Kingdom

The Smoke & Mirrors Project started in 2009 taking inspiration from the Truth Campaign in Florida. This region-wide initiative the project has worked with young people throughout the region and in partnership with existing anti-tobacco youth groups. It is now linked into the EU Help Campaign and has recently been awarded the 2010 Council of Europe Pompidou Drugs Prevention Prize.

The aim of the project is to encourage young people to ‘see through the illusion’ created by the tobacco industry in targeting young people to be their future customers, which it does in a young person focused way. It also encourages young people to take action against the industry.

Young people have a significant lead role within the project ,steering strategic direction and developments, as well as undertaking their own self directed anti-tobacco projects.

This presentation will focus on the work and experiences of the young people from the anti-tobacco groups across the North West and who are part of the Smoke & Mirrors Project Action Group. It is proposed that two young people would present their work.

Key Outputs: • A film competition and a campaign weekend for 100 young people; Producing three winning film ideas engaging young people in the film making and linking to campaign actions online - and disseminating three films virally; screening one film at cinemas on youth-rated films to almost one million audience; • A Resource Pack aimed at 14-18-year olds in partnership with respected youth work consultant Vanessa Rogers and distributing to 670 Schools and 270 youth groups - piloting the pack across the North West; • Delivering a young people’s networking event in March 2010 to support young people in delivering their chosen actions from the initial campaign weekend in October 2009 and a training event in the summer of 2010 using interactive youth activities to build confidence and skills; • Facilitating young-people to express their views in person at the EU and UK Parliaments and at ASH Wales event 2010; • Scoping research examining young people’s attitudes and knowledge of the tobacco industry; • Providing opportunities for young people to develop life skills, through raising confidence, raising aspirations and empowering them to have their voices heard; • Ensuring that young people involved are represented accurately and fairly and sourcing appropriate training and resources so they can achieve their goals.

Parallelsessions 3: March 29, 11.15-12.45 99 3H - Workshop Tobacco Advertising, Promotion and Sponsorship (TAPS) 2.0: Turning off the TAPS in the digital world – an interactive session

Becky Freeman School of Public Health - University of Sydney

The WHO Framework Convention on Tobacco Control (FCTC) bans all forms of tobacco advertising, promotion and sponsorship. However, despite near universal adoption of advertising bans, the tobacco industry has a history of exploiting novel and emerging advertising methods. The comprehensiveness of these bans has yet to be tested by online social networking media like Facebook. Explosive rises in use of social networking and user generated content websites is fuelling tobacco product promotion through electronic media. In contrast, there is a very limited body of public health research on these “new media” advertising methods. Two detailed case studies of tobacco industry marketing through Web 2.0 platforms will be presented. The first will explore how this technology has blurred the line between marketing and market research and the second will detail the promotional activities of a transnational tobacco company on the popular social media site, Facebook. Additionally, the initial results of a research project built on these same principles of online community building and engagement to monitor TAPS will be presented. Challenges for tobacco control policy development and implementation will be discussed in light of these technological and marketing advances.

Parallelsessions 3: March 29, 11.15-12.45 100 Parallelsessions 4 Tuesday March 29, 14.00-15.30

4A - Session Effects of mass media campaigns

4A.1: Evaluation of the Effects of the Campaign ‘Every cigarette is doing you damage’ in Switzerland

A.A. Agarwal1, V.F. El Fehri1, H.K. Krebs2, R.M. Müller3 1Swiss Association for Smoking Prevention, B…RN, Switzerland 2Hans Krebs Kommunikation und Publikumsforschung, ZÜRICH, Switzerland 3Richard Müller, LAUSANN…, Switzerland

Background Four commercials produced by the Australian anti-smoking campaign ‘Every cigarette is doing you damage’ are being tested for four months in one region of Switzerland. The commercials are being shown in movie theatres and on TV. With their drastic portrayal of the consequences of smoking cigarettes, all four commercials play heavily on viewers’ fears. The message the commercials put across loud and clear is: ‘Stop smoking now!’ By displaying the phone number of a Quitline prominently on the screen, they throw out a lifeline to anyone interested in quitting.

Objectives The medium-term objective is to support the negative trend currently observed in the percentage of the population that smokes. The operational objectives during the test phase include a 20 % increase in calls to the Quitline and a 3 % increase in attempts to quit. People aged 20 to 54 with a low level of education make up the main target group.

Methods The hoped-for effects on the attitudes and behaviour of the Swiss population will be recorded via a continuous tracking method using CATI. Sales figures for nicotine-containing medications and the number of calls to the Quitline will be recorded by pharmacies and the Quitline, respectively.

Results The campaign came across well, both in the general public and in the smoker target group, receiving a high level of approval. During the campaign month, the number of people calling the Quitline in the Canton of Ticino increased dramatically. Similarly, the sales of NRT also increased. Thus it can be said that both male and female smokers were affected by the campaign. But their readiness to give up smoking appears to have remained unaffected. These results are intended for critical discussion.

Parallelsessions 4: March 29, 14.00-15.30 101 4A.2: Best Practice Tobacco Control Media Campaigns in Russia and Eastern Europe (2008-2010)

N. Toropova /R. Perl, I. Morozova, A.A. Kotov, N. Murukutla, World Lung Foundation, N…W YORK, United States of America

Russia, Poland and Ukraine - countries where smoking prevalence is among the highest in Europe, were able to utilize a campaign first created in New York City where it was found to be highly effective in reducing smoking prevalence. The campaign materials were pre-tested, inexpensively adapted for the countries and evaluated post-campaign using intercept surveys. The ad “Cigarettes are Eating you Alive”was utilized for mass media campaigns that included TV, radio and billboards as well as the news media to extend the reach of the campaign. The campaigns were supported by World Lung Foundation in conjunction with National and regional ministries and NGOs and were designed to support smoke-free initiatives, in an effort to begin to reduce smoking prevalence and change social norms around smoking. In Russia, the ads generated significant discussion among those who saw it, in Ukraine one in two smokers considered quitting after seeing the ads and in Poland calls to the National quit line increased significantly compared to previous months in that year (2009) and the same period a year earlier.

4A.3: Mass Media Campaigns to Support Smoke-free Environments

S. Hamill1, S. Ratte2, N. Tunalit3, T. Durgut4, E. Dagli5 1World Lung Foundation, N…WYORK, United States of America 2International Union Against Tobacco and Lung Disease, PARIS, France 3Stratejic Fokus, ISTANBUL, France 4Yesilay, ISTANBUL, Turkey 5SSUK, ISTANBUL, Turkey

World Lung Foundation, a member of the Bloomberg Initiative to Reduce Tobacco Use, examines how mass media efforts can support smoke-free policies, focusing on successful campaigns in Turkey. The success of Turkey’s two-stage smoke-free policy, first extending to public places in 2008 and then to bars and restaurants a year later, both can attribute their success in part to well-implemented and evaluated mass media campaigns. Using Turkey as a lens for discussion of successes and challenges and offering an interactive focus-group component, session participants will learn and discuss how best-practice mass media campaigns can prepare the way for smoke-free policies mandated under the FCTC, ease implementation, and reinforce compliance.

4A.4: Impact of the media campaign ‘Cigarettes eat you alive’ smoking behaviors in Poland

K. Przewozniak1, A. Fronczak2, W.A. Zatonski1, K. Suszek2, R. Perl3, A. Wojtyla4, P. Bilinski4, E. Lata4, G. Miloszewska2, A. Koziel5, M. Petryniak6, M. Cedzynska1, J. Lobaszewski1, P. Miskiewicz5, I. Morozova3, N. Murukutla3, I. Przepiórka1, A. Wójcik6 1The Maria-Sklodowska Curie Cancer Center and Institute of Oncology, WARSAW, Poland 2Ministry of Health, WARSAW, Poland 3World Lung Foundation, N…W YORK, United States of America 4Chief Sanitary Inspectorate, WARSAW, Poland

Parallelsessions 4: March 29, 14.00-15.30 102 5WHO Country Office in Poland, WARSAW, Poland 6MANKO Association, KRAKÓW, Poland

Background Each year smoking kills almost 70,000 Poles, 43,000 at middle age. In addition, over 8,700 adult Poles, including 1,800 non-smokers die prematurely from SHS-related diseases.

Objective In 2009, the World Lung Foundation assisted the Polish Ministry of Health and other Polish institutions to execute a media campaign aimed at increasing awareness of the tobacco harm and changing public attitude towards smoking.

Methods From November to December 2009, two graphic ads ran on major Polish TV stations and Internet. One was dedicated to the health consequences of active smoking, another one to the harmfulness of secondhand smoke, with focus on children’s health. A national quitline supported smokers who have been encouraged by the campaign to quit. Campaign efficacy was evaluated through nationally representative baseline and post-campaign surveys of adults (15+) conducted in July and December 2009. The surveys measured the proportion of the population exposed to the campaign, their reactions to the campaign messages, and changes in knowledge, attitudes and behaviors. In addition, the nation-wide telemetric study was conducted. Moreover, the coverage of the campaign has been analyzed both for national and local press. Finally, number of quitline calls were used to evaluate the campaign’s impact.

Results 83% of Poles have seen the campaign ads at least once and 64% at least three times. For over 50% of smokers the campaign was informative and relevant to their life. Half of smokers exposed to the ads said that it made them more concerned about their own or family’s health, more likely to stop exposing others to tobacco smoke and quit smoking. It was estimated that around 450,000 Polish smokers made serious attempt to quit smoking as a result of the campaign. Since baseline, there was an increase in knowledge about the tobacco harm and SHS exposure. There was also a concomitant increase in calls to the quitline during the campaign period when compared to the prior months of 2009 and to the same period in 2008.

Conclusion The campaign was successful media event that strengthened tobacco control activities in Poland. The campaign was broadcasted in prime-time in almost all major TV stations and met big interest of Polish adults. It seems that the campaign influenced both public knowledge on the tobacco harm and smoker’s intention to quit smoking.

Implementation The media campaign “Cigarettes eat you alive”is an effective tool for changing smoking behaviors and attitudes. As it was also successfully conducted in other countries, it seems that campaign can be realized in different societies and cultures. In Poland, there is a need to continue the campaign and make it more comprehensive by using other media, including press, radio and billboard ads.

Parallelsessions 4: March 29, 14.00-15.30 103 4A.5 A national campaign for supporting smoke-free policies in Poland

K. Przewozniak1, J. Lobaszewski1, M. Petryniak2, J. Jassem3, J.M. Jaworski4, W.A. Zatonski1 1The Maria-Sklodowska Curie Cancer Center and Institute of Oncology, WARSAW, Poland 2MANKO Association, KRAKÓW, Poland 3Medical University of Gdansk, GDANSK, Poland 4Health Promotion Foundation, WARSAW, Poland

Epidemiological estimates show that in 2000 tobacco smoking was the cause of approximately 70,000 deaths in Poland, of which 43,000 were premature deaths. Furthermore, over 8,700 adult Poles, including 1,800 non-smokers die each year from secondhand smoke. First attempt to ban smoking in worksites was made in 1974, when the Ministry of Health proposed a ban in health care settings. In 1980s, many state agencies also decided to limit smoking in their premises. However, those regulations were incomplete and not obeyed. Since mid-1990s, legislators have enforced comprehensive measures in order to reduce the health burden of smoking. The tobacco control legislation adopted in 1995 partially banned smoking in public places and worksites. Joining the FCTC in 2006, Poland was obliged to introduce a complete ban on smoking in such premises. Relevant legislative proposal was prepared by civil society movement and presented to the parliamentarian Health Committee in December 2006. Unfortunately, legislative work on this project has been prolonged and main battle for the complete ban on smoking took place in 2009 and 2010. Then Polish parliament debated on the last version of the new legislation and civil society movement, including the Polish Coalition “Tobacco or Health”, strongly called for complete indoor smoking ban in gastronomic venues and other worksites.

National surveys have showed substantial increase in public support for such regulations: level of support for smoking ban in all worksites increased from 27% in 1996 to 69% in 2009 and for gastronomic facilities this support was doubled (from 31% to 63%, respectively). With respect to these data, the coalition of non-government and medical organizations was monitoring parliamentarian activities and has been represented on all parliamentarian meetings on the abovementioned proposal. At the final stage of debate, the coalition conducted a multi-sectoral public campaign, calling for enforcement of the total ban on smoking. The ban proposal was discussed with representatives of all major political forces and government agencies. Workshops for trade unions and employers were also organized. Support letters for the ban were signed by 80 acknowledged representatives of Polish medical society, 9 major Polish medical organizations and 93 Polish non-governmental entities. 34 international organizations sent the signed letters to major Polish authorities, including Marshall of the Polish Parliament, chairmen of all parliamentarian clubs and political parties, Prime Minister and Minister of Health. Support was also achieved from 5 former Polish ministers of health, Public Health Department of the European Commission, CDC Foundation and Director General of the WHO Regional Office for Europe. The support was also expressed by owners of well- known foreign smoke-free hospitality venues. Unfortunately, accepting many restrictive provisions, parliamentarians have decided against the total ban on smoking. This issue still remains a future challenge for Polish tobacco advocates.

Parallelsessions 4: March 29, 14.00-15.30 104 4B - Session Tactics from the Industry and its documents

4B.1: Tobacco Industry’s efforts to prevent smoke-free legislation in the Netherlands for over a decade.

A. van den Bos, M.C. Willemsen STIVORO, the Dutch expertise centre for Tobacco Control, TH… HAGU…, The Netherlands

Objectives In 1990 a Dutch Tobacco Law was implemented, which included a partial smoking ban in Dutch governmental buildings. The law allowed for many exceptions. Smoking in non-governmental worksites was not prohibited by law. Instead, the decision to implement smoke-free policy was left to employers. Eventually, a workplace smoke ban was implemented in 2004 although the hospitality industry was exempted from it. In 2008 this exemption was abolished. The objective of this study is to determine how the tobacco industry tried to delay or prevent Dutch smoking restrictions in the 90’s.

Methods Tobacco industry documents, released to the public through US litigation, were used as a primary data source, triangulated with secondary data sources such as peer-reviewed academic articles, policy reports and newspaper articles. Documents were retrieved between February and June 2010 from the University of California San Francisco Legacy Tobacco Documents Library (www.legacy.library.ucsf.edu).

Results Tobacco documents show that the industry was already trying to prevent workplace smoking bans before the topic was even fully on the political agenda. Their focus was mainly on influencing the public opinion and social acceptability through highly successful tolerance campaigns, using the Dutch Smoker’s Rights Group successfully to prevent smoking bans and taking an interest to the mentality of the Dutch people, in order to ultimately influence government decisions. The main message of the industry was that smoking at the workplace should be left to tolerance between individuals and agreement between employers and employees. To prevent smoking in bars and restaurants, the industry maintained a successful partnership with the Royal Horeca Netherlands. Accommodation programs were used to maintain self-regulation. They even implemented the program in the Parliament restaurant in the Hague and were therefore directly able to show the government why accommodation should be preferred over legislation.

Conclusions The industry tried to influence the government directly and indirectly and booked several successes but ultimately smoking at the workplace and in the hospitality industry were prohibited by law. Their accomplishments can be attributed mostly to the Dutch Smoker’s Rights Group, the Dutch National Manufacturers Association, and the Dutch Tobacco Infor- mation Bureau which was responsible for the tolerance campaigns as well as successful partnerships with allies such as horeca associations and employers organisations. These organisations targeted the public, the workplace and the government with a clear message of tolerance. The tolerance campaign ‘Together we will solve it’ ran for many years and was described by the industry as very successful. This contributed to the public’s opinion

Parallelsessions 4: March 29, 14.00-15.30 105 regarding smoking in the 90’s and maintained the social acceptability of smoking. Even though smoke-free laws passed in 2004 and 2008, the ban in the hospitality industry is still struggling for acceptance.

4B.2: The hypocrisy of the Irish tobacco industry’s stance on price increases for tobacco products

F.O. Howell Health Service …xecutive, NAVAN, Ireland

Introduction and Objectives Increasing the price of tobacco is the most effective way to decrease consumption and encourage quitting. The tobacco industry is the main dissenter to this policy. However, it is not averse to increasing the price of tobacco products in order to maintain profits despite declining sales. The purpose of this study was to examine what the tobacco industry says to government in Ireland and what it does in reality.

Methods Using the Freedom of Information Act, the annual pre-budget submissions from the tobacco industry for 2000 to 2009 to the Department of Finance were obtained. A content analysis was carried out on their submissions. The annual budgetary and trade increases on tobacco products were also examined.

Results Key themes emerged from their submissions and these were consistent over the period and included the following: • Ireland has one of the highest tobacco taxes in the world and consequently the illegal tobacco market is actually getting worse year on year. • Cross-border shoppers will buy tobacco products outside Ireland because of price differentials thus losing revenue to the State. Illegal traders will sell illegal tobacco products to children without asking for proof of age. • Increasing taxes will not reduce smoking, rather, it will lead to: a growth in the internet trade; a demand for increased wages; and it will exacerbate inflation • Increasing taxes is unfair on poorer smokers • In light of the above, there should be no increase in the price of tobacco products for the forthcoming year.

Between 2001 and 2010 government increased the price of 20 cigarettes by €2.43, however, the tobacco industry further increased price by €1.35. For three of the years, government did not increase price, however for each of the years the tobacco industry increased price. Inter- estingly, the tobacco industry never commented on their price rises, and was rarely critical of the government price rises in the preceding year.

Most strikingly, in their 2009 submission they stated [3DOTS][3DOTS]in our view, every cent that is added to the price of a packet of cigarettes will only drive these figures upwards to a point where in the next 1-2 years , we believe some 25% of the market will be accounted for by non Irish duty paid product. Subsequently, the government increased price by €0.22 in the budget, and the industry increased price by €0.24 later that year.

Conclusion This analysis shows that the tobacco industry rhetoric on tobacco price is not matched by

Parallelsessions 4: March 29, 14.00-15.30 106 their actions. In addition to increasing their own profits, tobacco industry price increases are a lost opportunity to expand tax revenues. There is a need to cap the price that the industry can charge for its products.

4B.3: ‘Why should we be concerned about divestment’? Norway’s experience of ending government tobacco stock investments

N. Wander1, S.B. Lutnaes2 1University of …dinburgh, …DINBURGH, United Kingdom 2Norwegian Cancer Society, OSLO, Norway

Background Divestment (selling off) of tobacco stocks by governments, health and welfare institutions for ethical reasons has been promoted as a tobacco control strategy since at least 1981. It has been claimed that divestment campaigns can engage publics not otherwise concerned about tobacco control and activate tobacco control-involved publics in novel and expanded ways. However, previous studies have mainly focused on U.S. campaigns conducted between 1990 and 2000.

Objectives To develop a more general understanding of the processes and implications of tobacco industry divestment campaigns by comparing the U.S. cases with the 10-year campaign to divest Norway’s Government Pension Fund - Global (GPFG), successfully concluded in 2010.

Methods The Norwegian case was constructed from the records and recollections of participants and from contemporary electronic and print publications. It was analysed together with the U.S. cases, which had been constructed principally from tobacco industry documents obtained through U.S. state lawsuits, triangulated with documents from other sectors.

Results Norway’s divestment campaign began in 2001 with pressure to divest GPFG’s predecessor fund. From 2003, socially-responsible investment activists lobbied to have tobacco excluded under the developing ethical guidelines of the GPFG”’now the world’s second largest sovereign wealth fund. Tobacco control advocates came late to the process, which, in the event, stalled due to party differences within the then governing coalition in 2005. When the guidelines were reopened for discussion in 2008, however, the Norwegian Cancer Society led a successful campaign on the part of the national “Tobacco-Free”coalition to exclude tobacco investments on ethical grounds. The completed action was announced by the Finance Ministry in January 2010, following sale of holdings in seventeen named tobacco companies.

Conclusions The Norwegian case confirms essential findings of the U.S. one: the need to be prepared for an extended campaign; the requirement to develop a legal theory for socially-goaled (not just financially-valued) investments; the value of a policy champion within the political system. It also reveals weaknesses and ‘contradictions’ for divestment as a tobacco control strategy: e.g., using divestment to further tobacco industry delegitimisation requires publicity while investment funds may prefer to divest quietly to preserve reputation and wealth. Moreover, successful divestment might even lead to reduced public concerns about tobacco.

Parallelsessions 4: March 29, 14.00-15.30 107 Implementation The Norwegian case highlights the strategic value of academic research anchored in the tobacco industry documents: studies of the U.S. cases were used to develop arguments for the Norwegian campaign. It also points to the potential for alliances with social justice activists around issues of health, trade and development at home and abroad. It demonstrates the capacity of a respected fund to influence investment practices even in the private sector and beyond national boundaries.

4B.4: Resolving the ‘Social Acceptability Issue’: The Strategic Role of Tobacco Industry Research.

M.C. Willemsen1, A. van den Bos2 1CAPHRI Maastricht University, MAASTRICHT, The Netherlands 2STIVORO, the Dutch expertise centre for Tobacco Control - for a smokefree future, TH… HAGU…, The Netherlands

Objective Already in 1979, tobacco industry analysts identified “the social acceptability issue”as “the central battleground on which our case in the long run will be lost or won”. This battle has raged relentlessly since then. Little is known about the type of research that the tobacco industry undertakes to make strategic choices about where to direct their lobbying efforts to prevent and undermine smoking bans.

Methods Search of documents from the Legacy Tobacco Documents Library.

Results Newly disclosed tobacco industry documents reveal the type of research that the industry relies on. This turns out to be highly sophisticated and expensive multi-country studies showing their interested in whole populations, not individuals. These documents confirm that the industry assigns highest priority to influencing social acceptance of smoking worldwide. They are able to identify countries in which the public opinion is relatively open to governmental regulations and smoking bans, thus needing intensified and targeted action. Because of the large number of countries that were included in some of the industry paid studies, the industry was able to conduct cross-country analyses using country as the unit of analyses. This revealed strong associations between support for government actions on the one hand and annoyance from ETS and concern about health risks on the other.

Tobacco industry was interested in factors operating on a population level, ultimately determining reduction of tobacco consumption levels. Factors include level of awareness of health risk, level of societal acceptance of smoking, and level of support for governmental regulations.

Conclusions Industry documents suggest that the tobacco industry has put in place a well defined monitoring system specifically looking at important population level factors, and already did this long ago. The Industry seems more advanced than the EU and the WHO when it comes to collecting the right population data. Important population factors are not yet being monitored in a systematic and comprehensive (covering large numbers of countries) enough manner.

Parallelsessions 4: March 29, 14.00-15.30 108 4B.5: How can small Finland scare Big Tobacco

M. Hara2, M.T. Rauralahti1 1Cancer Society of Finland, H…LSINKI, Finland 2Finland’s ASH - Action on Smoking and Health, H…LSINKI, Finland

The tobacco control policy of Finland has since the 1970’s been build on four cornerstones: 1. Health education, 2. Price policy, 3. Legislation (Tobacco Act), and 4. Research. Like four legs of a chair these areas have to be in balance and each has an equally important role in supporting the whole. They also form a circle of progress: research shows trends, current tobacco use situation, possibilities, and attitudes of the people. Health education increases the knowledge and awareness of the people, changing their attitudes and preparing them for the next move. This paves the way for new legislative action, which has approval among the people already before the ideas are introduced into the Tobacco Act.

During the years the Tobacco Act has developed into its current form, the tobacco industry (BigT) has tried to lobby and in other ways oppose the amendments several times. Accord- ing to the internal documents of the BigT lobbying was especially active in mid 1970’s when advertising ban was on the table. Another example is from the end of the 1990’s, when banning smoking in restaurants was considered based on the carcinogenicity of environmental tobacco smoke (ETS). Despite of the very active lobbying of the BigT and scare campaigns of the hospitality industry, restaurants did become smoke-free and ETS was legislatively classified as an occupational carcinogen.

The latest amendment process (2007-09) of the Tobacco Act included suggestions for a total display ban at point-of-sale, ban on possession of tobacco products for minors, and making Finland smoke-free by the year 2040. In the consultation of stakeholders, BigT opposed the key reforms and lobbied e.g. the Finnish Grocery Trade Association to oppose the display ban. When the amended Tobacco Act went to the Parliament , BigT complained to the Office of the Chancellor of Justice that the display ban was unconstitutional, against EU principles, and there was no evidence of effectiveness. In addition, they complained that they had no chance to comment the new objective of the Act, smoke-free Finland by 2040. The key committees of the Parliament did not budge under the pressure and the amendments were passed. Just prior to the signing of the Act by the president in September 2010, BigT again complained to the Office of the Chancellor of Justice that the EU Commission should have been notified of the key changes in the Act.

The experience and evidence from Finland shows that even a small country can make the mighty tobacco industry nervous and reactive. The issues the industry has opposed the most are the ones that can become examples for other countries.

Parallelsessions 4: March 29, 14.00-15.30 109 4C - Symposium: ERS: Health Effects of passive smoke exposure to children and adults: facts and artefacts

Coordinator on behalf of ERS: Jorrit Gerritsen, MD, PhD Past-President …RS Chairs: Jorrit Gerritsen and John Britton 1st presentation: Health effects of passive smoke exposure in Children and Adults. A systematic review and recommendation for prevention

John Britton University of Nottingham, Nottingham, UK

Passive smoking in the home is a major hazard to the health of the millions of children in the EU who live with smokers. For a report for the Royal College of Physicians we have recently carried out systematic reviews to provide contemporary estimates of the effect of passive smoking on child health, to estimate the numbers of children affected, and methods of reducing passive smoke exposure. In this presentation I will summarise the most important factors governing exposure to children, and describe the impact of parental and household smoking on the risk of asthma, respiratory infection, wheezing, meningitis and sudden infant death, and also on the risk of incident smoking in the child. I will present estimates of the likely numbers of children affected by these outcomes in the UK. I will also summarise the policy responses at population and family level required to prevent this entirely avoidable cause of disease in children.

2nd presentation: Passive smoke exposure in Children and Adults: Relevance to Chronic Obstructive Disease

Johathan Grigg Queen Mary University London

This talk will review the long-term consequences of paediatric ETS exposure – with a emphasis on effects that may increase vulnerability to COPD in adulthood. Areas that will be covered include; 1) effects on lung growth – what we know and don’t know from epidemiological studies, 2) effects on infections and symptoms– do symptoms indicate a subgroup of children genetically predisposed to COPD? – and how important is ETS in increasing vulnerability to pneumonia? 3) common mechanisms – is particulate matter (PM) the common mediator of ETS effects in children and COPD in adults? 4) areas of further research.

3rd presentation: Smoking and passive smoke exposure in Children and Adults: Economic aspects

Onno van Schayck University Maastricht, Maastricht, Netherlands

Parallelsessions 4: March 29, 14.00-15.30 110 4th presentation: Passive smoking the whomb, at home and in cars, in the context of Smokefree

Luke Clancy Dublin, Ireland

Secondhand Smoke (SHS) is a Group 1 carcinogen with no safe level of exposure. Children are relatively more exposed to SHS than adults, are less likely to prevent their own exposure and at greater risk for future SHS related morbidity and mortality. The womb, the home and the car are now the most common sources of exposure to SHS since the introduction of Smoke- free legislation. While the prediction of some, including a British Secretary for Health, that Smokefree laws would displace smoking from pubs into homes is not true it still remains a fact that smoking at home is still commonplace. 60% of homes in Europe are estimated to be Smokefree but 82% for the USA. SHS exposure at home also results in a 62% increase in those children smoking. Recent studies that examined childhood SHS exposure in cars reported levels of 6.5% in Scotland, 26.3% in Canada, 40.2% in Nebraska, 14% in Ireland and the European estimate is that 17% of children are exposed to smoke in cars. The level of particle exposure can reach values greater than in smoky pubs and we have shown causes respiratory symptoms. Smokefree works and should be extended to cars and homes.

5th presentation: Passive smoke exposure in Children and Adults: The role of the European Union.

Florence Berteletti Kemp Brussels, Belgium

Within the European Union annually more than half a million die prematurely because of tobacco use. The estimate is that annually about 20.000 deaths are related to environmental tobacco smoke exposure. The economic loss for the European Countries caused by smoking amounted to more than €100 billion in the year 2000. The European Union and its member countries have taken several steps to reduce the use of tobacco smoke and tobacco smoke exposure. In this presentation the present and future role of the European Union in relation to tobacco control will be presented.

Summing up

Jorrit Gerritsen University Medical Center Groningen, Groningen, the Netherlands

The summing up will be focused on the conclusions of the presentations and on the future perspectives in relation to passive smoking in adults and children.

Parallelsessions 4: March 29, 14.00-15.30 111 4D - Session Availability and point of sales

4D.1: Don’t count your chickens before they are hatched: the campaign to remove tobacco point of sale displays in England from the perspective of a cancer charity J. King Cancer Research UK, LONDON, United Kingdom

The campaign to protect legislation removing tobacco point of sale displays and vending machines in England.

In May 2010 legislation in England to phase out point of sale (POS) displays of tobacco in shops and remove vending machines came into force, at the same time as a new UK Coalition Government came to power. Cancer Research UK (CR-UK) and its Smokefree coalition partners were very concerned that the hard fought for measures might fall victim to the anti-regulation approach favoured by the new Government. The tobacco industry used front groups to mount an intensive campaign to try to roll back the legislation, including disseminating false information about its impact and strong lobbying by shop owners who feared they would go out of business.

CR-UK in turn employed a full array of advocacy tools: we prepared briefings sent by the coalition to all MPs; we funded research evaluating the POS law in Ireland; we contacted many Ministers and advisers; we developed a detailed rebuttal of a widely quoted misleading report; we used press stories, opinion polls and celebrity letters; and we re-mobilised our supporters to write to their Members of Parliament (MPs) and local newspapers and to sign a petition. Our partners used similar methods and jointly we ran a full-page newspaper advertisement that was sent to all MPs and a letter from Chief Executives of major public health organisations.

This multi-tactic, multi-organisation approach left Ministers in no doubt about the strength of support for the measures. The evidence, rationale for tactics and key learning from the campaign will be outlined.

4D.2: Support for removal of point-of-purchase tobacco advertising and displays: Findings from the ITC Four-Country Survey

A.B. Brown1, C.B. Boudreau2, C.M. Moodie1, G.F. Fong2, G.L. Li2, M.T. Thompson2, L.H. Hassan3, A.H. Hyland4, H.Y. Yong5, J.T. Thrasher6, G.H. Hastings7 1Institute For Social Marketing, STIRLING, United Kingdom 2University of Waterloo, ONTARIO, Canada 3Heriot-Watt University, …DINBURGH, Scotland 4Roswell Park Cancer Institute, BUFFALO, N…W YORK, United States of America 5VicHealth Centre for Tobacco Control,, CARLTON, VICTORIA, Australia 6School of Public Health, University of South Carolina, COLUMBIA, United States of America 7Institute for Social Marketing, University of Stirling, STIRLING, SCOTLAND, United Kingdom

Background Most countries now have at least some form of restrictions on tobacco marketing but in order to continue promoting their products, the tobacco industry meet these restrictions by

Parallelsessions 4: March 29, 14.00-15.30 112 re-allocating marketing expenditure to unregulated channels, such as marketing within the retail environment.

Methods Longitudinal data from the International Tobacco Control (ITC) Four Country Survey was analyzed to examine a total of 10553 adult smokers’ support for complete bans on point- of-purchase (POP) tobacco advertising and displays across Australia, Canada, the United Kingdom (UK) and the United States (US), and how this varies over time. Respondents come from waves 5 (October 2006 - February 2007), 6 (September 2007 - February 2008) and 7 (October 2008 - July 2009) surveys conducted before and during the implementation of POP legislation in most Canadian provinces.

Results Smokers in Canada showed strong support for a complete ban on POP tobacco displays in stores and shops over the study period. Levels of support were always lowest in the US, where legislation banning advertising and tobacco displays in stores had been less discussed, and were higher than the US in Australia and the UK, where POP bans had been given serious consideration.

Conclusions This study serves as a timely reminder that the implementation of tobacco control measures, such as the removal of POP, increases support among those smokers, i.e. those members of the public most likely to oppose such measures.

4D.3: Exploring young people’s brand preferences in anticipation of the ban on point-of-sale displays

T.A. Tjelta, A. Amos, D. Ritchie University of …dinburgh, …DINBURGH, United Kingdom

Objectives To explore young people’s perceptions of factors influencing cigarette brand preferences in two areas of deprivation in Scotland.

Methods Twenty four individual, paired and triadic qualitative semi-structured interviews were undertaken with 13 and 15 year old young people in two disadvantaged communities in Edinburgh between March and November 2010. Interviews explored perceptions and experiences around smoking and cigarette access, including in relation to brand preferences. Participants were recruited via youth clubs, detached youth-workers and ‘third sector’ organisations. The interviews were recorded, transcribed and analysed thematically.

Results Participants expressed clear brand preferences and loyalties. These were communicated via references to factors including potency, price, visual appeal and relative asperity. The perceived ‘potency’ of the product was communicated in terms of the relative ‘strength’ of the cigarette and the perceived duration of ‘satisfaction’ following use, and price was represented as a proxy for product ‘quality’. ‘Visual appeal’ was conferred by the novelty and colour of the product design, and relative asperity refers to the perceived ‘smoothness’ or ‘harshness’ of the smoking ‘experience’. Preferred and ‘quality’ brands were described as ‘smooth’ where others were experienced as ‘harsh’ and ‘rough’. Illicit and counterfeit product

Parallelsessions 4: March 29, 14.00-15.30 113 in particular was described in pejorative terms and was avoided.

Conclusions Young people demonstrated clear awareness of branding and price points and individual product preferences were communicated via factors including potency, price, visual appeal and relative asperity. While the particular and relative salience of these in influencing purchasing behaviour is beyond the scope of the chosen methodology, packaging represents a key tobacco industry promotional vehicle following the increase in the age of sale and industry documents suggest marketing communications are primarily targeted at young people. Findings suggest young people actively interpret these communications, with factors such as price, pack design and novelty conferring ‘quality’, for example. The extent to which the notion of ‘quality’ is conferred on individual brands appears to be negotiated in the context of young people’s social networks. Unfamiliar or ‘foreign’ brands and cigarettes perceived to be counterfeit through pack design anomalies were represented as ‘fake’ and inferior product and were scrupulously avoided.

Implementation Findings support the introduction of point-of-sale display bans and generic packaging to sustain efforts to limit the potential for tobacco companies to communicate with prospective customers.

4D.4: Counter Measures: A case study of point of sale tobacco display law in Scotland

R. Morrison ASH Scotland, …DINBURGH, United Kingdom

Counter Measures, a report produced by ASH Scotland and funded by Cancer Research UK, is a case study in tobacco industry resistance to legislation that prohibits the display of tobacco products at the point of sale in Scotland. Around 11,000 newsagents, corner stores, grocers and supermarkets in Scotland sell tobacco products. In most of these locations, eye-catching and elaborate tobacco gantries take prime retail space, at eye level, and often in close proximity to confectionery. This prominence in the retail environment is highly valued, and hence restrictions on the point of sale display of tobacco has been described by financial services firm Morgan Stanley as one of the key regulatory changes that should ‘[3DOTS] concern the industry the most’. A breadth of published evidence, using varied study designs, across a range of countries concludes that such displays influence youth smoking uptake.

Recognising this, the Scottish Government, as part of a broad and comprehensive action plan on youth smoking prevention, brought forward legislation in January 2009. This legislation, the Tobacco and Primary Medical Services (Scotland) Act sought to strengthen tobacco sales regulation through a range of measures, including prohibition of tobacco displays. Throughout the parliamentary passage of the legislation the tobacco industry, through its funded lobby groups, and by taking advantage of its close relationship with retailers, sought to undermine, weaken and delay the onset of restrictions. Despite considerable industry activity, and as a result of evidence-based coordinated action in support of the public health measures in the legislation by a range of parties, it was successfully passed by the Scottish Parliament in January 2010.

The tobacco industry’s reaction and subsequent response to legislation that restricts its activities is relatively well documented. Counter Measures adds to this literature by drawing parallels between tobacco industry resistance to point of sale legislation, smoke-free indoor

Parallelsessions 4: March 29, 14.00-15.30 114 air laws, and historic industry activity. This presentation will provide a contemporary and topical analysis of tobacco industry strategies, intended to assist other nations and public and voluntary bodies who seek to implement similar legislation in their own jurisdictions.

4D.5: How to bench mark tobacco control and study the density of tobacco by an availability-map

Å. Lundquist, C.N. Nordlinder Swedish National Institute of Public Health, ÖST…RSUND, Sweden

Background The availability to tobacco effect the number of people how uses tobacco, not at least adolescents. To reduce the availability there is a number of comprehensive approaches and one of them is to reduce the number of underage whom can purchase tobacco and to have a functional end effective supervision of the tobacco law that forbid vendors to sell to underage. The tobacco law supervision in Sweden is not prioritised and there is a large problem with underage adolescents buying tobacco. In 2009 an investigation identified 11 700 point of sales but it is presumed to exist an unrecorded number as well. At the same time the knowledge of the impact that availability plays in reducing the number of tobacco users is low.

Objectives In the light of this the Swedish National Institute of Public Health has conducted a pilot to highlight the illegal sales to minor and to stress the importance of supervision as well as sheer some light over the importance that availability plays in tobacco control.

Methods Addresses of all tobacco point of sales and all compulsory schools (for children aged 7-16) were compare. To make the comparison possible and visible the addresses were put into a GIS-map (Geographical Information System). Also a tobacco control survey was developed and tested. The purpose was to map out, develop and evaluate the tobacco surveillance out of adolescents’ point of view.

Result The outcome was at one hand, an availability-map over every municipality and the map made it possible to calculate the average distance between point of sale and schools. The maps functions as tools in the everyday tobacco control work and as a foundation to build knowledge from as well as to identify problem areas which need special focus and attention. The availability-map can also be combine with other data such as tobacco consumption, adolescents attitudes towards tobacco and data over socio-economic status.

On the other hand the survey gave a comprehensive picture of which efforts need to be prioritised in order to reduce the number of minors that could by tobacco. It also gave an idea of which way support could be offered to the vendors so they would be better equipped when it comes to follow the law.

Conclusion This paper will discuss the availability-map that will be a new way of discussing tobacco control in Sweden. It could also be a tool in closing the health gap that may occur within and between municipalities due availability to tobacco. It will also discuss the survey which will be an important part of developing a bench marking system - where municipalities’ tobacco control work can be compared and standards can be sett.

Parallelsessions 4: March 29, 14.00-15.30 115 4E - Symposium: Quitlines in Europe – an overview and examples

Chair: Peter Lindinger, Smoking Cessation Training and Counselling, St. Peter, Germany Co-chair: Asgeir R. Helgason, Karolinska Institutet, Stockholm, Sweden

Presenters: Steve Crone, QUIT, London, United Kingdom; Andrew Stripp, …uropean Network of Quitlines, London, United Kingdom; Peter Lindinger, Smoking Cessation Training and Counselling, St. Peter, Germany; Asgeir R. Helgason, Karolinska Institutet, Stockholm, Sweden

Summary Quitlines are telephone-based programs for helping tobacco users quit that can reach large numbers of people and provide effective counselling. After the initial contact started by the smoker Quitlines provide services like mailed materials, automated messages, counselling on the spot and proactive call-back from a counsellor. Some Quitlines can offer their whole range of services with no costs for the caller. Call-back counselling and multiple sessions are a guideline-recommended format of psychosocial treatment.

1st: Global impact of WHO FCTC Article 14 Draft Guidelines: Lessons for Europe

Steve Crone, QUIT, London, United Kingdom

The WHO FCTC ART 14 draft guidelines are being presented, in Uruguay in Nov 2010, for final approval and adoption by the Conference of Parties. Quitlines feature heavily and will play a role as population based interventions, individual interventions (treatments) and in the wider tobacco cessation promotion (health literacy and education). ENQ, NAQC and the Asian Pactific network of quitlines have each prepared guidelines for their regions on how to set up quitlines and deliver evidence based services. This study focuses on the recommendations (similarities and differences), espoused by the three networks and in a series of Delphi meetings evaluated and posed policies, strategies and programmes needed to realise and fulfil the obligations that WHO FCTC signatory parties have undertaken. Results are predicted to show quitlines will play the following role in national tobacco control: • Conduct a national situation analysis • Create or strengthen national coordination • Develop and disseminate comprehensive guidelines • Address tobacco use by health-care workers and others involved in tobacco cessation • Develop training capacity

2nd: European Capacity Building Project: Central and Eastern Europe

Andrew Stripp, …uropean Network of Quitlines, London, United Kingdom

Robert West et al have identified 94 key competencies and skills necessary for smoking

Parallelsessions 4: March 29, 14.00-15.30 116 cessation practitioners to carry out their professional duties and responsibilities. The smoking cessation profession and public health in general took root in western and northern Europe in the 1980’s. Eastern and Central Europe is now developing its own public health agenda. The CEER programme was delivered in 10 Central and Eastern European countries, through mentoring, workshops, conferences, seminars and shadowing. Key outcomes shared will include: increased capacity within a quitline setting, increased reach and diversity, improved efficacy, enhanced impact and help to reduce health and inequalities. This will be presented with statistical call volume analysis for each country.

3rd: 3 years of proactive service in Germany – successes and surprises.

Peter Lindinger, Smoking Cessation Training and Counselling, St. Peter, Germany Mareike Strunk, Federal Centre for Health …ducation, Cologne, Germany Peter Lang, Federal Centre for Health …ducation, Cologne, Germany

The Federal Centre for Health Education (“Bundeszentrale fuer gesundheitliche Aufklaerung, BZgA) operates a Quitline called “BZgA telephone counselling for smoking cessation”. Since 2006 the number of the Quitline is imprinted on every 14th pack of cigarettes as part of the health warnings. Proactive service is available since 2007. Callers who intent to quit or ex- smokers for less than six months who called to prevent relapse are offered proactive counselling and asked for consent to get follow-up calls 3 and 12 months after their initial call. Data on demographics, smoking history, motivation to quit, tobacco dependence and self-efficacy are collected by counsellors during the initial call. The proactive protocol consists of up to five calls within one month after quit day or initial call. Follow-up calls are primarily based on the Minimal Data Set questions from North American Quitline Consortium (NAQC). Data from nearly 700 callers show superior abstinence rates for proactive callers after three and 12 month follow-up but differences are no longer significant at 12 month follow-up. While abstinence rates remained stable among procative callers between three and 12 month follow-up we found an increase of nearly 5% among non-proactive callers. Possible explanations will be discussed and easy ways of capturing data at a running quitline will be presented.

4th: Challenging methodological aspects in quitline evaluation: Examples from Sweden

Asgeir R. Helgason, Karolinska Institutet, Stockholm, Sweden

When comparing treatment outcome in a particular quitline over time and/or outcome (e.g. cessation rates) between different quitlines, we are faced with several interesting challenges. Few of those comprise; a) defining the study-base and outcome measures; b) assessing the client profile; c) describing the counselling/treatment protocol; d) assessing the counsellor com- petency in applying the treatment protocol; and e) describing the counselling/treatment intensity. Although many of these issues are common to all smoking cessation assessment, quitlines setting has its own specific problems and possibilities. Other questions that will be raised include the following: What is a call? What calls are cessation support calls? How can we (should we?) make use of tape-recording the counselling sessions? What are the ethical and legal aspects of tape-recording counselling sessions? Does tape-recording counselling sessions improve “treatment fidelity”? We will discuss these questions and give examples from the Swedish tobacco quitline.

Parallelsessions 4: March 29, 14.00-15.30 117 4F - Symposium: Smoking cessation interventions for low ses ethnic minority populations: lessons learned

Chair: Vera Nierkens, Academic Medical Center- University of Amsterdam (The Netherlands) Co-Chair: Corina Salis Gross, Institute for Public Health and Addiction Research, Univer- sity of Zurich and Institute for Social Anthropology, University of Berne (Switzerland)

Summary Prevalence of smoking is high among low socio-economic groups. In the Netherlands 30% of low educated people smoke compared to 22% among the highest educated people. In Switzerland 36% of the lower educated people smoke compared to 24% of the higher educated. In the UK, 27% of the manual workers smoke and 16% of those in non-manual groups smoke. Within this low socio-economic group, some ethnic minority populations deserve attention as well as the prevalence among these populations is even higher. For example, of the Turkish men in the Netherlands 50% - 60% smoke and 30% of the women smoke respectively. In Switzerland 53% of the Turkish men and 42% of the Turkish women smoke respectively. Among South Asians in UK the percentage of male smokers is up to 40% among Bangladeshi. Regular public health interventions generally do not reach low socio-economic groups including ethnic minorities. Last years, some interventions are developed and / or evaluated targeted to low socio-economic groups and ethnic minority groups in Europe. But do we know by what types of strategies we reach these groups of smokers and what strategies appeared to be effective?

The objective of the symposium is to gather and increase the knowledge about reaching the low SES populations including migrants and about promising elements of smoking cessation interventions for these groups. During the symposium four interventions that have been developed in Europe for low SES or ethnic minority smokers, will be presented.

The 1st presentation will be the impact of various mechanisms –social support to quit, addiction, motivation, treatment compliance and program characteristics – on the relationship between cessation outcomes and socio-economic position (SEP). The factors most likely to attenuate the relation between SEP and quitting varied but most commonly were age, addiction and treatment compliance.

The 2nd presentation will be about the results of a cluster randomized trial for Pakistani and Bangladeshi male smokers. The aim of this intervention was to increase the access to and success of English smoking cessation services. In this trial an outreach worker model was examined. A small not statistically significant increase in 4-week abstinent smokers was found in the intervention group compared to the control group.

The 3rd presentation will be about a study among Turkish migrants in Switzerland. The results show, that 37.7% of the 61 participants were smoke-free at the 12-month follow-up. The study also demonstrated the importance of “strong social ties” and the sensitivity of the program to socio-cultural, socio-economic (providing courses for free), and migration- specific (e.g. using informal outreach-strategy for recruiting) issues.

Parallelsessions 4: March 29, 14.00-15.30 118 The 4th presentation will be about will be about the results of a study about the reach and effectiveness of community based intervention for Turkish inhabitants in one part of Rotter- dam in the Netherlands. It appeared that the reach was substantially high, but participation in the program components was much lower (less than 10%). Differences in number of quitters or changes in determinants of smoking tend to be higher in the intervention group, but were not statistically significant. Per intervention the audience will be asked to write down what we can learn about the results in terms of potential promising elements for interventions for low socio-economic populations including ethnic minorities. After all presentations, we will discuss with the audience the similarities and differences in intervention elements and study outcomes and whether these can be related to the context of, among other things, socio-economic status, the country, or culture of the target group. We aim to end up with some conclusions about how to reach low SES populations living in Europe and how to increase smoking cessation among them.

1st: Social inequalities in quitting: What factors mediate the relationship between socioeconomic position and smoking cessation?

Authors Professor Linda Bauld and Dr. Rosemary Hiscock, UK Centre for Tobacco Control Studies, UK

Objective Although it is well established that smokers from lower socio-economic groups are less likely to be successful in a quit attempt than more affluent smokers, less attention has been paid to why such groups find quitting challenging even when they have accessed smoking cessation services. Our objective was to assess the impact of various mechanisms – social support to quit, addiction, motivation, treatment compliance and programme characteristics – on the relationship between cessation outcomes and socio-economic position (SEP).

Methods This was an observational study using routine monitoring data, collected by smoking cessation services from three sites in the UK, linked with survey data for 3,231 clients who accessed services between 2001 to 2003 (Nottingham and North Cumbria) and in 2007 (Glasgow). The outcome measure was CO validated smoking status at 52 week follow up. SEP was measured by a count of indicators of affluence. Quit rates were calculated by study site and programme format (one to one or group). Logistic regression was used to determine predictors of quitting and predictors of inequalities in quitting through the extent to which the relationship between SEP and quitting was attenuated by demographic and cessation related mechanisms.

Results A clear gradient was observed in quit rates by SEP with the most advantaged smokers more than three times (14.1%) more likely than the most disadvantaged (3.7%) to succeed in quitting (p<.001). After adjustment for demographic factors, those service recipients in the most advantaged SEP group were significantly more likely to have remained abstinent at one year follow up than those who were most disadvantaged (OR 2.5, CI 1.5 – 4.2). When the smoking cessation related mechanisms were added to a fully-specified logistic regression model across the three treatment locations the odds ratio was attenuated (OR 2.1, CI 1.2 – 3.6).

Conclusion The factors most likely to attenuate the relation between SEP and quitting varied but most commonly were age, addiction, and treatment compliance. Some caution is required in inter-

Parallelsessions 4: March 29, 14.00-15.30 119 preting the compliance findings due to ambiguity over the direction of causality. Motivation, support and programme features, although they were predictors of quitting, did not explain the relationship between SEP and quitting.

Implementation Cessation services need to consider how best to support disadvantaged smokers in their quit attempt. In particular, the relationship between a client’s nicotine addiction and the treatment available should be considered and particular efforts should be made to ensure that these clients are supported to use pharmacotherapy correctly and for long enough to maximise their chances of success.

2nd: Promoting smoking cessation in Pakistanis and Bangladeshis: cluster randomised controlled trial of community outreach workers

Authors: Rachna A Begh1, Paul Aveyard1, Penney Upton2, Raj S Bhopal3, Martin White4, Amanda Amos5, Robin J Prescott3, Raman Bedi6, Pelham Barton7, Monica Fletcher8, Paramjit Gill1, Qaim Zaidi9, Aziz Sheikh10*

Affiliation 1UK Centre for Tobacco Control Studies, Primary Care Clinical Sciences, University of Birmingham, Birmingham, B15 2TT, UK 2Psychological Sciences, Institute of Health and Society, University of Worcester, Worcester, WR2 6AJ,UK 3Public Health Sciences Section, Centre for Population Health Sciences, The University of …dinburgh, Medical School, Teviot Place, …dinburgh, …H8 9AG, UK 4Centre for Translational Research in Public Health, Institute of Health & Society, Newcastle University, N…2 4HH, UK 5UK Centre for Tobacco Control Studies, Public Health Sciences Section, Centre for Popu- lation Health Sciences, The University of …dinburgh, Medical School, Teviot Place, …dinburgh, …H8 9AG, UK 6International Centre for Child Oral Health, King’s College London, 26-29 Drury Lane, London, WC2B 5RL, UK 7Health …conomics, University of Birmingham, Birmingham, B15 2TT, UK 8…ducation for Health, 10 Church Street, Warwick, CV34 4AB, UK 9British Heart Foundation, 4 Fitzhardinge Street, London, W1H 6DH, UK 10Allergy & Respiratory Research Group, Centre for Population Health Sciences, The University of …dinburgh, Levinson House, Teviot Place, …dinburgh, …H8 9AG, UK & CAPHRI, University of Maastricht, The Netherlands

Objective To compare the effectiveness of Pakistani and Bangladeshi smoking cessation outreach workers compared with standard care to improve access to and success of English smoking cessation services.

Methods This was a cluster randomised controlled of natural geographical communities in Birming- ham, UK. The intervention in the control area was standard smoking cessation support and encouragement. In the intervention areas, four trained outreach workers made special efforts to encourage and support attendance at cessation clinics and provided their own clinics in areas frequented by groups who rarely used the cessation service. We recorded

Parallelsessions 4: March 29, 14.00-15.30 120 the number setting quit dates, validated abstinence from smoking at 4 weeks and stated abstinence at 3 months and 6 months. The impact of the intervention on adherence to medications, attendance at clinic appointments and patient satisfaction were also assessed.

Results More Pakistani and Bangladeshi men started quit attempts with the cessation service compared with control areas, rate ratio (RR) 1.32 (95%CI: 1.03-1.69). There was a small not significant increase in the number of 4-week abstinent smokers in intervention areas (RR 1.30, 95%CI: 0.82-2.06). The total cost of the intervention to achieve this was £124,000; an estimated cost per QALY of £8,500.

Conclusion The outreach workers expanded reach through providing smoking cessation clinics in diverse locations used by Pakistani and Bangladeshi smokers. The outreach worker model probably increases community cessation rates and could prove cost-effective, but the sample size was insufficient to determine this definitively. The English smoking cessation services have increased the proportion of Pakistani and Bangladeshi smokers treated and it is unclear whether definitive trials of this intervention are warranted.

Implementation The data are equivocal on whether this approach is the best use of resources and the rise in use of cessation services by minority ethnic groups suggest that the barriers to their use have been overcome without special culturally adapted approaches.

3rd: Developing a smoking cessation program for Turkish-speaking migrants in Switzerland: novel findings and promising effects

Authors: Salis Gross, Corina, Institute for Public Health and Addiction Research, University of Zurich and Institute for Social Anthropology, University of Berne (Switzerland) Schnoz, Domenic, Institute for Public Health and Addiction Research, University of Zurich Cangatin, Serhan, Institute for Public Health and Addiction Research, University of Zurich Schaub, Michael, Institute for Public Health and Addiction Research, University of Zurich Schwappach, David, Institute for Public Health and Addiction Research, University of Zurich Grichting, Esther, Institute for Public Health and Addiction Research, University of Zurich

Objectives Recent studies show that smoking prevalence in the Turkish-speaking migrant population in Switzerland is substantially higher than in the general population. A specific group treatment for Turkish-speaking migrants was developed and tested in order to provide the migrant population with equal access to smoking cessation programs and to improve the migration-sensitive quality of such programs by socio-cultural targeting.

Methods The evaluation of the program included quantitative (questionnaires t1& t2, follow-up by telephone) and qualitative methods (participant observation, semi-structured interviews).

Results The results showed that 37.7% of the 61 participants were smoke-free at the 12-month follow-up. The factors of being in a partnership and using nicotine replacement products during the program were positively associated with successful cessation. We also demon-

Parallelsessions 4: March 29, 14.00-15.30 121 strated the importance of “strong ties” (strong relationships between participants) and the sensitivity of the program to socio-cultural (e.g. social aspects of smoking in Turkish culture which were addressed in relapse prevention), socioeconomic (e.g. low financial resources, which were addressed by providing the course for free), and migration-specific (e.g. under- developed access to smoking cessation programs, which was addressed using outreach- strategy for recruiting) issues.

Conclusion Overall, the smoking cessation program was successfully tested and implemented as a regular service of the Swiss Public Health Program for Tobacco Prevention (by the Swiss Association for Smoking Prevention).

Implementation It is now planned, to multiply the program to other migrant groups. Complementary to the Therapy-Program we started this year with the intervention-study “Tiryaki Kukla” (puppet the addict). We multiplied this communication-campaign (Turkish/Kurdish media, Clubs and communities) from Britain and adapted it to the Swiss context. The aim is to change norms behaviour within the Turkish/Kurdish population towards smoke-free clubs and homes. (see www.tiryakikukla.ch). The intervention is going to be tested by questionnaires (t1/t2) among 500 people of the population. First results can be showed at the Symposium. Both studies are financed by the Swiss Tobacco Prevention Fund.

4th: Reach and effectiveness of a community program to reduce smoking among Turkish-origin residents in Rotterdam

Authors: Vera Nierkens, Department of Public Health, Academic Medical Center, University of Amsterdam, Netherlands Anton Kunst, Department of Public Health, Academic Medical Center, University of Amsterdam, Netherlands Toon Voorham, GGD Rotterdam-Rijnmond, Rotterdam, The Netherlands Hein de Vries, Department of Health …ducation and Health Promotion, Maastricht University, Netherlands Karien Stronks, Department of Public Health, Academic Medical Center, University of Amsterdam, Netherlands

Objective More than 40 percent of Dutch residents from Turkish origin smoke. To reduce smoking prevalence, a culturally targeted program was developed in Rotterdam in the Feijenoord area. Activities included group education meeting, information in a Turkish language newspaper, and a quit and win contest between local organisations. We aimed to assess the reach and effectiveness of this program.

Methods The study had a quasi-experimental design. A pre-test survey among 18-60 old Turkish residents was hold in the Rotterdam area (n=390) and in a control area in the city of Utrecht (n=380). After 24 months, an identical post-test survey was hold. The surveys included measures of the reach (knowledge and participation to the program in Rotterdam) and measures of effectiveness (smoking behaviour and their determinants). Logistic regression analysis was applied to measure changes in the effectiveness measures over time. Odds ratios (OR) and their 95% confidence intervals (CI) expressed the rate of change in the intervention

Parallelsessions 4: March 29, 14.00-15.30 122 area as compared to the control area, adjusting for area differences in demographic and social variables. In addition a process evaluation was carried out including semi-structured interviews and observations.

Results A substantial part (61.2 %) of respondents in Rotterdam was aware of the community program. Less than 10% of the respondents, however, actively participated in one or more components of the program, mostly in information via the Imam. (8.9%), seeing the posters (8.0%) and advise via the GP (4.2%). Results of observations and semi-structured interviews indicated that smokers who participated liked the program components and were positive about the project as a whole. Over time, substantial declines were reported in the proportion of smokers in Rotterdam reporting positive attitudes to smoking (62% decline) and pro-smoking subjective norms of friend (31.5%), whereas declines were small for self effectiveness (4%). Compared to Utrecht, in Rotterdam the declines tended to be larger but none was statistically significant. The percentage of quitters was higher in Rotterdam than in Utrecht (8.6% vs. 6.2%, adjusted OR=1.57, CI=0.56-4.46).

Conclusions Although the smokers tend to change more in Rotterdam than in the comparison group in Utrecht, the differences were not statistically significant. This might be explained by the low participation rate of the smokers in the sample.

Implementation More intensive implementation of the program is needed to achieve a demonstrable effect on (direct precursors of) successful smoking cessation.

Parallelsessions 4: March 29, 14.00-15.30 123 4G - Symposium: the role of dental care in the prevention and cessation of tobacco addiction

Chair: Dr J.E. Jacobs PhD, IQ healthcare, Radboud University Nijmegen Medical Centre, The Netherlands Co-chair: Dr Christoph A. Ramseier, MAS, Dr. med. dent., Periodontist SSO, …FP University of Bern, Switzerland

Presenters: Dr rer. med. Sabina Ulbricht Dipl.-soz. MPH, University of Greifswald, Germany ME Schoonheim - Klein, Dr. med. dent, ACTA, University of Amsterdam, The Netherlands J. Rosseel MSc, med. dent., Radboud University Nijmegen Medical Centre, The Netherlands Dr Vivian I. Binnie, BDS,MPH,PhD,FHEA, Glasgow Dental School, United Kingdom

Summary Tobacco use has been identified as a major risk factor for oral disorders such as cancer and periodontal disease. Tobacco use cessation on the other hand, is associated with the potential for reversal of precancer, enhanced outcomes following periodontal treatment, and better periodontal status compared to patients who continue to smoke. Consequently, helping tobacco users to quit has become a part of both the responsibility of oral health professionals and the general practice of dentistry. International and national associations for oral health professionals are urged to act as advocates to promote population, community and individual initiatives in support of tobacco use prevention and cessation. How best to engage oral health professionals in these tasks is still unclear. An international group or oral health professionals and researchers made an inventory of barriers and stimuli concerning the engagement of oral health professionals. In 2010 international consensus guidelines were published giving an overview of suitable interventions in dental care and the necessary infrastructure and professional education. 1-6

The aim of the symposium is to inform the participants of the guidelines concerning the role of oral health professionals in the prevention and cessation of tobacco addiction. The recommendations for the implementation of these guidelines will be illustrated with examples from Switzerland. After this presentation active participation of the audience will be promoted in small group discussions about the possibilities of the consensus statement recommendations in the particpants’ own professional settings (practice, education, public health, research). The second half of the symposium will be used to have a further look on the evidence base for the role of oral health professionals in smoking cessation policy and practice. The results from implementation experiments in various countries will be presented.

The following questions will be addressed: 1. Are patients amenable to tailored smoking cessation advice in primary care dental practice? (Germany) 2. Can short cessation advice and more intensive counseling be integrated in daily dental care and does this lead to more counseling and quit results? (The Netherlands) 3. What effects does the integation of motivational interviewing in the dental undergradu ate training have on students and patients (The Netherlands) 4. And finally a summay will be presented of the existing evidence in various countries of

Parallelsessions 4: March 29, 14.00-15.30 124 the effectiveness of the integration of smoking cesation activities in daily dental practice. At the end of the symposium a panel will discuss some propositions concerning the opportunities and barriers for the actual involvement of oral health professionals in public health approaches and the priorities for the near future. All participants in the smposium will will be asked to be actively involved in this pro-con debate by voting for or against the propositions.

References: International Dental Journal Issue February 2010: 60 1. Consensus Report: 2nd European Workshop on Tobacco Use Prevention and Cessation for Oral Health Professionals. Ramseier CA, Warnakulasuriya S, Needleman IG, Gallagher JE, Lahtinen A, Ainamo A, Alajbeg I, Albert D, Al-Hazmi N, Antohé ME, Beck-Mannagetta J, Benzian H, Bergström J, Binnie V, Bornstein M, Büchler S, Carr A, Carrassi A, Casals Peidró E, Chapple I, Compton S, Crail J, Crews K, Davis JM, Dietrich T, Enmark B, Fine J, Gallagher J, Jenner T, Forna D, Fundak A, Gyenes M, Hovius M, Jacobs A, Kinnunen T, Knevel R, Koerber A, Labella R, Lulic M, Mattheos N, McEwen A, Ohrn K, Polychronopoulou A, Preshaw P, Radley N, Rosseel J, Schoonheim-Klein M, Suvan J, Ulbricht S, Verstappen P, Walter C, Warnakulasuriya S, Wennström J, Wickholm S, Zoitopoulos L 2. Public health aspects of tobacco control revisited. Jennifer E. Gallagher, Ivan Alajbeg, Silvia Büchler, Antonio Carrassi, Marjolijn Hovius, Annelies Jacobs, Maryan Jenner, Taru Kinnunen, Sabina Ulbricht and Liana Zoitopoulos 3. Oral health risks of tobacco use and effects of cessation. Saman Warnakulasuriya, Thomas Dietrich, Michael M. Bornstein,Elias Casals Peidró, Philip M. Preshaw, Clemens Walter, Jan L Wennström, Jan Bergström 4. Education of tobacco use prevention and cessation for dental professionals--a paradigm shift. Davis JM, Ramseier CA, Mattheos N, Schoonheim-Klein M, Compton S, Al-Hazmi N, Polychronopoulou A, Suvan J, Antohé ME, Forna D, Radley N. 5. Role and models for compensation of tobacco use prevention and cessation by oral health professionals. Jon Crail, Aira Lahtinen, Johann Beck-Mannagetta, Habib Benzian, Birgitta Enmark, Tony Jenner, Ron Knevel, Martina Lulic and Seppo Wickholm 6. Improving the effectiveness of tobacco use cessation (TUC) Ian G Needleman, Vivian I Binnie, Anja Ainamo, Alan B Carr, Angela Fundak, Anne Koerber, Kerstin Öhrn and Josine Rosseel

1st: European Workshop consensus statements and guidelines for oral health professionals illustrated with Swiss experiences

Christoph A. Ramseier University of Bern, Switzerland

Background Helping tobacco users to quit is about to become a part of general practice in dentistry. In order to facilitate the adoption of quit strategies by oral health professionals, a level of care model has been proposed by the recent 2nd European Workshop on Tobacco use prevention and Cessation for Oral Health Professionals which includes 1) basic care: brief interventions for all patients in the dental practice to identify tobacco users, assess readiness to quit, and request permission to re-address at a subsequent visit, 2) intermediate care: interventions consisting of (brief) motivational interviewing sessions to build on readiness to quit, enlist resources to support change, and to include cessation medications, and 3) advanced care: intensive interventions to develop a detailed quit plan including the use of suitable pharmacotherapy.

Objectives The aim of the Swiss National project “Smoking – Intervention in the dental practice” was to assess to what extent dentists have been evaluating the smoking status of their patients in 2002, 2005 and 2008 and what attitude they reported towards counselling their patients.

Parallelsessions 4: March 29, 14.00-15.30 125 Methods In 2008, a 29 item follow-up questionnaire was sent to 3311 Swiss dental practices. Data obtained was compared to the results of two previous surveys conducted in 2002 and 2005.

Results 1102 (33.3%) valid questionnaires were returned. 8% (11% in 2002; 8% in 2005) of the responding dentists were smokers which was well below the prevalence of smokers in Switzerland (27% in 2008). 77% of the respondents reported to take records of the smoking status of their patients (54% in 2002; 66% in 2005). 73% asked their patients regularly about their willingness to quit and 35% asked smokers whether they prefer further assistance in smoking cessation (up from 17% in 2002). 27% recommended nicotine replacement therapy, (up from 17% in 2002). In 2008, 25% routinely delivered brief interventions. Barriers towards the implementation of tobacco prevention and cessation strategies were reported: 43% of the dentists assumed that patients were not interested, 41% reported insufficient training, 35% did lack the time to discuss tobacco related issues with their patients, 17% reported the issue of a missing reimbursement, and 6% were afraid of losing their patients.

Conclusions From 2002 to 2008, Swiss dentists have shown increased activities in helping their patients to quit tobacco. However, in 2008, still the majority did not deliver brief interventions. Therefore, more education and training is needed for dentists to raise their confidence in providing tobacco prevention and cessation in their daily practice.

2nd: Open – mindedness among patients in dental practices for a smoking cessation intervention

Sabine Ulbricht, Haug S, Haut M, Meyer C, Biffar R, Kocher T, John U. University of Greifswald, Germany.

Objective So far, little is known about the acceptance of smoking cessation intervention among patient in dental care. Considering the efficacy and feasibility of computerized intervention strategies in general practices, this kind of intervention was offered in dentalcare.

Methods A random sample of 13 dental practices in a defined region was drawn, 10 practices participated. All patients showing up during a period of 2 weeks were asked about their smoking status. Current smokers aged 18–70 years, visiting the practice for the first time during the study period, were considered to be eligible. One computerized smoking cessation intervention was offered, consisting of a tailored feedback letter.

Results A total of 1457 patients were screened for smoking status. The screening was refused by 2.4% (n=35). A total of 250 current smokers were identified. From these 88.8% participated in the intervention. Among these patients, 68% were not motivated to stop smoking within the next six months.

Conclusion There is a high acceptance of a systematic screening procedure in the dental care setting. The majority of smoking patients could be reached with a brief individualized smoking intervention.

Parallelsessions 4: March 29, 14.00-15.30 126 Implementation Establishing brief smoking cessation intervention as a routine might be feasible.

3rd: A controlled trial using a patient-mediated implementation strategy to stimulate smoking cessation treatment in dental care (TAPS-study)

Josine Rosseel, Annelies Jacobs, Hilberink S, Segaar D, Akkermans R, Maassen I, Plasschaert A, Grol R. IQ healthcare. Radboud University Nijmegen Medical Centre, The Netherlands

Objective To improve the involvement of dental professionals in tobacco addiction treatment. We investigated the effectiveness of a multifaceted intervention including patientreported feedback to increase the provision of smoking cessation counseling during daily dental practice.

Methods A cluster-randomized controlled trial was performed. Primary care general dental practices in the Netherlands (n = 62) were randomly allocated to the intervention or control condition (usual care). The intervention group received small-scale education for the dental team, repeated patient-mediated feedback to the team regarding provided smoking cessation advice and counseling, supply of patient education materials, and a tobacco addiction treatment protocol (minimal advice option or more intensive counseling option). Main outcome measures: Process: changes in patient-reported receipt of smoking cessation advice and support from dental professionals, measured at baseline and after 6 and 18 months. Patient outcomes: self-reported as well as biochemically verified seven-days point prevalence of smoking cessation at 24 months.

Results At baseline and at 6 and 18 months respectiveley 425, 267 and 330 smoking patients reported about the smoking cessation advice and counseling they had received during regular practice visits. The provision of advice, support and patient education was doubled after 6 and 18 months and now performed in about 50% of the practice visits of smoking patients. Motivational stage of the patients (i.e., contemplation, preparation), daily smoker status of patient and fewer assistants in the dental practice influenced to these changes. After 24 months a fixed sample of smoking patients who had at least 2 visits to the practices (462 in intervention en 287 in control condition) reported no significant between-group differences in smoking cessation outcomes.

Conclusion Feedback from patients stimulated dental professionals to adhere to national guidelines for tobacco addiction treatment. However, no differences in patient smoking cessation outcomes could be demonstrated.

Implementation Long-term feedback as well as better referral options to specialised smoking cessation services should be explored as support mechanisms for dental professionals to integrate smoking cessation counseling in routine care and raise the role of dental care in the prevention and treatment of tobacco addiction.

Parallelsessions 4: March 29, 14.00-15.30 127 4th: Smoking cessation counselling in dental education

Meta Schoonheim-Klein M, Gresnigt C., van der Velden U. Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, The Netherlands.

Objectives 1. To test whether education in smoking cessation counseling (SCC) with Motivational Interviewing (MI) increases the number of patients that quits smoking. 2. To test whether this education increases the number of students that quit smoking. 3. To assess the attitudes of students on SCC.

Methods In 2007 a control student-group (MIs-0, n=70) did not receive education in SCC and MI. In 2008-2009 three subsequent student-groups (MI-1 n=58, MI-2 n=77, MI-3, n= 50) received education in SCC with MI. The extension of education in these groups was increasing in time. All dental students were asked to help their periodontal patients to stop smoking. In the 4 respective MI-patient groups (MI-0 n= 104, MI-1 n=89, MI-2 n=87, MI-3 n=106) all patients were asked about their smoking habits before and 6 weeks after their periodontal treatment. The MI-students completed a questionnaire to evaluate attitudes and education in SCC (Likert scale 1-5) and their smoking habits before and after the periodontal course.

Results The MI-0, MI-1, MI-2, and MI-3 group included 21%, 19%, 33%, and 15% patientsmokers, In the MI-0 group no patients stopped smoking, whereas in the MI-1, MI-2, MI-3 group 5%, 7%, and 25% of the patients stopped smoking. The MI-student groups included 14, 22, 10, and 16% smokers respectively. In the MI-0 and MI-1 group, no students stopped smoking, In the MI-2 and MI-3 group 12.5 and 25% stopped smoking, The dental students appreciated education in SCC (mean score 3.3). 80% consider SCC as their task. Around 60% wanted to have additional training in SCC.

Conclusion Newly implemented education in SCC with MI fits in the undergraduate periodontal curriculum and is appreciated by students. This education has a promising effect on smoking cessation of periodontal patients, and has additional positive influence on smoking habits of participating students.

Implementation Motivational interviewing can be implemented in regular undergraduate dental education.

5th: Smoking cessation in a dental setting: a review of best available evidence

Vivian Binnie Glasgow Dental School, College of Medicine, Veterinary and Life Sciences, University of Glasgow, 378 Sauchiehall St, Glasgow. UK. G2 3JZ.

Objective To look at the available evidence with regards to tobacco cessation in a dental setting. To consider the current evidence for referral, from dental to specialist services.

Parallelsessions 4: March 29, 14.00-15.30 128 Methods The highest level of evidence is that of a systematic review, and the Cochrane systematic review on tobacco use cessation was published in 20061. However, the evidence presented is largely derived from participants using smokeless tobacco. An updated version of the Cochrane, under the auspices of the European Workshop on Tobacco Use Cessation (TUC) was published in 20102 . This paper highlighted an additional 3 studies, of which 2 were to do with lit tobacco. In addition to the above, further consideration will be given to emerging evidence from more recent published literature, conference proceedings and grey (unpublished) literature for examples of best practice currently applicable in Europe. A review of the differing models of referral from dental services will also be considered.

Results With regards to the Cochrane published in 2006, of the 6 studies reviewed, 5 were associated with smokeless tobacco. It concluded that while smokeless tobacco cessation was effective, there was insufficient evidence to make recommendations for dental interventions with cigarette smokers. The updated version published in 2010, included 3 interventions with cigarette smokers, and concluded that while interventions in the dental setting increased the odds of quitting , compared to ‘usual care’, there was still the need for high quality research to investigate the most effective components of a TUC intervention. While some European countries, such as the UK, advise referral from the dental setting to the specialist stop smoking services, for advice and help for patients, there is still limited information available that dental personnel are engaging with this pathway.

Conclusion There is still a paucity of high quality information with regards to the evidence base for elements of tobacco cession strategies in a dental setting. Key issues such as funding, who gives the advice and at what intensity, whether it is given in the dental setting or referral for specialist advice will all be considered.

1. Carr AB, Ebbert JO: Interventions for tobacco cessation in the dental setting. The Cochrane Database of Systematic Reviews 2006, Issue 1. Art.No.:CD005084.pub2. DOI: 10.1002/14651858 2. Needleman I, Binnie VI, Ainamo A, Carr AB, Fundak A, Koerber A, Ohrn K, Rosseel J. Improving the effectiveness of tobacco use cessation (TUC). International Dental Journal(2010) 60; 50-59

Parallelsessions 4: March 29, 14.00-15.30 129 4H - Symposium: Implementing Smoke-Free Worksites in Central/Eastern Europe and Central Asian

Chair and co-chair: Frances Stillman, PhD (USA), Narine Movsisyan, MD, MPH (Armenia)

Organizers: The Centre for Health Services Research and Development, the American University of Armenia, Yerevan, Armenia The Institute for Global Tobacco Control, Bloomberg School of Public Health, Johns Hop- kins University, MD, USA

Panellists: Diana Petrosyan, MD, MPH (Armenia), Arusyak Harutyunyan, MD, MPH (Armenia), Gulnoza Usmanova, MD, MPH (Uzbekistan), Tatiana Andreeva, MD, PhD (Ukraine), Srmena Krstev, MD, PhD (Serbia), George Bakhturidze, MD, MHP (Georgia)

Introduction According to the World Health Organization, tobacco-related diseases kill more than 700,000 people a year in the Central and Eastern Europe and Central Asia and nearly 40 percent of middle-aged men die prematurely as a result of tobacco use (1).

Goals The goals of the proposed symposium are as following: a) review the evidence from countries that are in different stages of tobacco control in Central/Eastern Europe and Central Asia b) contribute to establishment of best practices on smokefree worksites in the region, c) facilitate regional cooperation through information exchange, networking and discussion, d) facilitate policy and behaviour change through the dissemination of the best practices.

The symposium will bring together a panel of national and international experts, as well as young investigators, to provide participants with an interactive and informative session to help in planning, implementing, evaluating and disseminating smokefree interventions. The session will consist of 6 oral presentations, followed by the discussion. The panellists will present their countries’ diverse experience in developing smokefree legislation and designing effective interventions to establish smokefree worksites. The importance of locally generated scientific data and their application in promoting policy and behavioral change will be emphasized in presentations. In the interactive part of the session, the panellists and participants will discuss lessons learned from recent successes and/or failures in their countries to establish the best practices on smokefree worksites. The moderators of the panel will lead the discussion and make concluding remarks. The session will facilitate regional cooperation and information exchange and serve as a forum for participants from Eastern and Central Europe and Central Asia.

Background Secondhand smoke (SHS) is a complex mixture of gases and particles that contains hundreds of carcinogenic and toxic compounds (2-4). Evidence now supports causal conclusions on acute and chronic adverse effects across the lifespan, including lung cancer and coronary heart disease in adults (5). As a result of the causal link between SHS exposure and acute

Parallelsessions 4: March 29, 14.00-15.30 130 and chronic health effects, policies aimed at eliminating SHS exposure indoors will have direct benefits to public health. Creation of smokefree environments reduces smoking prevalence and frequency among employees (6) and, as part of a comprehensive tobacco control strategy, can reduce overall smoking prevalence (7).

Methods In 2009, the American University of Armenia in collaboration with the Institute for Global Tobacco Control (IGTC) at Johns Hopkins Bloomberg School of Public Health (MD, USA) and support by FAMRI Center of Excellence in Translational Research at Johns Hopkins conducted a demonstration project with the ambitious objective of reducing SHS exposure in Armenia and the region. Monitoring of SHS exposure in indoor worksites provides critical information to: (a) document the distribution and extent of SHS exposure to estimate health risks of exposed employees; (b) motivate policy and monitor compliance and enforcement with existing regulations; and (c) monitor trends, compare buildings, cities, and regions, and evaluate the impacts of policies and interventions aimed at reducing SHS in indoor air.

Summary of the presentations Drs. Petrosyan and Harutyunyan will share the experience in using PM2.5 and air nicotine monitoring data to develop and evaluate smokefree interventions in Yerevan, Armenia. Dr. Andreeva from Kiev, Ukraine will present PM2.5 monitoring data in Kazan, Russia. Dr. Krstev from Belgrade, Serbia will present a national study of administrators’ readiness to implement the total smoking ban in all health institutions in Serbia, and Drs. Usmanova (Uz- bekistan) and Bakhturidze (Georgia) will speak on the issues in developing and implementing smokefree legislation in their countries.

Presentation 1: Smokefree hospitals: determinants of success

Authors: D. Petrosyan1, N. Movsisyan1, V. Petrosyan1, A. Harutyunyan1, L. Hepp2, E. Avika-Tang2, E. Donaldson2, F. Stillman2 1 Center for Health Services Research and Development, American University of Armenia; 2Johns Hopkins Bloomberg School of Public Health

Background Armenia has a tobacco smoking prevalence rate of 59.6 percent among men aged 16 years and older. Due to the high rates of tobacco use and the insufficient enforcement of tobacco control policy a large burden of disease and premature death are attributable to smoking and secondhand smoke exposure (SHS).

Aim The aim of this study was to develop an intervention to increase worksite compliance with smokefree policies and demonstrate its effectiveness through monitoring SHS exposure levels.

Methods The study team used TSI SidePaks AM510 to measure particulate matters (PM2.5) and filter badges to capture vapor-phase nicotine. Other methods included focus group discussions and baseline and follow-up surveys with employees at two hospitals in Yerevan, serving as control and intervention sites (“panel design”).

Intervention The study team shared with the administration of the intervention site the findings from

Parallelsessions 4: March 29, 14.00-15.30 131 baseline phase and had a number of joint meetings to develop and implement a series of activities. The new institutional non-smoking policy was launched on the National No Tobacco Day that was widely covered by the media. No-smoking signs and posters referring to the national law prohibiting smoking inside health facilities and the fines for breaking this law were posted all over the hospital. All ashtrays were replaced with garbage cans with a no smoking sign on them. The brochures “Why to quit smoking” and “How to quit smoking” were distributed among the nurses, patients and their relatives.

Results Overall 245 and 233 employees participated in baseline and follow up surveys at the intervention and control sites, respectively. The awareness of and the compliance with the worksite smoke-free policy increased statistically significantly between baseline and follow up assessments at the intervention hospital: more respondents rated the air quality (tobacco smoke level) as either excellent or good in the building (18.67% vs. 38.09%); the proportion of respondents reporting that smoking was forbidden anywhere in the hospital was higher (37.55% vs. 62.11%), and more respondents stated that the official policies about smoking in the building were followed at follow-up (36.91% vs. 72.61%). PM2.5 concentrations at baseline in both hospitals were as high as concentrations observed in bars in other countries. However, documented concentrations at follow-up in intervention site were much lower while they did not change at the control hospital.

Conclusion An objective assessment of exposure to SHS is critical to demonstrate the need for strengthening the enforcement of the tobacco control legislation to protect non-smokers’ rights. The involvement of the administration and employees in creating smokefree environments and continuing efforts are crucial for successful implementation of tobacco control interventions.

Presentation 2: Developing a model for smokefree universities

Authors: A. Harutyunyan1, N. Movsisyan1, V. Petrosyan1, D. Petrosyan1, L. Hepp2, E. Evika-Tang2, E. Donaldson2, F. Stillman2 1Center for Health Services Research and Development, American University of Armenia; 2Johns Hopkins Bloomberg School of Public Health

Goal The objective of the study implemented by the American University of Armenia in cooperation with IGTC at Johns Hopkins Bloomberg School of Public Health was to use secondhand smoke (SHS) measurements to develop and test interventions in the educational facilities in Yerevan, Armenia.

Methods The study team selected two universities, Yerevan State Medical University as a control site and Yerevan State Pedagogical University as an intervention site. The data were collected by passive and active air monitoring (PM2.5 and air nicotine), observations, surveys and focus group discussions. PM2.5 monitoring was conducted in the public lobbies, cafeterias and student lounges. Surveys were conducted among faculty, administrative staff and students to assess the level of awareness and compliance with smokefree policies before and after the interventions. Stratified random selection was used in the student survey. All faculty and staff members at the randomly selected departments who participated in the baseline survey were given a unique identification number to be followed up after the intervention

Parallelsessions 4: March 29, 14.00-15.30 132 (panel survey design). The study team conducted focus groups with the staff, students and faculty to develop interventions based on their suggestions.

Intervention After sharing the baseline results of air monitoring with the university stakeholders, the study team, in collaboration with the university administration and student volunteers, developed series of intervention activities. Those included celebration of the National No Tobacco Day, posting “no smoking” signs and posters to inform about the law and fines for breaking this law in the university buildings, replacement of all ashtrays inside the university buildings with garbage cans with a no-smoking sign on them, anti-tobacco essay and cartoon competitions among students, seminars/lecture series for the students, faculty, and staff, distribution of leaflets for raising awareness about the dangers of secondhand smoke and about the ban of smoking.

Results Overall, 1245 students and 211 employees from the intervention site and 1155 students and 237 employees from the control sites participated in baseline and follow-up surveys. PM2.5 concentrations in both universities at baseline were as high as concentrations observed in bars in other countries; however, the PM2.5 concentrations were significantly lower at follow-up than at baseline at the intervention site. Based on survey results, significantly lower proportion of participants observed smoking inside the university buildings (30 day recall). The proportion of survey participants who were aware on the worksite ban of smoking also increased by 30%.

Conclusions Sharing data on PM2.5 and baseline survey results with the students and staff helps to design and implement effective interventions. Involvement of the constituency in planning and implementation of the interventional activities likely helps to develop a sense of ownership among the university students and staff ensuring the success and sustainability of antismoking efforts.

Presentation 3: Smokefree policies and particulate matter air pollution in hospitals and universities in Kazan, Russia

Authors: T. Andreeva1,2,3, G. Ananjeva3 1Tobacco Control Resource Center for the countries of the former Soviet Union, Kiev, Ukraine 2School of Public Health, National University of Kyiv-Mohyla Academy, Kiev, Ukraine 3Choice Foundation, Kazan, Russia

Objectives Smokefree policies are an effective measure to protect people from secondhand smoke exposure; however, monitoring enforcement is a challenge. An exploratory study aimed to assess particulate matter air pollution and to evaluate additional opportunities provided by the Personal Aerosol Monitor measuring particulate matter (PM2,5)

Methods Fine particulate matter (PM2,5) air pollution was assessed with the use of TSI SidePak AM510 Personal Aerosol Monitor in the premises and on the territory of three city hospitals and eight universities in Kazan, Russia. ANOVA and General Linear Model analysis was used to explore factors which account for PM2.5 levels.

Parallelsessions 4: March 29, 14.00-15.30 133 Results In places where smoking occurred, PM2,5 concentrations were dangerous even for short-term presence of healthy people. Typical places of smoking were identified which included toilets and stairs in hospitals, toilets, corridors and hallways, as well as dormitory kitchens in universities. In those premises where smoking was not happening but to which tobacco smoke penetrated from the smoking areas, PM2,5 concentrations measured were beyond the levels considered healthy for vulnerable groups of people. In those universities where smoking was banned, PM2,5 measured at the entrances did not demonstrate excess concentrations, which shows that no compensatory outdoor smoking happens in smokefree universities. In the wards and personnel rooms in hospitals, as well as in those auditoriums if smoking was not practiced there and no tobacco smoke air pollution was documented in neighboring premises, the air quality was close to the recommended standards. The air on the territory of three hospitals and eight universities had different PM2,5 concentrations due to transport, industrial and heating sources of pollution; however, its quality influenced the inner air PM2,5 concentrations only in those premises where no smoking took place. PM2,5 concentrations measured at upper floors were on average higher than those at lower floors, which might be accounted for both by smoking and ventilation factors. It was shown that tobacco smell is a sensitive indicator which can be used where personal aerosol monitor is not available.

Conclusions Smokefree workplaces have particulate matter concentrations determined by the outdoor air quality and reliably protect personnel and visitors from PM2,5-associated risks. Ban of smoking within educational buildings does not cause compensatory smoking outdoors.

Implementation Ways to assess air quality need to include measurements in the designated sets of premises on different floors. Premises which typically were used for smoking or were polluted from other premises need to be included. Outdoor air quality needs to be taken into account. Smokefree policies in universities and hospitals should cover all premises and comprise toilets, stairs, student dormitories, personnel rooms, and territory near the entrances. PM2,5 measurements are recommended to be incorporated in the complex sanitary assessment of hospitals and educational institutions.

Presentation 4: Readiness of health institutions in Serbia to implement the total smoking ban

Authors: Krstev S, Simic S,Marinkovic J, Jovicevic A, Markovic-Denic L, Kotevic A. Public Health Association of Serbia, Belgrade, Serbia

Objectives Almost half of the work force (44.9%) in Serbia is exposed to secondhand tobacco smoke (SHS) at their workplaces (2006). The new Law on Protection from SHS was adopted on May 2010, and will be fully implemented on November 11, 2010. According to the Law, smoking will be totally banned in all healthcare facilities, including backyards, front doors, etc. Based on the high percentage of smoking prevalence among employees of healthcare facilities e.g., 39.9% total, we wanted to assess the current policy and practices related to smoking ban and assess the major obstacles for compliance with the new Law.

Parallelsessions 4: March 29, 14.00-15.30 134 Methods Research was carried out in 2009 in all healthcare facilities in Serbia, including Kosovo and Metohia, with predominantly Serbian population. A questionnaire, specifically developed for this study, was mailed to all 399 facilities, together with the support letter by the Minister of Health. Responses were received from 363 (91.0%) directors or other managers.

Results Total smoking ban was introduced in 28.1% of all healthcare facilities. In respect with the type of facility, a smoking ban was introduced in a half of all general hospitals (50.0%), and pharmacies (18.8%). Among facilities with partial smoking bans, almost all permitted smoking in common premises, corridors, designated rooms and entrances (96.1%, 97.6%, 99.7% and 94.5%, respectively). Healthcare facilities with a partial smoking ban, 10.0% permit smoking at some meetings, and 3.0% at all meetings. However, 41.1% of all directors stated that smoking ban was successfully implemented, while 4.7% stated that it completely failed. More than one third of all facilities (71.6%) discussed various topics of tobacco control at their scientific meetings including cessation. However, only 14.9% have smoking cessation services. The main obstacles for successful implementation of the smoking ban included the following: employee resistance (68.2%), no mechanism for penalties (46.3%), patients’ resistance (46.3%), visitors’ resistance (43.9%), lack of control mechanism (43.7%), no mechanism for incentives for employees, and no legal warranty of directors and managers. Directors and managers indicated that more education on health hazards related to tobacco (13.8%) and stricter control of law implementation (11.8%) would help to better enforcement of the new Law.

Conclusions Smokefree policies were introduced in almost all healthcare facilities, mostly from 2004, which coincidence with the more intensive and comprehensive anti-tobacco activities. However, only a quarter of entire healthcare facilities are said to be smokefree.

Implementation As the result of our study, we developed and disseminated a guide for implementation focused on different aspects of tobacco consumption and smoking prevention that had been distributed to all healthcare facilities; we prepared and distributed information to make the implementation of the Law easier and intensified education on smoking cessation for the teams in healthcare facilities in Serbia.

Presentation 5: Challenges in developing smokefree policies in Uzbekistan

Authors: G. Usmanova1, Sh. Shukurov2 , A. Yurekli3 1German Development Cooperation (GTZ), Uzbekistan (e-mail: [email protected]) 2“Health-2” and “Woman and child health development” projects Joint implementation Bureau under the Ministry of Health of the Republic of Uzbekistan (e-mail: [email protected]) 3Coordinator, Tobacco Control …conomics, Tobacco Free Initiative, World Health Organization (e-mail: [email protected])

With a mandate to be part of the WHO Framework Convention, the Ministry of Health of the Republic of Uzbekistan in 2004 with WHO developed the National Tobacco Control Program for 2005-2010. During the development of the National Programme it was recommended by the Ministry of Economy that the program be based on the best, scientific evidence. Uzbekistan has surveillance data on tobacco prevalence rates and its impact on population

Parallelsessions 4: March 29, 14.00-15.30 135 health and economy of the country (2005-2007). The goal of the National Programme is to reduce the annual consumption of tobacco products among adult males older than 15 years by 0.5 %, utilizing price and non price measures prescribed by WHO FCTC. These measures require multisectoral involvement such as, regulating the domestic market and export operations for manufactured cigarettes, changing behavior of target groups, organizing medical and psychological care provision to smokers who wish to quit smoking, establishing international cooperation, as well as managing and financing the National Program for Tobacco Control. A distinctive aspect of the National Tobacco Control Program in comparison with the CIS countries is that it covers the measures on reducing consumption of sub-lingual tobacco “nasvay”. One of the key components of the National Tobacco Control Program is increasing smoke- free public and work places to reduce second hand smoke exposure. The establishment of smoke free environment contains the following actions: • Require that managerial staff of enterprises, organizations and institutions ban smoking inside the production premises including for both staff and visitors, • Introduce disciplinary responsibility for managerial staff who fail to implement the measurement, • Require that managerial staff of all educational establishments to ban smoking for both students, staff and teachers inside of the schools or on school grounds, • Require that managerial staff impose a smoking ban on the premises of health care facilities and sanatorium-and-spa institutions with respect both to the staff and patients with their visitors, • Strengthen control over compliance to rule forbidding to smoke in public transportation, • Organize medical and psychological care to integrate tobacco dependence treatment into existing standard of care for people willing to overcome tobacco addiction. In the year 2010 “Year of harmonically developed generation” in Uzbekistan and according to the state’s work plan the Ministry of Health in collaboration with another ministries and agencies developed the law “About restriction on prevalence and consumption of alcohol and smoking by person under 20”. Currently, this law is submitted to the upper government body (The Cabinet of Ministries). Once this legislation is enacted and enforced it would reduce tobacco related mortality, morbidity and have favorable economic impact.

Presentation 6: Issues in enforcement of the tobacco control policy in Georgia

Authors: G. D. Bakhturidze, G. M. Magradze FCTC Implementation and Monitoring Center in Georgia

Objective To assess the current situation with the enforcement of the Georgian national law regulating the prohibition and restriction of smoking in public and workplaces.

Methods The study analyzed the Georgian national tobacco control legislation and its accordance to the WHO FCTC and reviewed web resources and other studies.

Results During the last 10 years Georgia made several steps in the developing of tobacco control policy. The first law on tobacco control was adopted in September 2003. Georgia ratified WHO FCTC in May 2006. The changes to national law on tobacco control based on the WHO

Parallelsessions 4: March 29, 14.00-15.30 136 FCTC obligations were introduced in December 2008. According to the national tobacco control law smoking is prohibited in all medical, educational, sport, cultural facilities (penalty for breaking the law is 10 Gel for physical person and 200 Gel for administration), buildings where an inflammable substances exist and public transport. In all other closed public and workplaces including also trains and ships smoking is restricted and there should be allocated places for smoking (penalty for breaking the law 5 Gel for physical person and 200 Gel for administration). In restaurants at least 50% of the space should be designated for non-smokers. Patrol and District Police are the rresponsible bodies for the enforcement of the Administrative Violations Code. The procedures related to the penalty are very complex and corresponding amendments in the Administrative Violations Code are necessary to establish effective enforcement mechanisms. Instead, the Georgian Parliament on the suggestion from the Government, postponed this date first till September 1, 2010 and later on till December 31, 2010.

Conclusions Implementation and enforcement of the tobacco control law is very low in Georgia.

Implementation There is a need to establish an effective system for implementation and enforcement of the Georgian tobacco control law through the amendment of the Administrative Violations Code.

References 1. WHO country profiles, available at http://data.euro.who.int/tobacco/Default.aspx?TabID=2444 2. US Department of Health and Human Services (USDHHS). The health consequences of smoking - chronic obstructive lung disease. A report of the Surgeon General. Washington DC: US Government Printing Office, 1984. 3. Jenkins RA, Guerin MR, Tomkins BA. The chemistry of environmental tobacco smoke: composition and measurement. Washington DC: Lewis Publishers, 2000. 4. Guerin MR, Jenkins RA, Tomkins BA. The chemistry of environmental tobacco smoke: composition and measurement. Chelsea, Michigan: Lewis Publishers, Inc., 1992.U.S. 5. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. 2006. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 6. Fichtenberg CM, Glantz SA. Effect of smoke-free workplaces on smoking behavior: systematic review. Br Med J 2002;325:188. 7. Decline in smoking prevalence-New York City, 2002-2006. MMWR Morb.Mortal.Wkly.Rep 2007;56:604-8.

Parallelsessions 4: March 29, 14.00-15.30 137 4I - Workshop All you need to know about The European Commission, DG Sanco, the European Parliament, Directives, Greenbooks, etc. – a practical lecture

What This practical lecture will address the following items: • Which EU Institutions are dealing with tobacco control • EU legislation on tobacco • Tobacco control in other policies - how to cooperate between different departments • Decision making process - from scoping paper to the report on the implementation of a legislative act • Revision of the Tobacco Products Directive - decision making process and the role of citizens and stakeholders in it.

How This session will be an interactive workshop – presentation, alternated with questions and answers.

Who Terje Peetso & Martina Potschke-Langer

Parallelsessions 4: March 29, 14.00-15.30 138 Parallelsessions 5 Tuesday March 29, 16.00-17.30

5A - Symposium: Minimising Exposure to Second-hand Smoke. Findings from the International Tobacco Control Policy Evaluation (ITC) Project Chair: Ann McNeill, University of Nottingham Co-chair: Marc Willemsen, CAPHRI, Maastricht University

Presenters Gera Nagelhout, CAPHRI, Maastricht University, the Netherlands Ute Mons, Unit Cancer Prevention and WHO collaborating Centre for Tobacco Control, Germany Sara Hitchman, Department of Psychology, University of Waterloo, Ontario, Canada Geoffrey Fong, Department of Psychology, University of Waterloo, Ontario, Canada

Summary Smoke-free laws are crucial to protect non-smokers from exposure to second-hand smoke and to de-normalize smoking. Smoke-free environments can be achieved across a broad range of venues, including workplaces, public venues including bars and restaurants, cars, private homes, and outdoor environments. This symposium explores progress with several smoke-free laws in Europe, will compare this to results from countries outside Europe, and will discuss new frontiers in smoke-free environments. Data are from the International Control Policy Evaluation (ITC) Project.

Gera Nagelhout presents data from Ireland, France, Germany and The Netherlands on the effectiveness of smoke free policies in bars, showing that partial smoke-free legislation (Netherlands, Germany) is insufficient to prevent continued smoking in bars. Comprehen- sive bans (Ireland, France) are needed. Furthermore, Gera will present the results of analyses examining individual smoker characteristics that are predictive of continued smoking in bars.

Ute Mons examines factors associated with the adoption of home smoking restrictions. She compares data on smokers from four countries (Ireland, France, Germany, The Nether- lands), collected before and after the implementation of national smoke-free policies. The proportion of smokers having smoking restrictions varied between countries, but increased significantly in all four countries after the introduction of a national smoking ban. Smoke-free policies in public venues thus might stimulate smokers to establish smoking bans in their homes as well.

Sara Hitchman presents data on prevalence of smokers smoking in cars in the presence of non-smokers across 7 countries. Data from four ITC Europe countries (Germany, France, the Netherlands, and the UK) will be contrasted to data from Australia, the UK, Canada and the

Parallelsessions 5: March 29, 16.00-17.30 139 US. In addition, potentially modifiable characteristics of smoking in cars will be examined.

Geoffrey Fong will discuss these presentations on smoke-free laws in the light of ITC findings from outside Europe and will discuss new frontiers in smoke-free initiatives.

1st: Prevalence and predictors of smoking in “smoke-free” bars. Findings from ITC Ireland, France, Germany, and the Netherlands

Gera E. Nagelhout1,2, Ute Mons3, Shane Allwright4, Romain Guignard5, François Beck5, Geoffrey T. Fong5, Hein de Vries1, Marc C. Willemsen1,2 1 CAPHRI, Maastricht University , the Netherlands 2 STIVORO for a smoke-free future, the Netherlands 3 Unit Cancer Prevention and WHO Collaborating Centre for Tobacco Control, German Cancer Research Center, Germany 4 Department of Public Health and Primary Care, Trinity College Dublin, Ireland 5 Institut National de Prévention et d’Éducation pour la Santé (INP…S), France 6 University of Waterloo and Ontario Institute for Cancer Research, Canada

Objective The first aim of this study was to investigate how successful the smoke-free hospitality industry legislation was in Ireland, France, Germany, and the Netherlands in reducing smoking in bars. The second aim was to assess individual smokers’ predictors of smoking in bars post- ban across countries. The third aim was to examine differences between socioeconomic status (SES) groups in predictors. The fourth aim was to examine country differences in predictors.

Methods This study used nationally representative probability samples of 3,147 adult smokers from the International Tobacco Control (ITC) Europe Surveys who were surveyed pre- and post-ban.

Results While the partial smoke-free legislations in the Netherlands and Germany were effective in reducing smoking in bars (from 88% to 34% and from 87% to 44% respectively), their effectiveness was much lower than the comprehensive legislation in Ireland and France, which almost completely eliminated smoking in bars (from 97% to 3% and from 84% to 3% respectively). Across all countries, greater support for the ban, greater awareness of the harm of SHS, and more negative opinions about smoking were predictive of not smoking in bars post-ban. Support for the ban and perceived societal approval of smoking were stronger predictors of smoking in bars post-ban among high SES smokers, while SHS harm awareness was a stronger predictor among low SES smokers. Support for the ban was a stronger predictor in Germany and smokers’ attitudes towards smoking and perceived societal approval of smoking were stronger predictors in France.

Conclusion Continued smoking in bars post-ban was more prevalent in countries with partial smoke-free legislation. To decrease the probability that individual smokers smoke in bars post-ban, it is important that there is sufficient support for the ban and that smokers are aware of the harm of SHS pre-ban.

Implementation The results indicate the need for strong comprehensive smoke-free legislation without ex-

Parallelsessions 5: March 29, 16.00-17.30 140 ceptions. This should be accompanied by educational campaigns in which the public health rationale for the legislation is clearly explained.

2nd: Adoption of home smoking bans after the implementation of national smoke-free laws. Findings from ITC Ireland, France, Germany and the Netherlands Ute Mons Unit Cancer Prevention and WHO Collaborating Centre for Tobacco Control, German Cancer Research Center, Heidelberg, Germany

Objective To measure changes in prevalence of, and to understand predictors of, home smoking bans among smokers in four European countries after the implementation of national smoke-free policies.

Methods Two waves (pre- and post-smoke-free legislation) of the International Tobacco Control Policy Evaluation Project (ITC) Europe Surveys, prospective panel studies conducted in Ireland, France, Germany and the Netherlands were utilised. Of 6393 smokers interviewed before implementation of a national smoke-free legislation, 4632 (72.5%) were followed up after implementation and were included in the analyses. Multiple logistic regression models were computed in order to identify factors associated with the presence or adoption of home smoking restrictions among smokers.

Results Most smokers had at least partial smoking restrictions in their home, but the proportions varied significantly between countries. After implementation of national smoke-free laws, the proportion of smokers with a total home smoking ban increased significantly in all four countries. Multiple logistic regressions indicated that having a young child in the household and supporting smoking bans in bars were important predictors of banning smoking completely at home. Prospective predictors of imposing a home smoking ban between survey waves were planning to quit smoking, supporting a comprehensive smoking ban in bars, and the birth of a child.

Conclusion The findings support the hypothesis that smoke-free policies do not lead to more smoking in smokers’ homes, which is further evidence against the claim of a displacement of smoking into the private home following the implementation of smoke-free policies in public places. On the contrary, the findings suggest that smoke-free legislation might even stimulate smokers to establish total smoking bans in their homes.

Implementation Smoking bans in the hospitality sector may encourage smokers to ban smoking at home.

Parallelsessions 5: March 29, 16.00-17.30 141 3rd: Smoking in cars with nonsmokers: Findings from Australia, Canada, France, Germany, the Netherlands, UK, and US

Sara Hitchman1, Geoffrey T. Fong1,2, Martina Pötschke-Langer3, Ute Mons3, Marc Willemsen4,5, Gera Nagelhout4,5, Romain Guignard6 1 University of Waterloo, Waterloo, Canada 2 The Ontario Institute for Cancer Research, Toronto, Canada 3 German Cancer Research Center, Heidelberg, Germany 4 STIVORO for a smoke-free future, The Hague, the Netherlands 5 CAPHRI, Maastricht University, Maastricht, the Netherlands 6 Institut national de prévention et d’éducation pour la santé, France

Objective Air quality monitoring studies show that smoking in cars produces much higher levels of second-hand smoke compared to those found in smoky bars. This paper will present the prevalence of smokers who smoke in cars with non-smokers across seven ITC countries, their characteristics, and the potentially modifiable characteristics of this behaviour.

Methods Nationally representative samples of smokers from the ITC Surveys in Australia, Canada, France, Germany, the Netherlands, the UK, and the US.

Results Hitchman et al., (2010) found that the prevalence of smoking in cars was 29% in Australia, 29% in the UK, 34% in Canada, and 44% in the US. Daily smokers who were from the US, male, and younger were the most likely to smoke in cars. New findings from the ITC Surveys in France, Germany, and the Netherlands will be compared and contrasted with these results.

Conclusions Reports of smoking in cars with non-smokers varied greatly across countries. Several potentially modifiable correlates of this behaviour were found.

Implementation Promotion of smoke-free spaces and education about the health risks of second-hand smoke may encourage smokers to adopt smoke-free cars.

4th: Achieving Smoke-Free Environments: ITC Findings Outside Europe, New Frontiers, and Basic Principles for Success of Smoke-Free Initiatives

Geoffrey T. Fong 1,2,3, Ryan David Kennedy3, Sara Hitchman1 for the ITC Project Team 1 Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada 2 Ontario Institute for Cancer Research, Toronto, Ontario, Canada 3 Propel Centre for Population Health Impact, University of Waterloo, Waterloo, Ontario, Canada

Objective To summarize and comment on the symposium presentations on smoke-free laws and their consequences, compare and contrast the results in Europe with ITC findings outside Europe, and to discuss new frontiers in smoke-free initiatives, for example, in outdoor patios, outdoor spaces (such as recreational fields), and in multi-unit dwellings.

Parallelsessions 5: March 29, 16.00-17.30 142 Methods Analysis of key evaluation measures for smoke-free laws from ITC Surveys outside of Europe (e.g., China, Thailand, Mauritius, Mexico, Brazil, Uruguay).

Results Smoke-free laws in hospitality settings have led to reductions in smoking in all countries, but the level of success varies greatly across countries. Expanding smoke-free laws to quasi- outdoor and outdoor environments can be successful.

Conclusions Smoke-free laws have been less effective in countries where the tobacco industry is strong because of exclusions, poor implementation, few or no efforts to educate businesses and the public, and poor enforcement. Guidelines for successful smoke-free initiatives in leading-edge venues such as outdoor environments are the same as those that have been used for indoor environments.

Implementation Smoke-free environments can be achieved across a broader range of venues and throughout the world through the application of basic principles.

Parallelsessions 5: March 29, 16.00-17.30 143 5B - Session Network analysis

5B.1 Ireland SimSmoke: the effect of tobacco control policies on smoking prevalence and smoking-attributable deaths

M. Currie1, L. Clancy1, D. Levy2 1TobaccoFree Research Institute Ireland, DUBLIN, Ireland 2Pacific Institute for Research and …valuation and University of Baltimore, BALTIMOR…, United States of America

Objectives To examine the impact of tobacco control policies implemented since 1998, individually and in combination, and the potential impact of stricter policy alternatives on smoking prevalence and related mortality in Ireland.

Methods IrelandSS - an adapted version of the dynamic simulation model SimSmoke, combines data from various sources to examine the effects of tobacco control policies over time within a complex social system. IrelandSS includes a population model, a smoking model, a smoking-attributable death model and policy modules. The simulation model begins with a baseline year for which a large-scale survey of smoking rates is available (1998 SLÁN Survey of Lifestyles Attitudes and Nutrition), and divides the population into smokers, never smokers, and previous smokers by age and gender. Population data (population by age and gender, fertility rates, mortality rates, and net migration) were attained from the Central Statistics Office. A discrete time, first order Markov process is employed to project future population growth and smoking rates from the base year to future years with population growth evolving through fertility and deaths and smoking rates evolving through smoking initiation, cessation and relapse rates. The smoking-attributable deaths model calculated death rates by age, gender and smoking status using relative risks from large-scale studies in the United States. The policy module employs effect sizes (percentage reductions) derived from thorough literature review and expert consultation. The estimated policy effects are applied to smoking prevalence in the year of policy implementation and to initiation and cessation rates in future years if the policy is sustained. IrelandSS considers cigarette taxation, smoke-free legislation, advertising bans, health warnings, media and educational campaigns, cessation treatment and youth access restrictions.

Results The model estimates the policy effects for the tracking period 2003 - 2009 for smoking prevalence and smoking-attributable mortality and projects future outcomes for 2010 - 2030. Preliminary analysis suggests IrelandSS overestimates the effect of tobacco control policies over the tracking period. The model also indicates considerable potential for stronger policies to reduce smoking rates and smoking-attributable deaths in future years.

Conclusions Preliminary results suggest that policies have not had the effect anticipated by experts and evidenced elsewhere in the literature. With more recent data, we are considering whether the policies are taking longer to affect smoking rates than expected, or whether the combination of past policies was insufficient (e.g. inadequate cessation treatment or anti-smuggling policy).

Parallelsessions 5: March 29, 16.00-17.30 144 Implementation The development of IrelandSS is a partial deliverable of the PPACTE Project. Models are concurrently under development for other EU MS and will be used to examine why tobacco policies have not met expectations in European nations. The models will also allow ongoing monitoring of tobacco control policy impact and the development of policy recommendations.

5B.2 Network analysis of North American Quitlines: Quitlines: mapping networks to improve pratice

J. Leischow1, K. Provan1, J. Bonito1, J. Beagles1, G. Moor2, J. Saul3 1The University of Arizona, TUCSON, United States of America 2In-Source, GR…GG.MOOR@IN-SOURC….CA, Canada 3North American Quitline Consortium, MINN…APOLIS, United States of America

Objectives The network of tobacco cessation quitlines in North America has evolved into a formidable entity over the past several years, yet we know little about the network and communications mechanisms by which stakeholders in the North American Quitline Consortium (NAQC) - especially state/provincial-level funders and service providers/vendors - interact, share new knowledge, make decisions about how and when to implement new knowledge, and actually adopt practices that they believe will improve quitline outcomes.

Methods We implemented the first of three yearly surveys in consultation with NAQC members to collect data about network relationships between quitline organizations, decision-making processes, the implementation of quitline practices, and learning organization characteristics from each of the organizations responsible for funding and implementation of the 63 quitlines in North America.

Results Results of the first year survey show that distinct country-specific differences exist regarding decision-making: In Canada, the provider is more influential; in US, funder or combination funder/vendor as decision-making is most common. The coordinating organization for NAQC plays a central role in brokering information because of its extensive ties to quitlines that would otherwise have very few ties to the rest of the network. In addition, those organizations with the highest reputation scores played the strongest brokerage roles in the network. Decision-making by quitline vendors relative to funders will be presented, along with factors related to implementation of evidence-based practices.

Conclusions The results are expected to increase our understanding of how to bridge the gaps between researchers, services organizations, providers, and clients, and to explore how new knowledge - especially new scientific evidence and innovations - is disseminated, implemented, and integrated.

Implementation This research has significant relevance to implementation of FCTC Article 14 and the WHO EMPOWER recommendations.

Parallelsessions 5: March 29, 16.00-17.30 145 5B.3 Smoking prevalence and smoke-free policy implementation and national characteristics of European Union countries

I. Bogdanovica, A. McNeill, R. Murray, J. Britton UK Centre for Tobacco Control Studies/ University of Nottingham, NOTTINGHAM, United Kingdom

Objectives The prevalence of smoking differs markedly, in absolute level and in rate and direction of change, between European Union (EU) Member States. Effective tobacco control policies have been identified for several decades, but have been implemented to highly variable degrees throughout Europe. Since preventing smoking should be a high priority for all governments, this heterogeneity of policy and prevalence suggests that factors other than public health interest influence tobacco control activity. The aim of this study was to explore the association between a range of national characteristics, including public sector corruption and other variables, and the prevalence of smoking across the current 27 EU Member States.

Methods We investigated associations between smoking prevalence and variables describing various characteristics of the 27 EU countries, including economic development, social inclusion, quality of life, importance of religion, and perceived level of public sector corruption. We also explored the association between some of these variables and daily exposure to tobacco smoke in the workplace as a measure of implementation and compliance with smoke-free policies.

Results At national level, smoking prevalence was significantly higher in relation to higher perceived corruption, material deprivation and gender inequality, and lower gross domestic product (GDP) per capita, social spending, life satisfaction and human development scores. There was no significant correlation between smoking prevalence and income distribution, unemployment rates, educational levels or religion. The two independently significant predictors of smoking prevalence in a multiple regression model involving all of the country characteristics studied were GDP per capita and public sector corruption. The prevalence of exposure to tobacco smoke in the workplace for 1 hour a day or more was not associated with smoke-free policy at national level, but was correlated with corruption scores (R=-0.435; p=0.03 after controlling for the effect of smoking prevalence).

Conclusions Smoking prevalence tends to be higher in the EU countries with greater poverty and higher levels of public sector corruption. Smoke-free policies are less likely to be effective in more corrupt countries.

Implementation The tobacco industry enjoys greatest success in countries that are poor and corrupt.

Parallelsessions 5: March 29, 16.00-17.30 146 5B.4 Longitudinal assessment of smoking cessation rates across social groups in a hospital population

K. Doherty1, L.D. Daly2, A.C. Clarke2, P.F. Fitzpatrick2, C.K. Kelleher2 1St. Vincent’s University Hospital, DUBLIN, Ireland 2University College Dublin, DUBLIN, Ireland

This was a cohort study of a quasi-systematic sample of 1086 smoking inpatients, with a follow-up rate at six months of 76.7%. A baseline questionnaire was administered during admission and a further questionnaire at follow-up. Reported smoking cessation at follow-up was biochemically validated. Education levels, employment status and entitlement to free medical benefits (General Medical Service [GMS]) were used as indicators of socio-economic status. The Fagerstrom Test was used to measure nicotine dependency.

The overall validated point prevalence smoking cessation rate was 11.4% at follow-up. The continuous smoking cessation rate was 7.3%. Multi-variate analysis identified several socio- economic factors associated with high levels of nicotine dependence during admission: low levels of education, unemployment or being unable to work due to sickness/disability. Similarly, those uninterested in quitting had lower levels of education. At follow-up, being strongly motivated to quit was associated with successful quitting (OR 2.0 [95% CI: 1.2 - 3.4]). However there was no evidence of independent relationships between the socio- economic factors and successful quitting. Patients with GMS entitlement were less likely to quit but not significantly so (OR 1.4 [95% CI: 0.9 - 2.2]).

Socio-economic inequalities were associated with nicotine dependency but dependency did not emerge as affecting quit rates; however the influence of education level on motivation to quit may be of concern, as motivation levels had a strong effect on sustained quitting. While those with GMS entitlement or who were unemployed found it harder to quit, this difficulty was not significant.

For those with socio-economic disadvantage, smoking cessation interventions should be geared initially to increasing motivation to quit, with appropriate follow-up supportive measures.

5B.5 The politics of European smoke free policy

Author: Weishaar, H.B.W., University of Edinburgh, Edinburgh, United Kingdom

Objectives The devastating effects of second-hand smoke on European citizens and the need to protect people from exposure to second-hand smoke have been widely acknowledged. Throughout the last decade, substantial progress has been made towards the implementation of smoke free policies at global, supranational, and national levels. The European Council Recommen- dation on smoke free environments, adopted in November 2009 and calling on European member states to implement comprehensive legislation that bans smoking in workplaces and public places, presents a successful example of increasing Europe-wide protection from

Parallelsessions 5: March 29, 16.00-17.30 147 second-hand smoke.

Policy networks have been recognised as a central feature of European Union (EU) policymaking and are assumed to impact on political decision-making and the outcome of European policy. Building strong networks and advocacy coalitions with likeminded organisations seems to be a crucial factor for successful interest mediation in the development and implementation of tobacco control and smoke free legislation.

The presentation explores policy networks and advocacy coalitions in the European Com- mission consultation on smoke free policies. It provides an overview of stakeholder engagement and explores the interdependence and relationships between various political actors (European, national, regional and local authorities, tobacco- and health-related organisations and social partners) in the development of European smoke free legislation.

Methods Applying a case study approach, the presentation draws on social network analysis (SNA) to analyse interaction between political actors who took part in the European Commission consultation on smoke free policies. While SNA has proven useful for the investigation of policymaking in the EU, this study is the first to investigate networks in European public health policy.

Results The paper analyses networks in European smoke free policy on three levels by investigating the following: (a) the overall structure of the network including connectedness within the network, its core-periphery structure and its hierarchical structure; (b) the subgroups within the network, analysing group cohesion and characteristics of the relationships within each subgroup; and (c) the individual organisations and their position, location, role and potential importance and opportunities for action within the network. Patterns of cooperation and coalition building between political actors, their impact on European smoke free policy and potential for policy transfer across the EU will be discussed.

Conclusion and Implementation By investigating stakeholder engagement in the European Commission consultation on smoke free policies, the presentation explores the “politics of smoke free policy” and the factors that facilitate and obstruct the development of effective smoke free legislation. An analysis of policy networks in the development of smoke free legislation at European level can inform and improve politicians’ and advocates’ approaches to current tobacco control policies in the EU, European member states and beyond.

Parallelsessions 5: March 29, 16.00-17.30 148 5C - Symposium: Is Tobacco Control Good value for money?

Chair: Maureen Rutten-van Mölken Institute for Medical Technology Assesssment/ Institute of Health Policy and Management, …rasmus University, Rotterdam, The Netherlands

Overall aim Smoking is a risk factor causing a large burden of disease to society, in terms of health loss, health care cost and production loss. Many different interventions have been proposed, developed, evaluated and implemented to prevent the uptake of smoking and increase smoking cessation. These interventions can roughly be divided into interventions targeting (subgroups of) the general population and interventions supporting individual smokers to quit. The former refer to tobacco control policy measures such as tax increases, legislation to prohibit smoking in public places, bans on advertising and promotion, and public reimbursement of smoking cessation support as well a mass media campaigns and health promotion programs. The latter primarily include smoking cessation counseling in many different varieties and pharmacotherapy. In this symposium we address the question whether these interventions provide good value of money. More specifically, the aim of this symposium is to present the latest information on the cost-effectiveness of tobacco control policy measures and the cost-effectiveness of individual smoking cessation support in both the general population of smokers and in patients who have already acquired a smoking-related disease.

1. Cost-effectiveness of tobacco control policies: tax increases and smoking bans

Speaker: Prof. Anne Ludbrook, University of Aberdeen

Governments considering intervention in the tobacco market need to weigh the costs versus the benefits. When considering fiscal and regulatory interventions, this is not straightforward as ‘experimental’ evidence is rare, in the sense of randomised or other controlled designs. This may limit the estimation of both benefits and costs. This presentation addresses some of the methodological issues that arise and then assesses the international evidence base relating to taxation and regulation of smoking in public places. The type of data available is one limiting factor in the analysis that can be undertaken and study designs have to ensure that confounding factors and other sources of bias are controlled for. Potential confounding factors include differences in the population characteristics, differences in social or legislative context, and interactions with other policy or economic changes taking place at the same time. Studies may only show relationships between price or regulatory intervention and consumption rather than causality. A particular issue to consider is attribution of effects between fiscal measures and regulation, on the one hand, and other interventions. Whilst both theory and empirical evidence support the effectiveness of taxation and smokefree policies in influencing consumption, the size of the effect may be related to the use of other interventions which may either enhance or reduce the effect. Health promotion campaigns and direct interventions such as smoking cessation services might increase the impact and it may be more difficult to accurately attribute the effects. Similarly, strict regulation of the supply of tobacco may reduce the

Parallelsessions 5: March 29, 16.00-17.30 149 impact of taxation because price becomes a smaller component of total cost. Estimates for the effects of tax or price on tobacco consumption are mostly drawn from studies of time series data relating aggregate consumption to price and income. The majority of results are in the range of -0.3 to -0.5; i.e. the effect of a 10% price increase may range between 3% and 5%. The effect on smoking prevalence will be smaller. Studies of restrictions on smoking in public places suggest the effect on smoking prevalence is around 2% but benefits also accrue to non smokers. The cost of these interventions depends on the perspective taken for the analysis: public sector or societal. A study carried out by WHO found taxation to be the most cost-effective intervention available. Enforcing clean indoor air regulation was more cost-effective than smoking cessation interventions. All interventions fall so far below the thresholds that are used to determine value for money that any uncertain- ties in the estimates would not alter the conclusion that they are worthwhile investments.

2. Cost-effectiveness of community anti-smoking campaigns and health promotion programs

Speaker: Dr. Karen Gutierrez, Director Global Dialogue for …ffective Stop-Smoking Campaigns

This presentation will summarize a variety of data collected internationally regarding the cost-effectiveness of tobacco control mass media campaigns. Data indicate that public education campaigns that help adult and youth smokers quit, help former smokers from relapsing, and prevent youth from ever starting to smoke will produce enormous healthcare cost savings because of reductions in smoking-caused illnesses and deaths. Mass media campaigns can be extremely cost effective versus other healthcare interventions as well, and sometimes even versus other tobacco control interventions. Key content of the presentation will include the role of public education mass media campaigns; the link between these campaigns and reductions in tobacco consumption or youth tobacco uptake; and the corresponding analyses regarding cost-effectiveness of mass media campaigns (in the absolute and versus other interventions). The presentation will also cover proven strategies for stretching limited funds to effectively build awareness, knowledge, and support for tobacco control policies, and to change attitudes and behaviors. These cost- efficient strategies include 1) large, graphic tobacco pack warnings, 2) gaining news media coverage, 3) adapting communications materials from elsewhere versus developing original materials, and 4) using short-burst campaigns tactically to support policy efforts.

3. Long-term cost-effectiveness of smoking cessation support in the general public when accounting for costs during life years gained: comparison with other preventive interventions Speaker: Dr. Pieter van Baal, National Institute of Public Health and the …nvironment, Bilthoven, The Netherlands

Objective While smoking cessation generates savings in health care costs due to reduced incidence in smoking related diseases, these savings are often outweighed by the medical spending in life years gained. Thus, smoking cessation could increase health care costs without even taking into account the costs of public policy that might induce people to stop smoking. The aim of this study was to estimate the cost effectiveness of smoking cessation interventions

Parallelsessions 5: March 29, 16.00-17.30 150 in the general public explicitly considering medical costs in life years gained.

Methods The effects of counseling, pharmacotherapy and tobacco tax increases were translated into effects on smoking quit rates. The RIVM Chronic Diseases Model was used to project incidence, prevalence and health care costs of the major chronic diseases conditional on smoking status over time. Comparing to a current practice scenario, the differences in healthcare costs, life years and QALYs from these interventions were estimated.

Results Excluding medical costs in life years gained most interventions can be considered as cost saving. If medical costs in life years gained are included, smoking cessation is not cost saving anymore. However, the cost per QALY ratio of all smoking interventions remain favourable even when the cost increase due to the prolongation of life is included.

Conclusion Smoking cessation is cost effective but not a cure for increasing health expenditures.

4. Long-term cost-effectiveness of smoking cessation support in patients with a smoking-related disease: the case of COPD

Speaker: Martine Hoogendoorn, Institute for Medical Technology Assessment, …rasmus University Rotterdam, The Netherlands

Objective Little is known about the long-term cost-effectiveness of smoking cessation interventions in patients who already have a smoking-related disease. In this study we aimed to estimate the long-term (cost-)effectiveness of smoking cessation interventions for patients with chronic obstructive pulmonary disease (COPD).

Methods A systematic review was performed for randomized controlled trials evaluating a smoking cessation intervention in COPD patients. Inclusion criteria were COPD-confirmed by spirometry or physician, follow-up at least 12 months, reporting biochemical validated abstinence rates and published in English. The different interventions were grouped into four categories: usual care, minimal counseling (less than 90 minutes counseling), intensive counseling (more than 90 minutes counseling) and intensive counseling plus pharmacotherapy (NRT, bupropion or nortriptyline). For each category the average 12-months continuous abstinence rate and intervention costs were estimated. A dynamic population model of COPD disease progression was used to project the long-term (cost-effectiveness) of one year implementation of minimal counseling, intensive counseling and intensive counseling plus pharmacotherapy for 50% of the smoking COPD patients compared to usual care. Uncertainty and one-way sensitivity analyses were performed for variations in (the calculation of) the abstinence rates, the type of projection, intervention costs and discount rates.

Results Nine studies were selected. The average 12 months continuous abstinence rates were estimated to be 1.4% for usual care, 2.6% for minimal counseling, 6.0% for intensive counseling and 12.3% for intensive counseling plus pharmacotherapy. Compared to usual care, the costs per QALY gained for minimal counseling, intensive counseling and pharmacotherapy were €16,900, €8,200 and €2,400, respectively. If each intervention was compared to the

Parallelsessions 5: March 29, 16.00-17.30 151 next most effective intervention, the cost per QALY of intensive counseling versus minimal counseling was €4,600, while intensive counseling plus pharmacotherapy versus intensive counseling alone was cost saving. One-way sensitivity analyses showed that the cost per QALY gained compared to usual care ranged from €8,800 to €18,200 for minimal counseling, from €3,500 to €11,900 for intensive counseling and from cost saving to €6,100 for intensive counseling plus pharmacotherapy. Results were most sensitive to variations in (the estimation of) the abstinence rates and discount rates.

Conclusion Compared to usual care intensive counseling with and without pharmacotherapy resulted in low costs per QALY gained with ratios comparable to results presented for smoking cessation in the general population. Intensive counseling plus pharmacotherapy was cost saving compared to intensive counseling alone and dominated the other interventions.

Implementation Intensive counseling plus pharmacotherapy should be the first choice for smoking cessation in patients with COPD, both from a clinical as an economic perspective.

5. I Don’t Smoke But Why Should I Be a Subject in the Evaluation of Smoking Cessation Programmes?

Speaker: Martha Trapero-Bertran, Brunel University Health …conomics Research Group

Objective The aim of this study is to explore the potential impact of incorporating external effects on decision making of public health programmes in a UK setting, using smoking cessation as an example. Passive smoking and smoking during pregnancy were incorporated on an economic evaluation of smoking cessation programs informing NICE guidelines.

Methods An economic evaluation of smoking cessation interventions which informs policy making in UK, based on a Markov chain model, was replicated to have an economic evaluation base case to refer to. We value passive and during pregnancy smoking using a Markov model, and these external effects were incorporated on that economic evaluation. Passive smoking was measured by having lung cancer and coronary heart disease for adults, and asthma, wheeze, cough, otitis media with effusion and acute otitis media for children. Smoking during pregnancy was measured through higher rates of sudden unexpected death in infancy, and smaller birth weight for children, and also by ectopic pregnancy and pre-eclampsia for the pregnant smoker. The societal perspective was adopted. A cost-utility analysis was used, with costs reported on £ (2010) and effectiveness measures by quality adjusted life years (QALYs). When incorporating external effects, extra costs and QALYs lost were calculated. Costs and consequences were discounted at 3%. Univariate and probabilistic analysis were calculated.

Results Accounting for passive smoking is costing per adult smoker and children passive smoker 150.50£; and every adult and children is loosing 0.5574 QALYs because of the passive smoking. Moreover, accounting for smoking during pregnancy is costing per pregnant woman and baby 23.26£; and every women and baby are loosing 0.0006 QALYs. Distant results, including or not external effects, were obtained by the cost-effectiveness analysis.

Parallelsessions 5: March 29, 16.00-17.30 152 Conclusion To avoid wasting limited resources and contribute to a healthier society, the social costs should be considered in the choice of the most cost-effective programmes to reduce smoking. Our discussion considers how much the decision making process would be affected considering or not external effects on economic evaluation of smoking cessation interventions. We also discuss whether other valuation approaches for external effects, such as cost- benefit analysis, would be appropriate and in which cases.

Implementation The SCOTH (1994) report was the first national epidemiological published evidence in the UK context around epidemiological data and clinical evidence of passive smoking and smoking during pregnancy. Economic evaluation of NICE guidelines, which inform policy decisions, does not account for external effects. There is a need for reconsideration the incorporation of external effects in such evaluations.

Parallelsessions 5: March 29, 16.00-17.30 153 5D - Symposium: Working with communities to reduce health inequalities: protecting children and young people from tobacco

Chair: Mr Francis Grogna …uropean Network for Smoking and Tobacco Prevention Co-chair: Ms Sandra Davies Liverpool Primary Care Trust

Presenters: Mr Krzysztof Przewozniak, Civil Coalition ‘Tobacco or Health’, Poland Ms Alison Reid, Manchester Stop Smoking Service, NHS (National Health Service) Manchester Ms Elizabeth Tamang, Regional Referent for smoking prevention – Veneto Region Mr Joseph Osman, ACTIF & OFT Ms Sandra Davies, Liverpool Primary Care Trust

Background Smoking kills over 650,000 people each year in Europe. Most of people who smoke start at young age and children and young people are broadly exposed to secondhand smoke. This seriously determines their health both in childhood and adulthood. Those who begin to smoke at young age are more likely to become tobacco dependent, less likely to stop smoking, smoke more heavily and for a longer time and, as a result of the increased health risk, die early from smoking attributable diseases.

Objectives The project goal was to develop effective methods of engaging local communities and peer groups for protecting children and young people from tobacco and secondhand smoke. The assumed project methods and tools aimed to tackle high smoking prevalence amongst children and young people and their exposure to tobacco smoke from others.

Traditional symposium Design In order to reduce health inequalities, the project was focused on children and young people from socially disadvantaged communities that have poor health indicators and was conducted both in Western and Eastern part of the European Union. The project was led by the Liverpool Primary Care Trust and funded from the EU Public Health Programme. Ten associated and six collaborative partners from Czech Republic, France, Italy, Latvia, Lithuania, Poland, Romania, Spain, and UK took part in development of the project. Within the project, a series of integrated activities and pilot interventions were delivered to effectively engage local communities and peer groups. The effectiveness of these interventions and applied tools have been assessed and a cross-cultural, community engagement tool-kit as well as the policy recommendations have been prepared.

Methodology In France (Paris), Latvia (Riga) and the UK (Liverpool) pilot peer-to-peer interventions have been implemented in a total of 15 schools to raise awareness about the tobacco harm and to tackle smoking behavior amongst youngsters aged 11-15 years. In each school, trained

Parallelsessions 5: March 29, 16.00-17.30 154 peer advocates delivered tobacco control interventions within classroom settings to other, younger children. In Italy (Veneto), Romania (Manastirea) and the UK (Manchester) community- based pilot interventions have been realized to protect children from secondhand smoke at their environment. Each community engagement pilot utilized cultural-specific advocacy and health education methods. The effectiveness of both interventions, peer-to-peer and community-based, were assessed by quantitative and qualitative evaluation methods, including baseline and follow-up questionnaire surveys, focus groups, and semi-structured interviews with key informants. Evaluation of project effectiveness focused on the process of project development, achieving the assumed project objectives, and the transferability of the project model.

Planned outcomes (1) assessment of the effectiveness of pilot interventions, (2) preparing a cross-cultural tool-kit available for use by community public health leaders, non-government organizations, school staff and peer groups, health care professionals, and parents, (3) policy recommendations for European, national, regional and local decisionmakers.

Aim of the symposium The aim of the symposium will be to share and discuss the good practice and outcomes of the project, including commenting the toolkit for improved future interventions, and to encourage the implementation of similar interventions in other EU countries.

1st presentation: Project description, methodology and evaluation process

Authors: Krzysztof Przewozniak, Civil Coalition ‘Tobacco or Health’, Poland

Objective The main goal of the CHI-CY-TOBACCO Project was to develop effective methods of engaging local communities, families, teachers and peer mentors for protecting children and young people from tobacco and secondhand smoke. To reduce health inequalities between European Union countries, project made an attempt to tackle high smoking prevalence and secondhand smoke exposure amongst children and young people from socially disadvantaged communities of six European countries, including old and new members of the European Union.

Methods The project was led by the Liverpool Primary Care Trust and funded from the EU Public Health Programme. Ten associated and six collaborative partners from Czech Republic, France, Italy, Latvia, Lithuania, Poland, Romania, Spain, and UK took part in development of the project. Within the project, a series of integrated activities and pilot interventions were delivered to effectively engage local communities and peer groups. In France (Paris), Latvia (Riga) and the UK (Liverpool) pilot peer-to-peer interventions have been implemented in schools to raise awareness of pupils about the tobacco harm and to tackle smoking behavior amongst youngsters aged 11-15 years. In each school, trained peer advocates delivered tobacco control interventions within classroom settings to younger children. In Italy (Veneto), Romania (Manastirea) and the UK (Manchester) community-based pilot interventions have been realized to protect children from secondhand smoke at their environment. Each community engagement pilot utilized cultural-specific advocacy and health education methods. The effectiveness of both interventions, peer-to-peer and community-based, were assessed by quantitative and qualitative evaluation methods, including baseline and follow-up questionnaire surveys, focus groups, and semi-structured interviews with key informants.

Parallelsessions 5: March 29, 16.00-17.30 155 Results Evaluation of project effectiveness was mainly focused on the process of project development, achieving the assumed project objectives, the quality and usefulness of prepared materials and tools, and the transferability of the project model (possibility to use in different countries, cultures, and communities). Results of the project implementation will be presented in country-specific papers on pilot peer-to-peer and community-based interventions.

Conclusion The project is recommended as a best practice model for working with communities on protecting children and young people from tobacco smoking and exposure to secondhand smoke.

Implementation In order to make this project more effective for potential implementation in other countries and communities, a cross-cultural tool-kit was prepared for use by community public health leaders, non-government organizations, school staff and peer mentors, health care professionals, and parents. The lessons from the project experience were also expressed in seven key policy recommendations for European, national, regional and local decisionmakers.

2nd presentation: Wythenshawe Healthy Smokefree Families Pilot

Authors: Ms Alison Reid Manchester Stop Smoking Service, NHS (National Health Service) Manchester Ms Chris Bell Barnardo’s North West

Objective This session will look at the specific experience within Wythenshawe, Manchester, an area of deprivation with high smoking prevalence. It will talk about the way in which local parents, volunteers and staff were engaged and trained and how they worked together to develop and promote the project. The objective was to reduce health inequality through community participation, changing knowledge, attitudes and behaviour in relation to protecting children from second hand smoke, denormalising smoking in homes and vehicles and in the presence of children and young people.

Methods Manchester Stop Smoking Service worked in partnership with Barnardo’s North West, children’s services provider in Wythenshawe. Manchester developed one of the community engagement pilot interventions, which involved training 133 local staff and volunteers including 36 parents to deliver a brief intervention to parents and families in settings across the community. The pilot developed an innovative, visual ‘chemical soup’: Parents were encouraged to consider whether they would make soup from the chemicals in cigarettes and leave it bubbling on a stove while children played nearby. They were then encouraged to sign up to Manchester’s Smokefree Homes Scheme. Participants found the concept compelling, spreading the word in the community. The project was based in the visual display, in asking questions and in promoting simple key messages. Additional partnerships were made with Manchester United Foundation and the Royal Northern College of Music.

Parallelsessions 5: March 29, 16.00-17.30 156 Results: First year results: • 1149 households signed up as smokefree • More than 400 households with children changed their behaviour • Supported quit attempts in the area rose by 36% • Organisations which had not previously seen tobacco issues as core business showed increasing interest. • The pilot won NHS Manchester Improving Health Award and a North West Public Health Award.

Conclusion Engaging the community in promoting the protection of children from second hand smoke is a positive and successful method of achieving good outcomes. Visual tools (chemical soup, red cards) that provoke questions are key to success.

Implementation The lessons learned from the pilot have informed the policy recommendations and tool kit which we are promoting to all our contacts and through our libraries. The briefings for parents, volunteers and staff continue in Wythenshawe and begin across Manchester in 2011. Chemical soup is being used in promotional materials across the city and beyond.

3rd presentation: Promotion of healthy and smokefree lifestyles in primary school – Veneto Region Project

Authors: Ms Elizabeth Tamang, Regional Referent for smoking prevention – Veneto Region, Mr Alessandro Mantovani, Adria Health Authority – Veneto Region, Mr. Andrea Finessi, Adria Health Authority – Veneto Region

Objective The tobacco use in adolescence is today a severe public health problem and international publications suggest the need of health promoting interventions for children and their families. Most tobacco control interventions at regional and national level in Italy are addressed to students of secondary school from the age of 12-13, an age when attitudes and knowledge about tobacco are already structured and established. In this context, the objective of this project is to lower the focus of our preventing interventions to primary school children engaging the community as key resource. The aims are: • Preventing the smoking habit and promoting a tobacco free culture in children of primary school and their families; • Promoting behavioural competence and ability in children and their families; • Creating smoke free environments (schools, homes etc.); • Strengthening of community action.

Methods Veneto Region developed a three-year experimental project on health promotion for primary schools focused on strengthening and improving life skills in children as protective factors as an attempt to reduce their vulnerability to social pressures towards risk behaviours while involving at the same time families, schools and peers. This project adopts active group involvement of children and parents, taking into consideration individual and cultural differences and group dynamics. It mixes different kinds of interventions: educational activities in classroom (use of creative writings, dramatizations and drawing), educational activities with parents, campaigning activities in households and campaigning activity in the community.

Parallelsessions 5: March 29, 16.00-17.30 157 Results More than 70% of Health Authorities in Veneto Region carried out the project reaching about 2000 children. In Adria Health Authority, regional coordinator of the project, have been trained 15 teachers that involved 302 children from 8 to 10 y.o. attending primary school. It is possible to observe from the evaluation the following results : Intentions of smokers to quit has improved ; increase in proportion of respondents thinking babies, children and pregnant women should not be exposed to SHS ; increase in knowledge about harm to children being exposed to SHS ; increase in knowledge about harm to adults being exposed to SHS.

Conclusion A significantly aspect to obtain good results is to engage community adopting varying forms and tactics. Campaigning activities in the community and in the households (i.e. smokefree homes initiative) have been a plus for our project because we had the opportunity to raise awareness about tobacco problems in the main settings in which our children live.

Implementation We are preparing a manual of the project to distribute at regional and national level.

4th presentation: Peer to Peer Intervention in Paris

Authors: Mr J. Osman, Ms M. Osman, A. Binétruy ACTIF & OFT, Paris

Objective Convince young people to stop smoking as soon as possible or better not to start. Action is run in rather discriminated population.

Methods • Finding 4 colleges in Paris and obtaining the support of heads, teachers and parents. Selecting 4 classes in each college and 2 advocates in each class. • Administrating a questionnaire on tobacco smoking habits and environment, in 2 phases: before and after training. • Teaching the advocates the knowledge basis concerning tobacco misdeeds and the repercussion on health, • Asking the advocates to explain what they have learnt to their peers, under supervision of experts.

Results 16 classes have been trained, which means almost 500 children informed. This also means 16 presentations of almost 2 hours in total.

Conclusion In spite of many obstacles to organize the program in Paris, the children were happy to take part and found it useful, as well as teachers who were reluctant in the beginning. It is too early to see any effects, but this does not mean we should not continue. ACTIF and OFT have always noticed a decrease of smoking prevalence in schools when working on a regular base, and an increase once efforts are stopped. Fighting against tobacco industry, addictions and against the social and psychological needs of children is an endless struggle. We are noticing this year an increase of tobacco consumption in young people in Paris (selling tobacco

Parallelsessions 5: March 29, 16.00-17.30 158 under 18 is now forbidden), as well as in adults. Efforts should not stop.

Implementation We are confident that it is very possible to do better as long as: 1. we accept to make the program a communication program instead of a “scientific” one (too long and too demanding for schools in general and teachers in particular); 2. all the process is scheduled and organized far in advance; 3. we involve upstream all the partners (parents, teachers, heads…) explaining the challenge for our children in 4. the forthcoming years; 5. we have all partners realize that they have a major role to play to face those who know how bad smoking is, in particular for the young people, but who are led only by profit. We will disseminate from January to March the tool-kit to 500 schools and will try to interview 25 heads and 25 teachers afterwards. We will also propose 10 schools to organize an exhibition on the tobacco question. A questionnaire will be sent to the 500 schools to help reaching these goals. According success, we will do our best to enlarge this process and ask our partners in France to implement it each time it will be possible.

5th presentation: Liverpool’s Experience of the Peer to Peer Project, Overall Project Toolkit and Policy recommendations

Authors: Dr Sandra Davies, Associate Director of Public Health Liverpool Primary Care Trust; Susie Gardiner, Strategic Lead for Tobacco Control Liverpool Primary Care Trust, Francis Grogna, Secretary General of the …uropean Network for Smoking and Tobacco Prevention

Objective This session will look at the specific experience within Liverpool, talk about the way in which peer advocates were chosen and trained within the school setting and within the school curriculum, how the Project benefitted both the Advocates and the pupils who received the training, in terms of increased confidence and knowledge about tobacco and the impact of the tobacco industry, and the importance of the evaluation and the use of a modified version of the GYTS pre and post training. The Session will also look at the purpose and use of the Toolkit and the policy recommendations that have been developed from the Overall Project.

Methods Liverpool developed one of the peer-to-peer pilot interventions, which involved training 30 peer advocates to deliver tobacco control interventions to 500 younger school pupils, within classroom settings. Liverpool has a track record of developing youth advocacy programmes around tobacco and its youth Project, DMYST, won a World Health Organisation award in 2007 for its advocacy work in the lead up to the UK Smoke Free Legislation.

Results Evidence from evaluations of the pilots indicates that Peer advocates were the main beneficiaries of the Project with their in-depth involvement deepening their knowledge of tobacco, shifting or reinforcing their attitudes towards anti- smoking and encouraging some to attempt to change their smoking behaviour. It also boosted their self-esteem. Targeted pupils also benefited from an increase in their knowledge about tobacco control issues.

Conclusion It is concluded that both methods are important in the development of community based

Parallelsessions 5: March 29, 16.00-17.30 159 interventions to denormalise tobacco. The toolkit provides guidance for developing and implementing tobacco control interventions that adopt either of the two methods previously discussed and builds on evidence and good practice lessons derived from the Projects. The Toolkit is aimed at Policy makers, Service commissioners, Service providers and Tobacco control activists. It is supportive of a wide range of strategies at local, regional and national levels and complements public policy agendas that are wide ranging in their aim. The toolkit will help individuals develop comprehensive tobacco control strategies that are supported by partnership working.

Implementation The lessons from the project experience gave rise to a series of key policy recommendations that are pertinent for European, national, regional and local policy-makers, and these will be discussed in relation to wider tobacco control policy, and the most effective way to ensure that youth advocacy and community based approaches are incorporated into mainstream practice.

Parallelsessions 5: March 29, 16.00-17.30 160 5E - Symposium: Be inspired: supporting health care workers to implement tobacco free policies

Authors: Sibylle Fleitmann, Cristina Martínez, Christa Rustler, Ann O’Riordan, Esteve Fernán- dez for the Board of the …NSH-Global Network for Tobacco free Health Care Services.

Introduction The World Health Organization (WHO) emphasizes the important role of hospitals and health care services to become active in reducing the use of tobacco and its detrimental health effects. These obligations include not only the provision of active treatment and support for tobacco users in their quitting process but also the establishment of a tobacco-free environment to protect non-smokers. This obligation concerns medical, non-medical staff, and includes all kinds of health care facilities.

In this regard, ENSH-Global Network for Tobacco free Health Care Services has developed an organizational policy strategy which helps to enhance tobacco control activities in health care services to reduce tobacco consumption in society and its deleterious consequences.

This symposium offers evidence-based methods and tools to motivate health care workers and organizations in moving forward in tobacco control.

Objective of the symposium The aims of the symposium are: 1. To give new impetus to health professionals in Europe to join the tobacco free movement in support of the WHO Framework Convention on Tobacco Control. 2. To demonstrate the effectiveness of the ENSH concept and tools to motivate health professionals’ engagement in the overall tobacco control effort.

Background ENSH-Global Network for Tobacco free Health Care Services (ENSH) is an independent, international non-profit association registered under Belgium law, whose main aims are to develop a common strategy amongst healthcare services active in tobacco prevention and cessation (in all its forms) first in Europe and then worldwide. Since its creation in 1999, the ENSH has developed a practice based and continuously evaluated concept to establish comprehensive tobacco free policies in hospitals and health care facilities. The concept is based on a 10 point European Code. The ENSH proposes the implementation of its code and standards and the sharing of information and experiences through coordinated activities and projects. (http://www.ensh.eu/). During the last 10 years, the ENSH concept has also become an excellent advocacy tool to enhance the involvement of health professionals in tobacco control. Today, the ENSH network is active in more than 20 countries involving more than 1300 hospitals and health care facilities reaching “indirectly” more than one million health professionals. Its materials have been translated into 16 languages and used in different health care settings and countries showing their value and transferability. Evaluations of the projects have shown how ENSH members have obtained better outcomes in tobacco cessation programs and other control activities than non-ENSH members. The coordination office is placed at the Catalan Institute of Oncology in Barcelona (Spain) to assist the regional and national networks and the common

Parallelsessions 5: March 29, 16.00-17.30 161 ENSH initiatives and activities. To promote further involvement of health professionals not only in Europe but also at an international level, ENSH entered into partnership with the International Network of Health Promoting Hospitals & Health Services (HPH). From this partnership a collaborative task force named Tobacco Free United (TFU) was created in 2008. The strategic aim of TFU is to join first the forces of these two international healthcare networks in a way that strengthens links and collaborative activity on tobacco within hospitals and health services. On operative level the task force has three objectives: to develop advocacy tools to support greater personal and corporate engagement of health professionals, to identify and support the transfer of good practice on how to implement tobacco free health care settings and to evaluate the effectiveness of these activities.

Method of the symposium Participants of this symposium will learn how to use the ENSH materials and tools, and how to broaden their national/regional network of Tobacco free health care services. In addition, they will have an opportunity to exchange knowledge, practices and results on implementing tobacco free initiatives within the healthcare setting. To reach these objectives we propose to have two round tables and one forum discussion.

Round Table I: From theory to practice motivational tools and implementations strategies (15’)

Chair: Sibylle Fleitmann, Independent consultant. Speakers: Esteve Fernández / Cristina Martínez, Institut Català d’Oncologia, Spain.

Various tools have been developed by ENSH to facilitate application of the concept: implementation guide and standards, a self-audit questionnaire, a questionnaire to assess hospital staff smoking rates, training guidelines for health professionals, guidelines for tobacco free maternities and psychiatric services. The process is supported by a certification process which consists of four quality levels (membership, bronze, silver and gold) according to the organization’s implementation of the ENSH standards. This process motivates the constant improvement of the tobacco free policy and higher enforcement of the tobacco control initiatives.

The aim of the ENSH Table is to provide a forum for discussion between the developers of the ENSH concept and key stakeholders in different countries, sharing positive and negative experience and ways and means for successful implementation

Ideas and suggestions from the discussion will help to improve the processes of developing, implementing and evaluating tobacco control initiatives in hospitals.

Key points for discussion with the participants (15’) • Overview of ENSH concept– goals, objectives, strategies • Role and functions of the ENSH Coordinating Center • Results from the implementation of the ENSH concept within 20 different countries. • Effectiveness of the reporting process

Parallelsessions 5: March 29, 16.00-17.30 162 Round Table II: Multidisciplinary partnerships and advocacy TFU (Tobacco Free United) (15‘)

Chair: Sibylle Fleitmann, Independent consultant. Speakers: Christa Rustler, Deutsches Netz Rauchfreie Krankenhäuser & Gesundheits- einrichtungen, Germany.

TFU sub-group action on advocacy has developed the TFU Pact and the TFU Charter to promote multidisciplinary partnership action and personal advocacy on tobacco in all healthcare settings and by all health workers. The TFU Pact is designed to recruit signatures of organisations and institutions in support of a comprehensive tobacco free policy on local, regional, national and international level and the TFU Charter aims to gather signatures of individual health worker /professionals to motivate their personal engagement to prevent tobacco use of any kind (including stopping with themselves) and support tobacco users inside and outside health care facilities with particular emphasis on youth in cessation activities. The aim of the TFU Table is to stimulate forum discussion on how these tools can be used to influence policy/decision makers, reach organizations and institutions on corporate level and involve professionals and individual health workers. Key points for discussion: • Overview of the TFU tools (Pact and Charter) • Practical usage of the TFU tools, example in Germany/Ireland

DISCUSSION FORUM (60’)

Chairs: Sibylle Fleitmann and Ann O’Riordan

Participants will discuss how to promote the ENSH model and TFU tools beyond the ENSH- HPH community and their use to support effective implementation of the WHO Framework Convention on Tobacco Control. The session consists of two parts: 1. 4 short presentation of 5’ each to share practice experience 2. Questions and answers - general discussion.

Engaging health professionals in the movement (30’)

• Strategies to engage health workers in local organizations using the ENSH concept: Pauline Kent, Irish co-ordinator from the hospital view. • How to obtain the commitment of existing networks and develop partnership with them: David Chalom, Swedish co-ordinator of the ENSH Network • How to involve key professionals in the health care setting: The role of the • “tabacologist” in France and Belgium, Bertrand Dautzenberg, Groupe hospitalier • Pitié-Salpêtrière, Franc and Jacques Dumont, FARES Belgium. • Transferability of the ENSH concept, example of its usage and application in different countries: Tiiu Härm, Estonian ENSH Network. • Collaborating with other international projects, ENSH Network and the Bloomberg project to develop tobacco-free hospitals, Florin Mihaltan, Romanian ENSH Network.

Discussion Forum Questions that arose during the symposium will be collected and proposed for general discussion in addition to spontaneous questions from the floor.

Parallelsessions 5: March 29, 16.00-17.30 163 Results and Conclusions Findings from the symposium will be published in a consensus document. In addition, these results will be used to help amend and improve the ENSH concept and tools.

Parallelsessions 5: March 29, 16.00-17.30 164 5F - Symposium: Tobacco industry tactics: health policy and the European Union

Chair: Jeff Collin Director, Global Public Health Unit, Social Policy, School of Social & Political Science University of Edinburgh, United Kingdom

Presenters: Silvy Peeters Nathaniel Wanders R. Shirane, Siman Williams, et.al.

This symposium will show examples of the tactics of the tobacco industry in various ways. Whether it is through selling snus on the internet throughout Europe, gentleman’s disagreement between industries or opposing tax policies to prevent the most effective measure to be used.

After an introduction by Jeff Collin 3 presentations will be given: 1st Sales and marketing of snus on the internet: the European Union (EU)

Silvy Peeters and Anna Gilmore

Objective The sale of Swedish snus has been prohibited in the EU since 1992. When Sweden joined the EU a few years later it was granted a derogation of this ban, provided snus would not be placed on the market in other EU Member States. Snus can only be transported legally from Sweden to other Member States if a person travelling across the border takes the snus with them for personal use. However sales over the internet may be undermining the EU snus ban. This research examines the ease of buying snus online within the EU, looks at tax levied on online snus purchases, and explores how the internet is used to promote and market snus.

Methods From May to November 2010 online test purchases of snus were undertaken in 10 EU Member States. The work was coordinated by the University of Bath and colleagues in a purposive sample of 9 other Member States were recruited to undertake test purchases elsewhere. The 10 member states in which we carried out test purchases are: Czech Repub- lic, Germany, Greece, Ireland, Italy, Poland, Portugal, Slovakia, Slovenia, and United Kingdom. Analysis of the test purchases is complemented with secondary online data including snus user forums, YouTube, blogs, and Twitter.

Results In total forty-three purchases were attempted, of which forty-one were successfully made. Two attempts failed because the websites did not accept the buyers’ credit cards. All web retailers distribute snus from Sweden. Our findings indicate that they target non-Swedish customers and that ordering snus online from other EU countries than Sweden is quick and straight forward. The age verification process relies on self-reporting, and tax levied on the orders is not in line with EU Taxation and Customs guidelines for buying excise products over the Internet.

Parallelsessions 5: March 29, 16.00-17.30 165 Furthermore we found that online retailers heavily price-promote their products and use reward schemes to encourage consumers to recruit new business. More broadly, snus and snus use is heavily promoted using viral marketing techniques on internet sites popular with young people such as YouTube, Twitter, blogs etc.

Conclusions Snus can be easily purchased over the internet from Swedish online retailers, contravening the European Commission’s Tobacco Products Directive (TPD) and undermining the EU’s efforts to regulate the marketing of tobacco products. Youth access to snus is a concern as the age verification processes for the online sales rely on self-reporting which is unlikely to deter under-aged buyers. The internet offers new opportunities for the tobacco industry to market snus and snus use and create brand awareness, particularly amongst young people.

2nd A ‘gentleman’s disagreement in Europe: Understanding cooperation and competition between transnational tobacco companies

Nathaniel Wander Senior Research Fellow, Global Public Health Unit, University of Edinburgh. [email protected] Jeff Collin Director, Global Public Health Unit, University of Edinburgh.

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 ‘reasonable regulation’ at international level is significant to understanding the dynamics of tobacco

Parallelsessions 5: March 29, 16.00-17.30 166 policy within the EU. More broadly, such tensions within the industry assumes particular significance in the context of varying national and corporate responses to the WHO Frame- work Convention on Tobacco Control

3rd Pricing Policies and the Control of Tobacco in Europe: The Tobacco Industry in the Czech Republic

Risako Shirane, Katherine Smith, Simon Williams, Hana Ross and Anna Gilmore

Objectives Price is widely regarded as the single most important intervention in tobacco control. Exist- ing evidence indicates that tobacco industry influence over fiscal policy affects the degree to which tax and excise rates can optimise public health outcomes. Despite this, contemporary industry efforts to influence tax policy in European countries remains underexplored. This paper begins to address this gap by examining lobbying strategies used by Transna- tional Tobacco Companies (TTCs) to influence tax structures and rates in the Czech Repub- lic, a European Union Member State with notably weak tobacco control policies and high smoking rates.

Methods Analysis of internal tobacco industry documents triangulated with and expanded upon via 11 semi-structured interviews with key stakeholders. The time frame covered was 1989-2010, which incorporates the period in which the state tobacco monopoly was privatized and the Czech Republic acceded to the EU. A cursory review of 4,785 documents was initially undertaken to select a smaller number of more relevant documents for closer analysis. Using the Legacy Tobacco Documents database (http://legacy.library.ucsf.edu/), operative words such as “AND” “OR” or “NOT” were employed to combine words such as “Czech”, “Czechoslovakia”, “Tax” and “Excise”. A total of 352 tobacco industry documents were included in the final analysis.

Results TTCs lobbied simultaneously, and sometimes collaboratively, to try to keep tax rates low and these efforts appear to have been successful, with rates remaining relatively low (and consumption high). In contrast, industry efforts to influence tax structures were largely taken on an individual basis, with Philip Morris (PM) and British American Tobacco (BAT) each promoting substantially different structures with the aim of maximising their own market share: PM promoted a wholly specific system to benefit its premium brands while BAT advocated the early adoption of a mixed system. Having succeeded in its bid to take over the state tobacco monopoly, PM was initially more influential over taxation policy and dominated the Czech cigarette market during the 1990s. However, the EU accession process later aided BAT’s efforts to change the taxation structure to a mixed system more favorable to its products, enabling BAT to begin to eat into PM’s market share.

Conclusion and Implementation The results of this study shed light on the arguments and strategies used by TTCs in their efforts to influence tax policy and on the rationales underlying different TTC approaches. They highlight how the TTCs may collaborate in lobbying on tax levels but not on structure. The findings will be of relevance to anyone with an interest in tobacco taxation but are likely to be particularly useful for policymakers and health advocates based in other Eastern Euro- pean markets or in countries in which state-owned tobacco companies are being privatized.

Parallelsessions 5: March 29, 16.00-17.30 167 5G - Tobacco taxation – a practical lecture

What In this session the ins & outs of tobacco taxes will be presented. If you want to learn all about tobacco taxation, you should not miss this workshop!

Who Speakers: Hana Ross and Luk Joossens

How This workshop will provide answers on the following questions: • how are tobacco taxes organized • how the are calculated • Why or why not is a reflux from tobacco taxes into a tobacco prevention fund possible • What is the price elastic of a tax increase • Are high tobacco taxes related to smuggling • How to deal with the ministry of finances in order to increase tobacco taxes • Why is tobacco taxed differently than other products • What are the types of tobacco taxes applied on tobacco products • What is the impact of tobacco taxes on tobacco product prices and on tobacco use • Are tobacco products affordable and why is that important for tobacco control • What is the relationship between the tax rate and tax revenue • Is tax revenue affected when there is tax avoidance/evasion

Parallelsessions 5: March 29, 16.00-17.30 168 Parallelsessions 6 Wednesday March 30, 11.30-13.00

6A - Symposium: tobacco additives, FCTC articles 9 & 10 and the EU product directive

Chair: Antoon Opperhuizen, Head of the Laboratory for Health Protection Research, National Institute for Public Health and the Environment, The Netherlands and Chair of the WHO Tobacco Laboratory Network (TobLabNet)

Presenters: R. Talhout M. Poetschke-Langer U. Nair

Articles 9 and 10 of the FCTC concern additives to tobacco products. These guidelines were adopted in Uruguay in November 2010. The tobacco industry lobbied hard against the guidelines, saying that millions of jobs would be lost and economies ruined if countries follow through. But additives in tobacco products can make them more attractive, especially to young smokers. This symposium will discuss relevant developments and evidence on additives. It will also focus on early dependence in young smokers and the recommendations that may be included in the EU product directive.

1st: Overview of evidence and developments concerning additives in tobacco products

Antoon Opperhuizen and Reinskje Talhout National Institute for Public health and the Environment

In various studies and review papers it has been shown that additives have significant impact on the attractiveness of products. Recent report of Health Canada and of the SCENIHR scientific committee of DG SANCO summarized the literature on attractive of tobacco products. Other studies clearly indicate that attractiveness, including taste and smell, of tobacco products is very important for young tobacco users, or potential users. Data reported by industry to various governments show that almost all tobacco products, including cigarettes, cigars, water pipe and chewing tobacco contain large amount of additives. Sugars and other sweeteners are often used in significant quantities. But in addition many products contain tens of other types of additives which are applied by tobacco industry in individual products. Regulation of additives, including options for a ban, is now described in the partial Guidelines of the Articles 9 and 10 of the Framework Convention on Tobacco Control (FCTC). Some countries, like France and Australia, already started regulation of additives before the adoption of the partial Guidelines by the 173 signatories of the FCTC. Even the USA, a non-signatory of FCTC, created a legal

Parallelsessions 6: March 30, 11.30-13.00 169 framework to start regulating additives to tobacco products.

2nd: Improvement of youth and consumer protection by revision of the EU Tobacco Product Directive 2001/37/EC

Poetschke-Langer, M.P.L., German Cancer Research Center, Heidelberg, Germany Schneider, N.K.S., Heidelberg, German Cancer Research Center, Heidelberg, Germany

Objectives The European Commission recently started a public consultation on the revision of the Tobacco Product Directive 2001/37/EC. It will be discussed which further measures should be taken to improve tobacco control as well as the protection of youth, and consumers in general. To contribute to this process, the German Cancer Research Center, the biggest Health Research Center in Germany, suggests recommendations to the European Commission and the European Parliament.

Methods The German Cancer Research Center reviewed the existing Tobacco Product Directive 2001/37/ EC in the light of new findings and research on tobacco marketing, on tobacco additives and the experience with snus, the oral tobacco product used predominantly in Sweden, as only EU Member State where it is allowed. The Center’s researchers in the Unit Cancer Prevention used own expertise and those of external reviewers to suggest recommendations addressed to the EU Commission and the EU Parliament to improve the Directive according to protect youth and consumer health before the hazards of tobacco products.

Results Packages are an important advertising tool for the tobacco industry. Its appealing designs attract consumers and target special groups – in particular young people and women. A standardized package would not only deprive the tobacco industry of an important advertising instrument, but provides a cost-effective means of information for tobacco control.

Additives and flavours not only make tobacco products more appealing – in particular for young people – but they make smoking easier and more addictive. The tobacco industry uses up to 600 different substances such as flavours, humectants, or colorants as tobacco additives. They account for about 10 percent of the cigarette’s weight. In order to better protect youth and adult consumers any additives in tobacco products should be banned.

The marketing of certain smokeless tobacco products is prohibited in the European Union with the sole exception of Sweden. Smokeless tobacco products contain nicotine, cause damage to health , are addictive and may facilitate tobacco dependence of young people. To protect youth and health, the existing ban of smokeless tobacco products in the European Union has to be maintained.

Conclusions Every year tobacco kills more than 650 000 people in Europe. This enormous harm is legitimate reason to introduce all legal measures appropriate to curb tobacco consumption - such as standardized tobacco packaging, a ban of any tobacco additive and to continue the prohibition of smokeless tobacco products and any other new tobacco product

Parallelsessions 6: March 30, 11.30-13.00 170 3rd: Tobacco additives for developing early dependence in youth

Nair, U.J., German Cancer Research Center (DKFZ), Heidelberg, Germany

Tobacco related diseases take a heavy toll in long-term tobacco users. Cigarettes are the only consumer product which when used as directed kills its consumer. The tobacco industry was aware of this fact, and could only profit and survive if the lost consumers are continuously replaced by new ones. Additives have played a critical role in this objective to lure young consumers into this highly addictive web. Studies have shown that young smokers are three times as likely to use flavoured cigarettes as are older smokers. Furthermore, the younger a person at smoking initiation, the higher the likelihood of become addicted to nicotine. The tobacco industry documents clearly reveal that flavoured cigarettes ( mint, choco- late, cola, apple etc.) have been designed to target the youth. Nicotine, the main addictive alkaloid in tobacco results in harsh and bitter tobacco smoke which is not easily accepted by novice smokers. To address this issue the industry adds several additives to modify the flavour, improve the taste and sensation, aimed to make a better smoking experience, especially for young smokers. Besides, familiar flavours are used making the toxic cigarette appear interesting and attractive but not threatening to the young. Other additives are used to mask the heavy irritating effect of smoke that a novice smokers experience. Additives like menthol or eugenol can act as topical anaesthetics or have a cooling effect, resulting in less irritation of throat and upper respiratory passage resulting in easier and deeper inhalation and suppress cough. With an increase in public knowledge of the dangers of second hand smoke, the manufacturers are using additives to mask the smell and visibility of the second hand smoke without actually affecting the toxicity of the smoke. This lulls into complacence not only the smokers but also people surrounding them regarding the continuous toxic exposure to second hand smoke. Recently, some countries have banned flavoured cigarettes, highlighting the importance of tobacco additives in smoking initiation among children and youth. The crucial role of some additives in facilitating tobacco smoke/nicotine delivery in a very organoleptic manner by smoothing, flavouring, masking the irritation of main stream smoke, as well as the visibility and smell of side stream smoke, facilitating initiation in the young, leading to addiction to tobacco will be discussed. In conclusion, additives have been used effectively to target the young resulting in the development of early dependence.

Parallelsessions 6: March 30, 11.30-13.00 171 6B - Symposium: Tobacco taxes dedicated to fund specific programmes, in particular Health

Chair: Frank Chaloupka

Increasing tobacco prices through taxation is the most effective and cost-effective tobacco control measure to reduce consumption. In addition to reducing the burden of tobacco use, tobacco taxes also increase governments’ revenues and their abilities to spend for the public good. Public health advocates have been trying to promote the use of tobacco tax revenues for health purposes in order to correct for the cost imposed by the tobacco burden. The proposed session will go over the experience of two countries and one state in dedicating tobacco taxes for a specific purpose (in particular health). They will explain the process which led to the adoption of the dedicated tax and step back explaining the successes, setbacks and lessons learned from this experience. WHO will also make a presentation about a proposal for high-income countries to dedicate a small amount of taxes on cigarettes to support health in low and middle income countries where resources are scarce.

1st: Earmarking tobacco taxes: the ThaiHealth Promotion Foundation

Prof. Prakit Vathe, ThaiHealth Promotion foundation, Thailand (15 min)

The Thai Health Promotion Foundation was established in 2001 to promote public health. It acts as a catalyst and supports groups and organizations that are already working on public health issues. ThaiHealth is funded with an annual revenue of about US$35 million, derived from 2 percent of the excise taxes on tobacco and alcohol. The foundation has played a key role in the area of tobacco control providing support to develop public policies for tobacco control and enforce tobacco control measures. The foundation’s activities are very wide and touch upon all aspects of tobacco control, including strengthening surveillance, cessation work, media, academia and the civil society in general. The success of the foundation is now a reference for neighbouring countries, which have asked for technical support for establishing similar set up (e.g. Mongolia).

2nd: Earmarking tobacco taxes: the experience of California, USA

Stanton Glantz, Director, Center for Tobacco Control Research and …ducation, University of California San Francisco, USA (15 min)

The State of California’s tobacco control movement is looked at by all countries as an important example of good practice. California has also been among the first to earmark tobacco taxes for health. The California Tobacco Health Protection Act of 1988 increased the state cigarette tax by 25 cents per pack and added an equivalent amount on other tobacco products. The new revenues were earmarked for programs to reduce smoking, to provide health care services to indigents, to support tobacco-related research, and to fund resource programs for the environment. Part of the revenues fund the activities of the California Tobacco Control Program (CTCP) and the California Department of Education (CDE), which have been instrumental in reducing the tobacco epidemic in that State. The presentation will go over the history of the

Parallelsessions 6: March 30, 11.30-13.00 172 fund and will describe the impact of the introduction of this fund on tobacco consumption. 3rd: Earmarking tobacco taxes: the experience of Switzerland

Verena El Fehri, Swiss Association for Smoking Prevention, Switzerland (15 min)

The Tobacco Control Fund of Switzerland was set up in 2004 to finance measures to stop people from starting to smoke, make it easier to give up smoking and protect non-smokers against passive smoking. The fund receives 0.026 francs for each pack sold. This amounts to about 18 million francs a year available for tobacco control. The presentation will describe the contribution of this fund to tobacco control efforts in the country. It will also describe the efforts made by the Swiss Association for Smoking Prevention, along with other partners, to bring this fund on the agenda of politicians and the process that led to its establishment.

4th: Dedicating tobacco taxes to fund global health: a proposal

Anne-Marie Perucic, …conomist, Tobacco Free Initiative, World Health Organization (15 min)

With the challenges raised by the current financial crisis and the risks it represents for the provision of resources for the health sector, developing innovative means of financing is essential to ensure sustainability for low-income countries. Low-income countries could use more revenues from tobacco taxes earmarked to fund health directly. But also high-income countries could raise substantial revenues quickly and efficiently to be used as international aid for health by dedicating an additional 5 US cents per pack of cigarettes. If cigarette excise taxes were increased by 5 US cents per pack in high income countries, this would generate over $4.8 billion USD each year, quite a substantial amount for health aid in low- income countries. The additional 5 US cents per pack would not significantly increase the financial burden of smokers given the relatively high existing taxes and prices in these countries.

Discussion

(30 min)

Parallelsessions 6: March 30, 11.30-13.00 173 6C - Symposium: using FCTC to improve womens’ health

Chair persons: Elizabeth Tamang and Patti White (Chair and Secretary of INWAT …urope Foundation)

Objective To consider the WHO-FCTC from a gendered and women’s perspective. This session is targeted at young women professionals and students with a special focus on Eastern European women. It will illustrate how the industry is targeting women in these countries and how tobacco control advocates could use the FCTC to counteract as well as highlight where countries are lacking and what needs to be implemented. The symposium will consist in 5 presentations which will consider specific FCTC articles with a special focus on how it is being applied from a gendered and women’s perspective with case studies from different countries. A first presentation on Journalism and education efforts in Moldova to expose industry efforts to target young women, with examples of combating marketing to women with counter-Industry activity in Moldova. The second presentation will illustrate how smoking among women is increasing in the Central and Eastern European countries and what can help them to quit. Not the same cessation methods can be effective for both men and women. What needs to be communicated to women in terms of treatment to see what works for them. A third presentation on how Legislation and tobacco control measures have impacted differently on male and female patterns of smoking in Scotland, how children and adults still remain exposed to tobacco smoke in their homes. The need to effectively communicate these findings to policy makers. The fourth presentation is on how the tobacco industry is implementing its market in Russia and how young Russian women are their primary targets. The industry reaches women through all available channels of communication, including any loopholes left by legislation on tobacco advertising bans. The fifth presentation will concentrate on findings from a study carried out in Germany to investigate if the frequency of images and texts referring to tobacco or smoking increased in 6 popular national magazines targetting women and if these images and text references became increasingly positive after the implementation of the tobacco advertising ban in 2007. We hope these presentations will stimulate tobacco control activists, researchers and decision makers to take into account the gender perspective while carrying out any tobacco control interventions or studies. We welcome more researches which can help curb the tobacco epidemic that women all over Europe and specially in Central and Eastern Europe are facing with the new challenges brought on by the Tobacco industries.

1. FCTC Article 12 Public awareness campaign for smoke free policy education and communication

Victoria Tataru, [email protected] Centre of Information, …ducation and Social Analysis “CAPT…S” Director, Republic of Moldova.

Objective To increase the comprehensive understanding of girls and women regarding tobacco control issues through mass media.

Parallelsessions 6: March 30, 11.30-13.00 174 Methods The public awareness campaign “Every day without tobacco. It’s your right!”, organized by the Centre of Information, Education and Social Analysis (CAPTES) in partnership with the Centre for Investigative Journalism (CIN) and Country Office of the World Health Organization in the Republic of Moldova aims to increase women knowledge about the dangers of tobacco use and build adequate capacities to persuade them to become active advocates for effective FCTC and national tobacco control existing legislation implementation.

Results In order to enhance the role of mass media in raising the awareness of women about tobacco control and the need for effective tobacco control policy enforcement, the most attractive written mass-media, radio and TV channels for women from the Republic of Moldova were involved. The main topics addressed to women were concerning smoke free restrictions in public places, working places, public transportation; protection against exposure to secondhand smoke and tobacco industry advertising; other provisions of the FCTC and the national legislation.

Conclusions The informational and investigative materials, developed within the framework of the public awareness campaign, showed that mass media can play a leading role in highlighting the main difficulties of tobacco control related to female population and has identified essential draw- backs of tobacco control in Moldovan legislation, that does not fully comply with the WHO FCTC provisions, especially regarding smoking restrictions, advertising, pictorial warnings, taxes and penalties. Gender aspects of these regulations must be considered as well.

2. Article 14 – Tobacco Cessation from a women’s perspective – keys to success

Magda Cedzynska – [email protected] Director of Smoking Cessation Service Cancer …pidemiology and Prevention Department Cancer Centre and Institute of Oncology

Epidemiological estimates show that annually about 169/100.000 population of adult women from 10 Central and Eastern Europe (CEE) EU Member States 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. There is evidence that both sex (e.g. metabolism of nicotine) and gender (e.g. less confidence in ability to quit) differences may play a role in maintaining smoking and the response to cessation interventions. Numerous studies have established that women have more difficulties in quitting than men and that reason of relapses are different. There is a need to analyse the factors which predispose women to quit smoking, as a prerequisite for designing effective cessation policies.

The aim of this presentation is to show what literature says about effectiveness of different cessation methods (e.g. Nicotine Replacement Therapy) or strategies (e.g. intervention focused on preventing weight gain, exercise, education, social support, self-help programs for pregnant) focused on women.

Parallelsessions 6: March 30, 11.30-13.00 175 3. Title: Article 8 SHS Gender issues and Communicating to policy-makers

Jude Robinson, J.…[email protected] Deputy Director of the Health and Community Care Research Unit, Senior Lecturer in Health Sciences Co-Director of the Centre for Social Research in Health and Medicine http://www.liv.ac.uk/healthsciences/csrhm, …ditor Medical Sociology online (MSo) www.medicalsociologyonline.org

Objectives (i) To explore how tobacco legislation in the UK has influenced the public and home smoking behaviours of men and women and the impact on the exposure to SHS of adults and children in home settings. (ii) To assess the ways in which gendered SHS issues can be effectively communicated to policy-makers.

Methods Qualitative research with men and women in England and Scotland, UK

Results While legislation has significantly reduced smoking in all public places and levels of compliance are high, home smoking remains an issue for some families, with women’s smoking patterns less disrupted than men’s as a result of the legislation.

Conclusions Legislation and tobacco control measures have impacted on male and female patterns of smoking in different ways, and some children and adults remain exposed to tobacco smoke in their homes. These findings should be effectively communicated to policy makers to enable a better understanding of the gendered consequences of legislation.

4. Article 5.3 MARKETING TOBACCO TO RUSSIAN WOMEN

Irina Morozova, Rebecca Perl, Patti White [email protected] Communication Officer World Lung Foundation Moscow, Russia worldlungfoundation.org

Objectives To undermine Tobacco Industries promotion tactics and call for comprehensive TAPS ban.

Methods Research of Russian media environment.

Results Young women are the primary target of tobacco industry in Russia today. This is a promising largely untapped, easily manipulated and emotionally available market segment. This is confirmed by the fact that that Russia’s smoking prevalence among men has almost reached its peak and remains more or less stable during the last decade (over 60%)1. Meanwhile there is a disturbing trend of constantly growing female smoking. Since the collapse of the Soviet Union (the period when the transnational tobacco corporations pushed into the country with their aggressive advertising), the number of female smokers had doubled by 2007.2 Analysis of tobacco industry ATL and BTL activities shows, that they are designed with a clear understanding of the psychology of women and appeal to the values important to women. The image of a smoking ‘cover’ girl and by associating smoking with success, sex

Parallelsessions 6: March 30, 11.30-13.00 176 appeal and fashion. Today female advertising share prevails over male ones.

Conclusions The industry reaches women through all available channels of communication, including any loophole left by anti-advertising legislation. For every partial ban, the industry develops strategies by constantly changing its marketing tactics. Only a comprehensive ban on tobacco advertising, sponsorship and promotion can stop their pratices.

1. Global Adults Tobacco Survey, Russia, 2009 2. Perlman F, Bobak M, Gilmore A, et al. Trends in the prevalence of smoking in Russia during the transition to a market economy. Tob Control 2007; 16:299-305.

5. Article 13 (Ad bans). Impact of the tobacco advertising ban in the print media on the frequency of smoking imagery in women’s magazines in Germany Ute Mons, M.A., Research fellow, German Cancer Research Center, Unit Cancer Prevention and WHO Collaborating Centre for Tobacco Control, Heidelberg, Germany, [email protected]

Objective To investigate (1) if the frequency of images and of text referring to tobacco or smoking in popular magazines increased after the implementation of the tobacco advertising ban in 2007, and (2) if these images and text references became increasingly positive after the implementation of the tobacco advertising ban.

Methods The sample was a convenience sample of six popular German magazines, of which four magazines targeted women only, and two magazines targeted women and men. All obtain- able issues (291 of 300; 97%) between January 2006 and June 2008 were examined, thus the sample covered a period of two years with no tobacco advertising ban and a period of one and a half year with a tobacco advertising ban in place. Two coders did a full text search of all articles and noted the frequency of tobacco advertising and of articles with references to tobacco products, brand names and tobacco use in text or pictures. For each article with references to tobacco in text or images a questionnaire was completed, including questions on form, size, content and appearance and a qualitative assessment of the reference (being pro-tobacco, anti-tobacco or neutral). Linear regression models were calculated to test if a change in frequency of tobacco-related text references or imagery was statistically significant.

Results Overall, between 174 and 193 articles per year (and 112 in the first half of 2008) contained smoking depictions or references to tobacco. The share of articles with pro-tobacco and anti-tobacco connotation both accounted for about 35 to 40%. In four magazines no significant change in frequency of pro-tobacco references over the years was observed, but two magazines showed an increase in the frequency of articles containing pro-tobacco imagery or descriptions. The articles with pro-tobacco descriptions or imagery portrayed smoking as “contemporary, modern and trendy”. And especially in the fashion-oriented magazines, smoking imagery was associated with “beauty, luxury and glamour”.

Conclusion A substantial number of articles referred to smoking or tobacco either in the text or in the

Parallelsessions 6: March 30, 11.30-13.00 177 imagery, and a high share of these were pro-tobacco. As two of six magazines showed significant increases in articles with pro-tobacco depictions or descriptions, the effects of the advertising ban regarding a reduction of the exposure to pro-tobacco and pro-smoking messages in the print media might have been attenuated.

Implementation The FCTC demands a complete ban on direct and indirect marketing of tobacco products, but positive descriptions or depictions of smoking in the media might attenuate the effect of advertising bans. The print media should be sensitized for the potential impact of pro-tobacco imagery especially on young readers.

Parallelsessions 6: March 30, 11.30-13.00 178 6D - Symposium: From conception to delivery - theory and practice of state- of-the-art WATI

Chair: Andrée J. van Emst, STIVORO for a smokefree future, the Netherlands Presenters: Shahab, L., Smit, E.S., Elffedali, I, Selby, PM, Van Emst, A.J

Summary As shown by several recent reviews, web-assisted tobacco interventions (WATI) have great promise for helping smokers wishing to stop. Due to their interactive nature, easy access and world-wide availability, WATI have the potential to revolutionise current treatment for smokers, being able to combine the best of both worlds - the wide reach of minimal, low-efficacy interventions and the efficacy of intensive behavioural, low-reach interventions. However, much remains to be explored in this relatively new field of research concerning the development, implementation and evaluation of WATI to optimise their impact. This symposium draws together several strands of ongoing research into state-of-the-art WATI and aims to present optimal ways for designing evidence-based internet interventions for smoking cessation, targeting potential users and delivering as well as assessing their efficacy.

1st: Development of a web-based intervention to help disadvantaged smokers to stop (‘StopAdvisor’)

Authors: Shahab L, [email protected], Department of …pidemiology and Public Health, UCL, UK Michie S, [email protected], Department of Clinical, …ducational and Health Psychology, UCL, UK Gardner B, [email protected], Department of …pidemiology and Public Health, UCL, UK Geraghty A, [email protected], School of Psychology, University of Southampton, UK Miller S, [email protected], School of Psychology, University of Southampton, UK Yardley L, [email protected], School of Psychology, University of Southampton, UK West R, [email protected], Department of …pidemiology and Public Health, UCL, UK

Background Web-based interventions can be effective in aiding smoking cessation, but often do not reach low income groups.

Objectives To develop an effective web-based cessation intervention that would appeal to lower income UK smokers.

Methods A multidisciplinary research team first reviewed principles for engaging users with internet sites across the social spectrum and identified relevant behaviour change techniques (BCTs) to develop a web-based smoking cessation intervention which draws on a comprehensive theory of motivation. A subsequent iterative process of repeated user testing is underway to refine this prototype intervention to the point of full field testing.

Parallelsessions 6: March 30, 11.30-13.00 179 Results BCTs could be classified into those aimed at (i) boosting motivation to stop and minimising motivation to smoke, (ii) maximising self-regulatory skills and capacity, (iii) promoting effective use of adjuvant activities, and (iv) promoting continued engagement with the site. Using these BCTs, an intervention, StopAdvisor, was constructed which aimed at emulating traditional behavioural face-to-face support programmes. This involves a “tunnelled”, dynamically tailored series of sessions together with easy-to-access information on topics likely to be of interest and use. Qualitative analysis of initial user feedback is ongoing.

Conclusions The design stage has been effective in creating a smoking cessation website suitable for further field-testing.

Funding This study is funded by a joint grant from the NPRI/MRC.

2nd: Two different strategies to recruit smokers for participation in a web-based smoking cessation programme: effects on recruitment rates, sample composition, retention and behavior Authors: Smit E.S, [email protected], Department of Health Promotion, Maastricht, University, the Netherlands Hoving C, [email protected], Department of Health Promotion, Maastricht, University, the Netherlands Cox V, [email protected], Department of Health Promotion, Maastricht, University, the Netherlands De Vries H, [email protected], Department of Health Promotion, Maastricht, University, the Netherlands

Objectives The Internet has recently become a popular venue for delivering smoking cessation interventions. However, it is yet unknown whether the recruitment of smokers for participation in such interventions should also occur online. The present study investigated whether two samples of Dutch adult smokers recruited for participation in an online smoking cessation programme differed as a result of recruitment strategy used.

Methods Two recruitment strategies were used: recruitment via general practices and recruitment via online advertising. To test for baseline differences between the two samples two-sided t-tests and Chi-square tests were conducted. To investigate differences in retention rates at the first (i.e. two days after a set quit date) and second (i.e. six-week) follow-up and to determine whether the two samples differed with regard to reported quit attempts and abstinence, logistic regression analyses were conducted with recruitment method as the independent variable.

Results Via general practices a total of 409 eligible smokers were recruited, of whom 263 (59.8%) remained in the sample at the first follow-up and 210 (47.7%) also completed the second follow-up. Using online advertising 1154 eligible smokers were recruited, of whom 601 (47.8%) and 454 (36.1%) completed the first and second follow-up, respectively. Respond-

Parallelsessions 6: March 30, 11.30-13.00 180 ents recruited via general practices were lower educated, less addicted to nicotine, had a significantly higher intention to quit smoking and to maintain non-smoking, were less often male and more often suffered from cardiovascular or respiratory diseases, than respondents recruited online. Recruitment method significantly predicted retention rates at both first (OR 1.62; 95% CI 1.28-2.04) and second follow-up (OR 1.63; 95% CI 1.30-2.04): respondents recruited via general practices more often completed follow-up questionnaires than respondents recruited online. Moreover, recruitment method significantly predicted quit attempts (OR 1.74; 95% CI 1.29-2.35) and 24-hour point prevalence abstinence (OR 1.55; 95% CI 1.10- 2.16): respondents recruited via general practices more likely reported quit attempts and abstinence than those recruited online. However, the effect of recruitment method on retention and behaviour disappeared when controlling for baseline differences and for baseline differences and experimental condition, respectively.

Conclusions Online recruitment yielded a larger number of smokers participating in an online smoking cessation programme than recruitment via general practices. Recruitment via general practices led to higher retention rates and more smoking cessation behaviour than recruitment via the web. Yet, this appeared to be caused by the two different recruitment strategies attracting different types of smokers. Implementation: The findings suggest that recruitment strategy determines the number and type of smokers participating in an online smoking cessation intervention. Consequently, the choice for a particular recruitment strategy is expected to influence the potential public health impact of such online interventions.

Funding This study is funded by the Dutch Cancer Society

3rd: Testing the efficacy of a smoking relapse prevention program using computer-tailoring with multiple feedback moments.

Authors: Elfeddali I, [email protected], Care and Public Health Research Institute (Caphri) and Department of Health Promotion , Maastricht University, the Netherlands Bolman C, [email protected], Care and Public Health Research Institute (Caphri), Maastricht University,the Netherlands and Department of Psychology, Open University of the Netherlands, the Netherlands Candel M, [email protected], Care and Public Health Research Institute (Caphri) and Department of Methodology and Statistics, Maastricht University, the Netherlands Wiers R, [email protected], Department of Psychology, University of Amsterdam, 1018 WB Amsterdam, the Netherlands De Vries H, [email protected], Care and Public Health Research Institute (Caphri) and Department of Health Promotion, Maastricht, University, the Netherlands

Objective To date, many smoking relapse-prevention programmes have only modest behavioural effects. This study tested the efficacy of a smoking relapse prevention program targeting explicit cognitions using computer tailoring with multiple feedback moments after the quit attempt. The program is called Stay Quit for You (SQ4U!) and consisted of a baseline tailored advice targeting factors postulated as important for behavioral change in the I-Change Model, six diary assignments regarding preparatory planning and coping planning before

Parallelsessions 6: March 30, 11.30-13.00 181 and after the quit-date, and multiple feedback moments targeting self-efficacy, planning and negative affect after the quit-attempt.

Methods Participants (N=2700) were randomized into one of the three conditions: 1. control (measurements only), 2 experimental condition with baseline advice and diary assignments, 3. experimental condition with baseline advice, diary assignments and multiple feedback moments after the quit-attempt.

Results The results at six months (N=715) after baseline showed no significant differences between the three groups. However, after including implementation level (number of diary assignments made or feedback moments received) the results showed that the number of assignments and feedback moment predict smoking abstinence at six months and that these two factors strengthen each other. Additional analyses will be conducted to reveal when the experimental conditions become more effective than the control condition.

Conclusions In conclusion it can be said that diary assignments and multiple feedback moments are important components in the process of smoking relapse prevention and that more research is needed in the predictors of implementation level (what causes participants not to make the assignments or receive the feedback).

Funding This study is funded by the Dutch Organisation for Health Research and Innovation (ZonMw)

4th: Web enrollment and self assessment for NRT- feasibility and quit rates

Authors: Selby P, [email protected], Departments of Family and Community Medicine & Psychiatry and the Dalla Lana School of Public Health, University of Toronto, PI Ontario Tobacco Research Unit, and the Centre for Addiction and Mental Health, Canada Zawertailo L, Addictions Program, Centre for Addiction and Mental Health, Assistant Professor, Dept. of Pharmacology and Toxicology University of Toronto, Canada Hussaein S, Addictions Program, Centre for Addiction and Mental Health, University of Toronto, Canada Dragonetti R, Tobacco Control Projects, Nicotine Dependence Clinic, Addictions Pro- gram, Centre for Addiction and Mental Health, University of Toronto, Canada

Objective To define the quit rates of smokers using WATIs to access free NRT.

Methods We offered NRT for 5 weeks to motivated smokers in Ontario who wanted to quit by enrolling them on line where they completed a brief assessment. The NRT was mailed with free access to a quit line and WATI. Follow up was conducted at 5 weeks and 6 months first by e-mail followed by telephone if they did not respond to three e-mail attempts.

Results Over a 10 month period, 6,689 individuals (43% male; age 40 +/- 12years of age) enrolled on line were mailed NRT. At end-of-treatment, 3048 completed follow-up (a 45% response rate)

Parallelsessions 6: March 30, 11.30-13.00 182 with self-reported 7-day point-prevalent quit rate of 27.6% (95%CI:26.0, 29.2). At 6-month follow-up 2,353 participants responded (a 35% response rate), with a 7-day point-prevalent quit rate of 24.5% (95%CI: 22.7, 26.2). Using Intent to Treat analysis whereby all survey non- respondents are assumed to be smoking, the end of treatment quit rate was 12.6% and the 6-month quit rate was 8.6%.

Conclusion These quit rates are comparable to telephone and in-person methods of that offer behavioural intervention.

Implementation This study demonstrates that web-based smoking cessation studies ensure wide reach and ease of recruitment with little to no decrease in effectiveness. The costs and staffing associated with this method are minimal and can increase the use of WATIs by motivated smokers.

Funding This study is funded by Ministry of Health Promotion, Government of Ontario

5th: How to to find the StopSite: Search engine optimisation as a way to reach more people.

Authors: Van Emst A.J, [email protected], STIVORO for a smokefree future, the Hague, the Netherlands Fotiadis L, [email protected], STIVORO for a smokefree future, the Hague, the Netherlands

Background Although Web-based interventions can be effective in aiding smoking cessation, it is not easy to reach smokers on the internet. The ‘StopSite’ is a Dutch interactive website for smokers who want to quit, but as there is not much money to promote the site it is not easy for smokers to find it on the Internet.

Objectives To get the StopSite higher in rankings of search engines (e.g. Google) by way of a search engine optimisation (SEO) process

Methods In six months a SEO process was developed and evaluated to get the StopSite higher in search results of search engines. In this way more people can get enrolled in the StopSite. At first keyword research was done to find the words to focus on in the seo process. Based on this words it was analysed how easily the StopSite could be found, based on keywords like: smoking cessation, withdrawal symptoms, tips for quitting etc. Also the position of possible ‘competitors’ (i.e. acupuncture, pharmaceutical industry) was analysed before starting the SEO process. This process included new pages, based on the keywords selected. After the process was completed we got back to the original pages again to find out if the results could really be attributed to this SEO process.

Results After completing the SEO process it was found that the StopSite was found in the 3-40 first search results of Google (depending on keywords used), while before the process the StopSite was not found in the top 100 results (all words). Also the percentage of people who

Parallelsessions 6: March 30, 11.30-13.00 183 found the StopSite by using a search engine increased from 4 to 24%, and dropped to 11% after removing the new pages based on the SEO process.

Conclusion By doing a search engine optimization, a website can be found easier. This is important for implementing Web-Assisted Tobacco Interventions.

Funding This study is funded by the Dutch Organisation for Health Research and Innovation (ZonMw)

Parallelsessions 6: March 30, 11.30-13.00 184 6E - Session Youth and cessation

6E.1 Use and Acquisition of Nicotine Replacement Therapy Products among Adolescents - the Case of Finland

S.U. Raisamo, H. Huhtala, A. Rimpelä University of Tampere, TAMP…R…, Finland

Objectives There is limited evidence on the use and acquisition of nicotine replacement therapy (NRT) products in adolescence. In Finland, deregulation releasing the NRT products for general sale took place in 2006. The sale is prohibited to those under the age of 18. This study examined use, acquisition and awareness of NRT products one year after deregulation in a nationally representative sample of 12-18-year-olds.

Methods Nationwide mailed survey, the Adolescent Health and Lifestyle Survey, (N=5,840, response rate 61%) conducted in 2007. The main outcome measures were ever-use of NRT, acquisition of NRT products in different locations (retail outlet, family member, friend, health care personnel, pharmacy), and awareness of NRT. 18-year-olds were analyzed as a comparison group as they were at legal age to buy the products.

Results Among 14-year-olds, 2% of boys and 2% of girls had used NRT. The corresponding figures for 16-year-olds were 7% and 5%, and for 18-year-olds 10% and 8%. Few 12-year-olds had used NRT. Over a quarter of 12-year-old girls and 15% of boys did not know what NRT products were. Awareness increased with age. Of 12-16-year-old NRT users, 79% were daily smokers, 10% had smoked >50, but not daily, 10% had smoked <50, and 2% were never-smokers. The under-aged NRT users acquired the products mainly from friends (42%) but also from retail outlets (13%).

Conclusions One year after deregulation of the NRT product sales in Finland, NRT use among under-aged adolescents was uncommon. Also misuse seems rare. The overall awareness of NRT products was high, particularly among older adolescents. NRT products are sold to minors from retail outlets despite sales ban. However, the under-aged NRT users acquired the products mainly from friends.

Implementation Future research is needed to monitor the population-based changes in the long term in the use and the acquisition of NRT products in the adolescent population.

Funding This work was financially supported by the Ministry of Social Affairs and Health, Finland, the Academy of Finland (grant number 130481), the Competitive Research Funding of the Pirkanmaa Hospital District (grant number 9L084) and the Juho Vainio Foundation, Finland.

Parallelsessions 6: March 30, 11.30-13.00 185 6E.2 Prescribing of nicotine replacement therapy to adolescents in England

E. Langley, A. Lewis, M. McNeill, T. Coleman, Y. Huang, C. Szatkowski University of Nottingham, NOTTINGHAM, United Kingdom

Objectives In the UK, nicotine replacement therapies (NRT) are licensed for the relief of nicotine withdrawal during smoking cessation, and became available on prescription from the National Health Service in April 2001. Initially, safety concerns regarding the use of NRT by adolescents resulted in inconsistencies in the product information for NRT products, with most contra- indicating or not recommending their use by under-18s. In December 2005, based on a small number of studies providing evidence of the efficacy and safety of NRT in adolescents, the licensing arrangements were changed such that all forms of NRT can now be used by smokers aged 12 to 17 years. We have used data from The Health Improvement Network (THIN), a database of UK electronic primary care records, to explore patterns in NRT prescribing for adolescents in England between January 2002 and June 2009, and to estimate the effect of the licensing change.

Methods We identified all patients aged between 12 and 17 registered in THIN each month during the study period and calculated monthly rates of prescribing of NRT to adolescents by age (12-13, 14-15 and 16-17 year-olds). We examined trends in prescribing in each age group and carried out an interrupted time series analysis using segmented regression to estimate the effect of the broadening of the indications on prescribing of NRT to adolescents.

Results Prescribing of NRT to 14-17 year olds increased until 2006 before levelling off. Prescribing was highest in 16-17 year-olds, levelling off at around 100-150 prescriptions per 100,000 patients per month, with no change in the level of prescribing when the indications were broadened. By contrast, prescribing to 14-15 year olds increased by 19 prescriptions per 100,000 patients per month in the first month after the change in indications (p<0.001). There was no statistically significant change in the level of prescribing in 12-13 year-olds.

Conclusions The licensing change might have been expected to lead to an increase in prescribing to adolescents. In the context of national estimates of smoking prevalence in this age group, however, it is evident that rates of prescribing to adolescent smokers remain low. Recent changes in licensing arrangements appear to have had a limited effect on rates of prescribing, with rates reaching a plateau in older adolescents, and a small increase in prescribing in 14-15 year-olds. This suggests that factors other than the licensing change influence prescribing of NRT to adolescents in England.

Implementation Using NRT is less harmful than continued smoking. Further research is therefore required to understand why there is a low rate of prescribing of NRT to adolescents in the UK despite the licensing change, and how access to NRT might be improved for young dependent smokers in the future.

Parallelsessions 6: March 30, 11.30-13.00 186 6E.3 Short term effects of a smoking prevention and cessation program: the ‘Smoke Alert’ study

H.P. Cremers, L. Mercken, F. Dijk, H. De Vries Maastricht University, MAASTRICHT, The Netherlands

Objectives While smoking prevalence among Dutch adolescents shows a decline in the last decade, smoking remains a public health problem. Smoking prevention and cessation programs are important to reduce the early onset of smoking and in this way prevent potential harm to youngsters. The present study examined the short-term effects of a computer-tailored smoking cessation and prevention program in the Netherlands, focusing on the quit rates of smoking adolescents.

Methods Forty-two schools were randomly assigned to either one of the two intervention conditions (Letter or Internet condition) or the control condition, within the ‘Smoke Alert’ study. After completing the online questionnaire at baseline, only adolescents in the intervention condition received a tailored advice. This same procedure was repeated after 6 months of follow-up. The questionnaire as well as the tailored advices included information about adolescent smoking status and factors related to smoking based on the I-Change Model.

Results A multilevel (logistic) regression analyses was performed, using 3 levels (class, school, and the individual) to evaluate the effects of the intervention on quit rates among 470 smoking adolescents (mean age= 16.7 years). The intervention was significantly more effective for the Internet condition compared to the control condition (OR: 1.77; 95% CI: 1.07-2.91), resulting in a quit rate of 26.8%. Furthermore, the participants in the Internet condition showed a decrease in nicotine dependency after six months (decline from 2.54 to 2.25 on nicotine dependence scale). No other differences were found between the conditions.

Conclusion This study indicated that the computer-tailored cessation intervention is an effective method to help adolescents to quit smoking. Providing personal feedback through (personalized) letters did not result in higher quit rates than giving no personal information. Given the benefits and effectiveness future computer-tailored interventions better provide Internet advices instead of letter advices.

6E.4 Reach, acceptance, feasibility and cessation rate of a teen smoking cessation program

S.F. Floeter1, A. Schmidt1, L. Wegmann1, J. Thrul1, A.B. Bühler1, M. Strunk2, P. Lang2 1IFT Institut fuer Therapieforschung, MUENCHEN, Germany 2Federal Centre for Health Education (BZgA), KOELN, Germany

Objectives The risk of developing nicotine dependency in adulthood is increased by an early onset of smoking. Therefore smoking adolescents represent an important target group for smoking cessation. However, up to now only few smoking cessation programs are specifically geared to adolescents and their needs within the cessation process. Based on a systematic survey of established theories, latest studies and scientific literature a new smoking cessation

Parallelsessions 6: March 30, 11.30-13.00 187 program for adolescents was developed on behalf of the Federal Centre for Health Education. The objective of the project is to examine the reach, feasibility, and acceptance of this new youth specific smoking cessation program and to find a connection between personality traits (impulsivity/ depression) and behaviour change through the program.

Methods In a pilot study the new program was conducted at four schools. Data concerning acceptance and smoking behaviour were collected by standardized questionnaires. Reach and feasibility of the program were documented by the trainers. Subsequently, in a nation wide feasibility study the program was offered at 30 schools, 23 courses were realized. The standardized questionnaires were supplemented by items concerning personality traits.

Results In the pilot study 4 courses were conducted. Depending on school type, 30 to 40% of smoking pupils were reached. Of consented participants (n = 30), 100% completed the program until the end-of-treatment. At the end-of-treatment 36,7% of participants had quit smoking, the rest of participants had reduced smoking. At the end of aftercare 4 weeks later the quit rate still was 36,7%. Results of the feasibility study (n=139 participants) show a retention rate of 75% and cessation rate of 30% after six sessions and 25% at end of after care (Intention-to treat-analysis). Effectiveness of smoking cessation is moderated by impulsivity of participants but not by depressive mood.

Conclusion The problem of reach and retention in adolescent smoking cessation can be attenuated by genuine youth-oriented concepts. The notion of differential effectiveness depending on personality traits is discussed.

6E.5 Smoking and adolescence: exploring tobacco consumption and related attitudes in a Swiss population

M. Maggiori, M. Bosson, C. Gay, M. Gygax University of Fribourg, FRIBOURG, Switzerland

Objectives This experiment is a part of a longitudinal research called “Relevance of health warnings on cigarette packages: A psycholinguistic investigation”originally created to study cognitive processes of health warnings and develop strategic health warnings targeting young smokers and non-smokers. In this present study we were interested to get a new descriptive regard of adolescents’ smoking attitudes and related risky behaviors in a Swiss population aged from 14 to 18 (N=279). The main purpose of this study was to identify factors that would explain adolescent’s probability of smoking in regard to attitudes such as attitudes towards smoking, beliefs and risk perception about smoking behavior. This study was supported by the Tobacco Prevention Office (part of the OFSP, Switzerland).

Methods In our experiment adolescents had to fill in a questionnaire on smoking habits and socio- demographic measures which was administrated to all adolescents. The first part of the questionnaire was aimed at examining alcohol consumption, smoking habits, beliefs about smoking or not in the future, motivation to quit smoking, future risk of smoking, beliefs about smokers and sport practice. The second part was based on the Attitudes towards smoking scale (Etter, Humair, Bergman & Perneger, 2000), The Need for Cognition questionnaire

Parallelsessions 6: March 30, 11.30-13.00 188 (Cacioppo & Petty, 1986), The BIS/BAS scale (Carver & White, 1994) and the Social Desir- ability Scale (Crowne & Marlowe, 1960).

Results In logistic regression analysis, taking into account smoking status as the dependent variable and different social, environmental and personal variable, the variable that remained significant were Pleasure to smoke and Perception of negative effects (ATS) and alcohol consumption and frequency of drunkenness (p < .01). Comparing smoker and non-smoker on beliefs about health risks of smoking and social influences, analyze of variance showed a higher perceived short-term risks on personal health and fewer smokers in family among non-smokers adolescents. Among smokers (n = 41) significant correlations indicated that daily number of cigarettes smoked is positively associated with smoking after awaking, still smoking in five years and psychoactive effects (ATS) and negatively with ability to modify the smoking habits and to quit smoking.

Conclusions and Implementations Concerning predictors of smoking in adolescence, we need to take into account social, environmental and personal factors, as attitudes towards smoking, beliefs and risk perception about smoking habits. Moreover, these results raise question about preventive intervention should remain focused on specific behaviors or rather on adolescent’s life-style behaviors (i.e. alcohol consumption and drunkenness) as a whole.

Parallelsessions 6: March 30, 11.30-13.00 189 6F - Workshop The ‘ins’ and ‘outs’ of digital media: using the Internet and cell phone technology to communicate with your tobacco control audiences

What Facebook, Twitter, hyves, LinkedIn, YouTube and other Internet sites are gaining larger audiences daily, while more and more people globally are using cell phones in an increasing variety of ways. Social media and other forms of digital media should be an integral part of tobacco control media campaign strategies. How?

Who Speakers/facilitators: Becky Freeman & Karen Gutierrez

How In this workshop, the speakers will explain what Twitter, Facebook and other relevant social media are, how they work and in what ways they can help you in reaching and influencing your target groups. Ways in which the tobacco industry are using these technologies, as well as lessons learned from digitally-based tobacco control campaigns, will also be shared. Participants will discuss experiences to date and what digital campaign strategies appear to be most promising. Not more than 25 persons can attend this practical workshop.

Parallelsessions 6: March 30, 11.30-13.00 190

Poster presentations

Monday March 28 Policy related poster presentations

Tuesday March 29 Interventions related poster presentations

192 Monday March 28 2011 Policy related poster presentations

Topic 1: WHO Framework Convention on Tobacco Control (FCTC): challenges of implementing the FCTC guidelines at the national level

Topic 2: Scientific evidence for effectiveness of tobacco control policies

Topic 3: Experience with tobacco control in national contexts, with special focus on smoking bans, and point of sale bans - case studies

Topic 4: Tobacco industry document research

Topic 5: Product regulation - additives, new products, e-cigarettes

Topic 6: The tobacco pack: from pictorial warning to plain packaging

Topic 13: Harm reduction approaches: moving beyond fixed positions

Topic 14: The economies of tobacco control: cost-effectiveness studies, economic benefits, earmarking of tax revenues

Topic 15: Monitoring and surveillance of tobacco control progress

Topic 17: Successes or failures in the tobacco control advocacy

193 Topic 1: WHO Framework Convention on Tobacco Control (FCTC): challenges of implementing the FCTC guidelines at the national level

1.1 Tobacco control through physicians in health care service

V.F. Levshin Russian Cancer Research Center, MOSCOW, Russian Federation

Objective One of the main positions of the FCTC guidelines is to promote cessation of tobacco use. This position is especially urgent for Russia. The purpose of the study is to explore smoking rates among physicians and their awareness about tobacco control methods and to evaluate the effect of the special program aimed to encourage and to train physicians for smoking cessation counseling among patients.

Material and methods Two cross-sectional surveys were conducted among Moscow physicians using the standardized self-administered and anonymous questionnaire before and two years after the program implementation in Moscow region. The program to encourage and to train physicians for smoking cessation assistance among patients includes at first stage one-hour educational session provided for health professionals in outpatient and inpatient clinics. This session aims to educate and to motivate medical staff of clinics concerning smoking health hazards and smoking cessation assistance. At second stage the one-day smoking cessation training course have been provided for physicians who decided to visit such course. The purpose of the course is to teach and to train physicians for skilled smoking cessation assistance. Manual for physicians “Stop smoking assistance for your patients”; have been published in 3000 copies and distributed among medical community.

Results First survey were conducted before the program implementation and included 395 physicians ( 96 men and 299 women). Overall 44,2% men and 16,7% women currently smoked, 22,1% men and 9,4% women were former smokers. The proportions of physicians who answered that they as a rule ask patient about smoking and advise them to stop smoking were among current smokers, former smokers or those who never smoked correspondingly 33%, 54% and 64%, P<0,01. It is noteworthy that majority of all examined physicians (71%) could not also name any method of smoking cessation assistance. The control survey conducted in two years after the program implementation includes 637 physicians (191 men, 446 women) and revealed definite positive changes concerning physicians tobacco control knowledge and activity. The percent of current smokers among physicians decreased to 30% for men and 12% for women. Notably more physicians give their patients recommendation to stop smoking: 45% among current smokers, 59% among former smokers and 70% among those who never smoked, p<0,01. At the second survey 56% of asked physicians could name any method of smoking cessation assistance.

Conclusions There is a critical need for the creation and implementation of continually working program

Poster presentations: Topic 1, Monday March 28 194 and methods to encourage and to train physicians for smoking cessation assistance among their patients. The education and training program for Moscow physicians facilitate short- and long-term changes in health professional attitudes and behaviors concerning tobacco control and smoking cessation assistance.

1.2 The FCTC Implementation Questions in National Tobacco Control Legislation

T. Peikrishvili, G. Bakhturidze FCTC Implementation and Monitoring Center in Georgia, TBILISI, Georgia

Objective To learn correlation between the FCTC obligations and Georgian national legislation, particularly with tobacco control legislation. To find ways, terms and conditions for implementing the FCTC in national tobacco control legislation.

Methods Analyzing Georgian national legislation in tobacco control and authentically confirmed text of the FCTC.

Results During last 10 years formed some legislation basis in tobacco control in Georgia. There were created law on advertisement, Act of President regarding tobacco control activities, law on licensing of tobacco production, law on agriculture and tobacco, law on tobacco control. There are some questions in tax and administrative code regarding tobacco taxation and penalties for violation of tobacco control legislation. Ministry of Health of Georgia prepared draft changes in national legislation on the provisions of the FCTC and which was adopted in Dec 2008. From this law right now we have restrictions of smoking in all closed buildings and prohibition in medical, educational, sport, cultural facilities and public transport. Regarding smoking restrictions in restaurants there should be designated min 50% of places for non smokers. Law regulates of adding of health warnings on pack of cigarettes, which should cover 30% of both display areas. But we’ve no good experience of execution of smoking restrictions in public places. There is needed creation of effective system for implementation of concrete measures through administrative violations code. One of the serious steps to implement the FCTC in Georgia is to promote prohibition of all forms of advertisement during the next one year. Right now we have ban of ads through TV and Radio (Since April 2003).

Conclusions Harmonization and implementation level of the FCTC in national tobacco control law is very low in Georgia.

Implementation There are needs to follow the FCTC obligations and end implementation of all requested questions during next year, because Georgia is a member of this treaty since May 15, 2006.

Poster presentations: Topic 1, Monday March 28 195 1.3 Challenges of implementing the provisions of the FCTC Article 6 and Article 5.3 in Ukraine

K. Krasovsky1, T. Andreeva2 1Ukrainian Institute of Strategic Research of the Ministry of Health of Ukraine, KIEV, Ukraine 2School of Public Health, KIEV, Ukraine

The FCTC includes provisions both on tobacco taxation policy (Article 6) and on protection of public health policy from vested interests of tobacco industry (Article 5.3). In March 2009 the parliament of Ukraine voted for doubling tobacco excise rates starting from May 1, 2009. Tobacco industry opposed the tax increase, claiming that it would cause huge increase of cigarette smuggling to Ukraine, decline of legal tobacco production and eventually decline of public revenues, while population tobacco consumption would not decrease.

Objectives To study forecasts of the tax increase consequences from both tobacco industry and public health experts and compare them with real results.

Methods Media monitoring, governmental statistics data and survey results were used.

Results Smuggling. Tobacco industry claimed that after tax increase smuggled cigarettes would constitute 30-50% of tobacco consumption in Ukraine. Within the Global Adult Tobacco Survey (GATS), conducted in Ukraine at late 2009 - early 2010, respondents were asked to present a cigarette pack from the pocket. 98.5% of presented packs had Ukrainian health warnings, so cigarettes, smuggled to Ukraine, constituted not more than 1.5% of the national market. On the other hand, GATS results revealed that only about 70 billion cigarettes were consumed in Ukraine in 2009, while the legal sales were 112 billion cigarettes. It means that about 40 billion cigarettes, legally sold in Ukraine, were illegally moved out of the country. Production. Tobacco industry claimed that cigarette production in 2009 would decline by 30-50% compared to 2008, while public health experts said the decline would be only 8-13%. The real decline was 12%. Revenues. Tobacco industry claimed that governmental revenues in 2009 would not increase or the increase would be rather moderate, while public health experts said in 2009 the revenues will increase to 9 billion UAH compared to 3.5 billion UAH in 2008. The real tobacco excise taxation revenues in 2009 were 9.06 billion UAH. Smoking prevalence. Tobacco industry claimed that smoking prevalence would not decrease after tax increase, while public health experts estimated that tax and price increase would lead to smoking prevalence decrease by 5%. According to the governmental household survey smoking prevalence in 2009 was 23.5%, while in 2008 it was 25.6%, so the decline was 2.1 percentage points or 8%.

Conclusions Tobacco industry forecasts of tobacco tax increase consequences in Ukraine in 2009 revealed to be wrong. Tobacco taxation policy should be protected from vested interests of tobacco industry.

Implementation Model, used by public health experts in Ukraine to forecast consequences of proposed tobacco tax increase, could be used in other countries to counteract tobacco industry forecasts and provide solid economic arguments to governments.

Poster presentations: Topic 1, Monday March 28 196 1.4 Tobacco Control Scale scores in the EMRO Countries

G. Heydari1, L. Joossens2 1Tobacco prevention and control research center, T…HRAN, Iran 2Framework Convention Alliance, G…N…VA, Switzerland

Introduction According to the World Health Organization Framework Convention on Tobacco Control (FCTC) each country is held responsible for adapting and implementing effective tobacco control programs. Comparing the situation in different countries could not only shed light on their conditions compared to each other, but also motivate and stimulate them to implement and improve their tobacco control programs and strategies.

Materials and Methods A cross-sectional observational study using questionnaire based on WHO MPOWER guidelines was developed. A scoring system based on the Tobacco control scale methodology was used with total score of 100 in 6 major policies. Information about countries was also collected from the WHO report and the Tobacco Atlas 2009 and the World Bank report of 2008.

Results Among 21 Eastern Mediterranean countries, only 3 countries (14.2%) mainly Iran (61), Jordan (55) and Egypt (51), scored higher than 50. Mean score for countries were 29.7±3.6 points. More than 50% of the countries scored less than 26. Highest scores were achieved by Afghanistan in cigarette pricing, Oman in smoking ban in public places, Iran in budgeting, prohibition of advertisement and health warnings against smoking and Yemen in tobacco cessations programs.

Conclusion Countries in the EMRO region lack the ideal conditions for tobacco control and the related authorities are required to make changes and amendments in their policies for achieving desirable results.

1.5 Status of the Smoking Cessation and its Costs in Eastern Mediterranean Countries in 2009

G. Heydari Tobacco prevention and control research center, T…HRAN, Iran

Background Among the basic responsibilities of health care institutes in various countries is treatment of tobacco dependence. Methods applied have different costs and do not affect all people the same. Treatment is influenced by local environment and culture as well as individual interest and needs. This study was designed with the purpose to address the situation with smoking cessation efforts and its expenditure and to provide basis for future studies and implementing tobacco control programs across countries in the region.

Materials and Methods This was a cross-sectional observational study prepared succeeding the third Intergovernmental negotiation body3 in regards to illicit tobacco trade protocol of the framework convention on tobacco control in July 2009 in Geneva, Switzerland. The study was in form of questioning participating country representatives from the Eastern Mediterranean region who were

Poster presentations: Topic 1, Monday March 28 197 all either focal point individual or expert in tobacco control programs. Information needed included methods for tobacco cessation, cost of services including counseling by primary physician or specialist, gum or nicotine patch, Zyban, champix and other practices were collected.

Results In 10 countries (47.6%), smoking cessation programs and counseling was directed by primary physicians. Also, 8 countries (38%) provided services through specialists. In 13 countries (61.9%), nicotine gum and in 14 countries (66.7%) nicotine patch is accessible in pharmacies. In 6 countries (28.6%), Zyban (Bupropion 150 mg) and in 7 countries (33.3%), Champix (Varnicline 1 mg) are available at pharmacists with written prescription. The mean costs of each service were higher than a pack of cigarette significantly.

Conclusion In countries with support services for tobacco cessation, directors need to provide care at society level, less costly and accessible for every body and in countries where such programs have not been initiated, it is recommended that effort to do so occur.

1.6 Prevalence of smuggled and foreign cigarette use in Tehran, 2009

G. Heydari1, L. Joossens2 1Tobacco prevention and control research center, T…HRAN, Iran 2Framework Convention Alliance, G…N…VA, Switzerland

Background Iran is one of two main target markets for tobacco smuggling in the WHO’s Eastern Mediterranean Region. Iran has a local tobacco monopoly but there is high demand for international brands. Informal reports show about 20% of cigarette consumption is smuggled. This pack survey study is the first in Iran to gather information on use of smuggled cigarettes.

Methods Randomized cross-sectional household survey, Tehran 2008-09 of 1540 smokers aged 16-90 (83% male), including interviewer checking of cigarette packs.

Results 20.9% of cigarettes were smuggled; 61.1% preferred foreign tobacco; 6.7% of domestic branded cigarettes were smuggled. There was no significant difference between consumption of illegal cigarettes by sex. (Fisher exact test P=0.61) Use of smuggled cigarettes higher among young ages (P=0.01)

Conclusion Gravity towards illegal cigarettes is high and implementing tobacco control programs and informing the laws and licensing are needed

Poster presentations: Topic 1, Monday March 28 198 1.7 Development of FCTC Implementation Guidelines: Methods used for Art.12 and the need for harmonisation

N.K.S. Schneider1, A.E.O.O. Ogwell Ouma2 1German Cancer Research Center, H…ID…LB…RG, Germany 2WHO Regional Office for Africa, BRAZZAVILL…, Congo

Objectives The WHO Framework Convention on Tobacco Control is the first public health treaty negotiated under the auspices of the World Health Organization (WHO). The development of implementation guidelines offers extensive possibilities to governments, public health researchers, educators and advocates, but the work processes were not yet described. Although these guidelines do not have the same force of international law, as do conventions and protocols, they are a result of consensus among the Parties with international commitment to address the recommendations in the guidelines. We aim at unveiling the methods used.

Methods We assessed the guideline development process between 2007 and 2010 using the Art.12 guidelines as a case study and triangulated them against existing literature and other guidelines.

Results The guidelines were developed following a system of feedback loops, including the key facilitators, external experts, the working group and the Parties to the Convention. In 2007, 4 key facilitators and 26 partner countries volunteered to participate in the working group. The working group met in Berlin 2008 and Istanbul 2009 to discuss an outline and develop draft guidelines in cooperation with experts and civil society. A progress report was presented and adopted by the 3rd session of the Conference of the Parties in 2009. The draft guidelines were made available to all Parties through a protected website and all Parties were invited to send comments on the draft guidelines. All comments received, were duly considered and incorporated by the key facilitators. Where comments were not identical or leaned towards different directions, the key facilitators developed compromise positions, which included most aspects of the proposed changes. The final draft guidelines were presented for discussion and adoption to the 4th session of the Conference of the Parties (COP4) in November 2010. A comparison of the three draft guidelines presented at COP4 revealed the need for further harmonization.

Conclusions Although the work process was mainly based on the experiences on the Art. 8 guidelines and complemented by the experiences of the other working groups, every working group had different approaches, structures and working methods. A meeting on cross-cutting issues brought all key facilitators of the intersessional working groups together in 2009 to develop a common structure for the future. Although much progress was made since COP3, the guidelines to date are still inconsistent in style and scope. Streamlined and harmonised guidelines will be necessary to ensure their success in assisting parties in the implementation of FCTC on national level.

Implementation Ongoing communication between civil society, researchers and policy makers is crucial to make best use of limited resources and develop research-based guidelines leading to successful FCTC implementation and the exchange of best practices on national level.

Poster presentations: Topic 1, Monday March 28 199 1.8 Health benefits attributable to a reduction in environmental tobacco smoke exposure after new regulations

B.M. Van Gelder1, H.C. Boshuizen1, R.M. van der Meer2, T.L. Feenstra1 1RIVM, BILTHOV…N, The Netherlands 2STIVORO, the Dutch expertise centre for Tobacco Control, TH… HAGU…, The Netherlands

Objectives Exposure to environmental tobacco smoke (ETS) may cause a variety of health effects. In the Netherlands, several tobacco control activities to reduce exposure to ETS were implemented since 2004. However, to our knowledge data on the impact of changes in ETS exposure on health in the Netherlands are lacking. The objective of this study is to estimate the health benefits caused by a reduction in ETS exposure among non-smokers since 2004.

Methods Changes in ETS exposure since 2004 were based on annual questionnaires from the Dutch expert center on tobacco control (STIVORO) about exposure and disturbance among non- smoking men and women (aged 15 years and over). Meta-analyses of available cohort studies were used to estimate disease risks from ETS exposure. To estimate the health benefits attributable to the observed reduction in ETS exposure, the Population attributable risk (PAR) for passive smoking will be computed.

Results Literature shows strong evidence that exposure to ETS increases the risk of lung cancer and heart disease by 20-30%. Since 2003, experience of ETS disturbance from tobacco smoke from other persons decreases every year with 6%. From 2005, exposure to ETS decreased at several locations (like work, restaurants, cafÃ©s, shopping centers, sports canteens and community centers). No differences in ETS exposure were found at home, at schools and in sport accommodations.

A forementioned information will be combined to estimate the potential health benefits attributable to a reduction in ETS exposure. During the conference the first results of these analyses will be presented.

Conclusion The current study will present first estimates of possible health benefits due to reductions in ETS exposure since 2004 in the Netherlands. While it remains difficult to disentangle effects of regulation and autonomous trends in exposure, a clear decrease in exposure was observed, enabling to find the related health benefits.

Implementation Still a sizeable part of the population reported ETS exposure in locations other than their house, which points at further options for a reduction of ETS exposure.

Poster presentations: Topic 1, Monday March 28 200 1.9 Adopted smoke-free legislation in spite of tobacco industry’s resisting tactics

N.L. Lazarevic1, S.K. Krstev2, A.J. Jovicevic3, S.U. Ukropina4 1Ministry of Health of the Republic of Serbia, B…LGRAD…, Serbia 2Institute of Occupational Medicine of Serbia, B…LGRAD…, Serbia 3Institute of Oncology and Radiology of Serbia, B…LGRAD…, Serbia 4Institute of Public Health of Vojvodina, NOVI SAD, Serbia

Background Serbia is European country with high smoking prevalence (33.6%) and very high exposure to second-hand tobacco smoke (SHS) (45% at work; 72% of children in public places and 77% at home). To decrease the burden of tobacco related diseases Government adopted in 2007 Tobacco Control Strategy based on WHO FCTC, ratified in Serbia in 2006. Protection from exposure to SHS is a high priority measure, since non-comprehensive Law on Ban on Smoking in Enclosed Premises, enacted in 1995, was poorly implemented.

Policy measures Continuous campaigns on harmful effects of exposure to SHS, running from 2007, prepared the ground for introduction of the new smoke-free law. In 2009, when the Ministry of Health (MoH) prepared Draft Law on Protection from Exposure to Tobacco Smoke, completely in line with Guidelines for implementation of Article 8 of the WHO FCTC, public support to 100% smoke- free policy was 75%.

Tobacco industry’s tactics Some of the tobacco industry’s tactics to undermine adoption of 100% smoke-free law were: intimidation of hospitality sector; engagement of front groups and media to create doubt about evidence on the health effects of SHS and effectiveness of smoke-free policies; establishment of so-called “Public initiative - protection instead of ban”; public events aimed at crushing support to 100% smoke-free law; collecting citizens’ signatures to support tobacco industry’s draft legislation “designed to protect human rights”; writing “Proposal of the Law on Ban on Smoking in Enclosed Public and Working Premises”and submitting it to the Parliament by front group “Public initiative - protection instead of ban”; negotiations with the government.

Effects of tobacco industry’s actions Tobacco industry’s law proposal, submitted by front group “Public initiative - protection instead of ban”, was rejected by the Parliament, based on MoH’s arguments. However, due to the direct pressure from tobacco industry the proposed 100% smoke-free law was weakened. Chance to strengthen it back in the Parliament by lobbying with parliamentarians and proposing amendments was missed due to dearth of civil society organizations able to advocate and put pressure. Finally, in May 2010, Parliament adopted Law on Protection from Exposure to Tobacco Smoke with some exceptions and voluntary smoking restrictions for restaurants and bars. Full implementation will start in November 2010.

Conclusions Although adoption of 100% smoke-free law in Serbia was undermined by the tobacco industry, decisive implementation of the new Law on Protection of Citizens from Exposure to SHS should enable 100% smoke-free in most of the working and public places. Evidences gained on the effectiveness and benefits of 100% smoke-free environments along with collected evidences on non-effective voluntary measures in restaurants and bars should be used by governmental and civil society to advocate for a comprehensive 100% smoke-free law.

Poster presentations: Topic 1, Monday March 28 201 1.10 A Systematic Review of Published Research on Pictorial Tobacco Warning Labels

M. O’Hegarty1, L.L.P. Pederson2, A.M.M. Malarcher1, M.A.T. Tynan1, S.B. Bailey3, J.A.F. Francis1, K.M.S. Snyder3 1Centers for Disease Control and Prevention, ATLANTA, United States of America 2McKing Consulting Corporation, ATLANTA, United States of America 3Oak Ridge Institute for Science and …ducation, OAK RIDG…, United States of America

Objectives Conducted a systematic review of published research from 1990-2010 on pictorial tobacco warning labels on cigarette packs. Pictorial warning labels incorporate a picture, graphic image, pictogram, or photograph (or a combination of these elements) that provides information on the health effects of smoking or ways to quit smoking.

Methods 20 databases, containing data from 1990-2010 and 2,233 potentially relevant citations were identified. Two scientists from the Centers for Disease Control and McKing Consulting Corporation independently examined the articles for inclusion and the review resulted in the identification and ordering of 305 articles. Five additional CDC researchers assisted with the review of articles. Teams of two CDC scientists independently abstracted relevant information from each article onto coding sheets and met to review their findings and reach consensus on discrepancies. A total of 39 articles addressed pictorial warning labels. There were 40 unpublished documents and government reports identified. Of these, 12 were relevant and included in the review. Each of the 39 published articles and 12 unpublished and government reports were coded for: author, date, study location, study design, mode of data collection, study population, study variables that were measured, major study findings (i.e. prevalence estimates, proportions, odds ratios) and comments on the quality for the study (international articles were included).

Results Pictorial warnings were associated with promoting interest in quitting, educating smokers about the health effects of tobacco, providing information on assistance for quitting, attracting attention of smokers, increasing beliefs about risks associated with smoking, increasing knowledge about exposure to secondhand smoke, decreasing cigarette consumption, leading to actions that may result in cessation (i.e. call a quitline), recall of labels, and avoidance of labels.

Conclusion Warning labels on tobacco products provide a cost effective health communication strategy. Knowledge of health effects and risks of tobacco use can be improved after viewing pictorial labels; these improvements lead to changes in intentions concerning tobacco use and in behavior that can lead to cessation.

Implementation Labels should be distinct and include graphics that depict pictures and messages that evoke emotionally negative responses such as disfigurement caused by pathologic destruction or radical therapies for tobacco related conditions. A program for developing, testing, rotating and revising the labels should be part of the implementation and ongoing management, as well as a plan for evaluations. Regulations need to specify both the timing of tobacco industry compliance with labeling and retailer compliance with sales of products that display the new warning labels. In the United States, full implementation of new labels on tobacco products can occur within a 12 month time period.

Poster presentations: Topic 1, Monday March 28 202 1.11 Malaysia Schoolchildren’s exposure to Secondhand Smoke (SHS) and its association with asthma symptoms

E. Zainal Abidin1, S. Semple1, A. Omar2, H. Abdul Rahman3, S. Turner1, J. Ayres4 1University of Aberdeen, AB…RD……N, United Kingdom 2Institute of Medical Research, KUALA LUMPUR, Malaysia 3Universiti Putra Malaysia, S…RDANG, Malaysia 4University of Birmingham, BIRMINGHAM, United Kingdom

Objectives To measure salivary cotinine concentrations among schoolchildren in Malaysia following recent partial smoke-free restrictions and to examine associations between asthmatic symptoms, parental-reported smoking habits, home smoking restrictions and exposure hours to secondhand smoke (SHS).

Method A cross-sectional study in Kuala Lumpur and Negeri Sembilan, Malaysia involving 1050 schoolchildren aged 10 to 11-years old from 24 schools.

Results The geometric mean (GM) salivary cotinine concentration for non-smoking schoolchildren was 0.46 ng/ml (95% CI 0.42 to 0.50). Schoolchildren who were reported not to be exposed to SHS at home had salivary cotinine GM of 0.37 ng/ml (n=469). Parental report of child exposure to >4hours SHS at home was associated with a significantly higher cotinine concentration (0.68 ng/ml (n=90; F=12.501, p<0.0001). Schoolchildren living in households with no smoking restrictions in place had the highest salivary cotinine (GM=0.76 ng/ml; n=68). For households that allows smoking in the common room and those with full smoking restriction, salivary cotinine concentrations were 0.51 ng/ml (n=219) and 0.44 ng/ml (n=670) respectively. A significant difference in salivary cotinine was observed between children from homes with no smoking restrictions and full smoking restriction (F=3.527, p=0.03). Among schoolchildren with doctor-diagnosed asthma (DDA) (n=259), none of the self-reported symptoms were significantly associated with salivary cotinine except for speech disturbed while wheezing (0.36 ng/ml vs 1.52 ng/ml; t-value=3.156, p=0.002). Among boys, symptoms of dry cough at night (with and without DDA) and speech disturbed during wheeze (among boys with DDA) were significantly associated with higher cotinine concentrations (0.46 ng/ml (n=390) vs 0.73 ng/ml (n=42); t-value=2.078, p=0.042 and 0.37 ng/ml (n=42) vs 1.22 ng/ml (N=8); t-value=3.359, p=0.002 respectively). None of the asthma symptoms were found to be associated with salivary cotinine concentrations among girls.

Conclusion Schoolchildren’s salivary cotinine concentrations reflected parental reported smoking conditions in the home with duration of SHS exposure and household smoking restrictions. A marker of severe asthma (speech disturbance) was associated with salivary cotinine. Although none of the other self-reported asthma symptoms were associated with exposure to SHS.

Implementations Home smoking restrictions need to be promoted and targeted within Malaysia in order to protect the 50%+ of children who live with a smoking adult.

Poster presentations: Topic 1, Monday March 28 203 1.12 European citizens’ initiative for a European Directive on smoke free environments

N. Radu-Loghin, F.G. Grogna …uropean Network for Smoking and Tobacco Prevention - …NSP, BRUX…LL…S, Belgium

Article 8 of the WHO Framework Convention on Tobacco Control (FCTC), signed in June 2003 by all WHO members, and so far ratified by 171 Parties, including the European Community and 26 of its Member States, creates a legal obligation for its Parties to adopt and implement in areas of existing national jurisdiction as determined by national law and to actively promote, at other jurisdictional levels, the adoption and implementation of effective measures to protect people from exposure to second-hand tobacco smoke in all indoor workplaces, public transport and indoor public places and, as appropriate, other public places.

The Second Conference of the Parties to FCTC in July 2007 adopted guidelines on protection from exposure to tobacco smoke to assist Parties in meeting their obligations under Article 8 of the Convention.

European Council Recommendation on smoke-free environments (2009/C 296/02) hereby recommends to the member states to provide effective protection from exposure to tobacco smoke in indoor workplaces, indoor public places, public transport and, as appropriate, other public places as stipulated by Article 8 of the WHO Framework Convention on Tobacco Control (FCTC) and based on the annexed guidelines on protection from exposure to tobacco smoke adopted by the Second Conference of the Parties to FCTC.

As we are certainly aware many Member States have already taken action to reduce this burden of ill-health, however these actions vary greatly in scope and nature. There is no uniform or comprehensive protection for citizens / workers in the European Union as regards exposure to Environmental Tobacco Smoke.

On the other side the Treaty on European Union introduces a whole new dimension of participatory democracy alongside that of representative democracy on which the Union is founded. It reinforces the citizenship of the Union and recognizes every citizen’s right to participate in the democratic life of the Union. It enshrines the key standards of civil dialogue to which the institutions must live up to and codifies the Commission’s existing practice of carrying out broad public consultations. And, above all, it introduces an important innovation in the democratic functioning of the Union by providing a citizens’ initiative right whereby one million citizens may invite the Commission to bring forward certain legislative proposals.

Is it, now, the right time to initiate a citizens’ initiative for a European Directive on smoke- free environments?

If YES, ENSP can coordinate this action at European level!

Poster presentations: Topic 1, Monday March 28 204 1.13 Particulate matter measurements in Swiss restaurants: Effect of spatial separation between smoking and non-smoking areas

C.K. Kooijman Swiss Lung Association, B…RN 14, Switzerland

Background and Objective Worldwide, a variety of non-smoking policies have been implemented for public places. In Switzerland, four different smoking regulations can be encountered in hospitality venues within a relatively small geographic area: i) complete smoking bans, ii) designating of smoking and non-smoking areas in the same room, iii) separating smoking and non-smoking rooms, and iv) no restrictions. The impact of such regulations on ETS exposure levels is still unclear.

Methods We performed 124 measurements of particulate matter (PM2.5) in 95 hospitality venues. We compared PM2.5 concentrations between venues with different smoking regulations, taking relevant characteristics of the venue into account, such as the type of ventilation, the presence of additional PM2.5 sources and outdoor fine particle concentration. In particular, we evaluated the effect of different types of spatial separation between smoking and non- smoking areas within the same venue on PM2.5 levels.

Results In non-smoking venues with a complete smoking ban, the geometric mean PM2.5 level was 20.4 µg/m_. In venues with smoking restrictions, geometric mean PM2.5 levels were 56.5 µg/m_ in non-smoking areas and 119.0 µg/m_ in smoking areas. In venues without smoking restrictions mean PM2.5 concentration was 98.5 µg/m_. PM2.5 levels in non-smoking areas that were located in the same room as smoking-areas were 75.6 µg/m_. Even if the non-smoking areas were spatially separated into two rooms in the same venue, geometric mean PM2.5 levels were still considerably increased compared to entirely smoke-free venues (52.2 µg/m_ vs. 20.4 µg/m_).

Conclusions Significantly increased PM2.5 levels were found in non-smoking areas if smoking was allowed anywhere in the venue. This study shows that spatial separation of smoking room does not effectively protect non-smoking areas from ETS.

1.14 Influence of smoking cues in movies on explicit and implicit smoking cognitions among children

K.C. Lochbuehler1, R.H.J. Scholte1, J.D. Sargent2, S. Pieters1, R.C.M.E. Engels1 1Radboud University Nijmegen, Behavioural Science Institute, NIJM…G…N, The Netherlands 2Dartmouth Hitchcock Medical Center, L…BANON, NH, United States of America

Objectives Experimental research has shown that short exposure to movie smoking affects smoking cognitions in adolescents. The aim of the present study was to test whether the exposure to smoking cues in movies has an immediate effect on children’s explicit and implicit smoking cognitions. We expected that children who are confronted with smoking characters in a movie segment have more favorable cognitions towards smoking than children confronted with non-smoking characters.

Poster presentations: Topic 1, Monday March 28 205 Methods In two experiments, a total of 206 children (8-11 years old) were exposed to either a cartoon or family movie and randomly assigned to 20-minute segments with or without smoking characters. Explicit (questionnaire) and implicit (stIAT) smoking cognitions were assessed after watching the movie.

Results The majority of both samples of children had very negative cognitions regarding smoking. Exposure to movie smoking had no effect on any explicit or implicit smoking cognition in either experiment.

Conclusions Movie smoking exposure from cartoon and family oriented movies had no immediate effect on explicit and implicit smoking cognitions in young children. This could be due to a floor effect, in which young children are very cognitively resistant to social influence prompts. It could also be due to lack of salience of movie smoking prompts from cartoons and family oriented movies.

Implementation As previous studies showed that the cumulative exposure to movies with smoking cues influences smoking initiation among adolescents, further research is needed to examine underlying mechanisms of this association. Understanding the underlying mechanisms of this effect allows improving the prevention of early smoking initiation in children and adolescents.

1.15 Relevance of health warnings on cigarette packages: a psycholinguistic investigation

M. Maggiori, M. Bosson, C. Gay, M. Gygax University of Fribourg, FRIBOURG, Switzerland

Objectives Smoking prevention most often targets youth population. However little is known about how youth process warnings labels and how we could improve their impact on adolescents smoking behaviour. Based on a longitudinal experiment, we investigated the mental representation that adolescents build when reading tobacco warnings in order to improve them. In a previous research (Gygax, Bosson, Gay & Ribordy, 2010), we showed differences between the age groups and between smoking experiences in the sensitivity to tobacco warnings. For example, 7th grade students seemed to be sensitive to messages with high severity. 9th grade were seemed sensitive to image and smokers of this age were more sensitive to short-term messages focused on health. This study was supported by the Tobacco Prevention Office (part of the OFSP, Switzerland).

Methods In our experiment, 7th, 9th and high school students (N=279) filled three times the same questionnaire on demographics, health beliefs, attitudes towards smoking and exposure to tobacco. Before completing the questionnaire the second time, participants were presented with a tobacco warning previously identified as extremely salient to them (i.e., Gygax et al., 2010).

Results If we expected changes in health beliefs and attitudes towards smoking due to the messages

Poster presentations: Topic 1, Monday March 28 206 read, the results showed that other variables related to the particularities of these age groups (i.e., alcohol consumption,...) were mostly interfering with the messages, resulting mainly in a only slight or absent changes in the different attitudes we measured.

Conclusion and Implementation This experiment presents how health prevention could gain from psycholinguistic concepts without neglecting others personal and environmental variables. This approach could complete others by taking into account the initial mental processes that may lead to attitude changes in healthy behaviours.

1.16 Improving quality on tobacco-free policies in healthcare services - evaluation of ENSH Germany.

C.R. Rustler1, S.M. Mühlig2, M.N. Nehrkorn1, J.S. Sahling1, A.N. Neumann-Thiele2, G.T. Teumer2, E.B. Bothen2 1…NSH Germany, B…RLIN, Germany 2Technical University Chemnitz, CH…MNITZ, Germany

Objective According to the code of the ENSH-Global Network for Tobacco Free Health Care Services their members commit to take an important role to reduce tobacco smoking in patients and staff. A 10 point standard and peer review process for quality evaluation certificates in Bronze and Silver, and international recognition on Gold Level supports the implementation of this code. The ENSH Network Germany establishing was funded by the Ministry of Health and started one year after Germany ratified the Framework Convention of Tobacco Control in 2005. A member survey was conducted in 2010 to evaluate the quality of the network organization, the acceptance of the tobacco regulations and implementation of cessation services in different hospital settings. The results will be presented in relation to the requirements of the FCTC implementation Article 12 and Article 14.

Methods The member survey (N = 181) by Technical University of Chemnitz was conducted as an online questionnaire (78 items), which included following aspects: acceptance of tobacco control by staff and patients, the status of implementation of tobacco policy measures, tobacco cessation services, qualification of cessation providers, evaluation of the certification process and other support needs.

Results over two third (67,4 %) of network members participated in the survey. Nearly 60% hold one of the certificates (43% Bronze, 17% Silver), two hospitals achieved the international GOLD Level. Membership in the ENSH Germany is seen predominantly as a useful (eg information extraction: 86,4% Visibility: 70%). Different cessation interventions are implemented (Motiva- tional Interviewing: 46,7%; brief intervention: 44,8%; individual therapy sessions: 44,8%), in 61,5% of hospitals with medical support. Brief intervention is offered primary by physicians (62,8%), nurses (51,2%) and psychologists (51,2%), based on guidelines in 39% of clinics. Significant better quality in all areas is seen in silver and gold certified hospitals and with increasing duration of membership.

Conclusions The Code is widely accepted and implemented consistently. Shortcomings still exist with regard to evidence based practice, train-the-trainer skills and follow-up which is mainly due

Poster presentations: Topic 1, Monday March 28 207 to missing financial support and lack of time. However,the results of the survey show that the ENSH concept strengthen the role of health care services in the implementation of the FCTC in a structured and self administrated way supported by regional and national network exchange.

1.17 Proven performance and shared good practice. Results of the implementation of ENSH in Germany

C.R. Rustler1, M.N. Nehrkorn1, J.S. Sahling1, A.B. Batra2, S.M. Mühlig3, S.F. Fleitmann4 1…NSH Germany, B…RLIN, Germany 2University Hospital Tübingen, TÜBING…N, Germany 3Technical University Chemnitz, CH…MNITZ, Germany 4Independent Consulting Tobacco Control, DORTMUND, Germany

Background The German Network of Health Promoting Hospitals has initiated a German Network of Tobacco Free Hospitals based on the code and standards of the ENSH-Global Network for Tobacco Free Health Care Services. The implementation of the ENSH concept aim to strengthen the important role in tobacco control of health services according to the FCTC requirements on practical level and evidence based. The ENSH standards and self audit, the participation in the network and a peer review on certification levels support performance quality and sustainable improvement.

Objective In two pilot projects funded by the German Ministry of Health, a coordinating centre was established and over 300 hospitals and health care services joined the ENSH network in Germany. Partners for implementation were identified and the concepts and material were distributed in national and regional conferences and workshops. The second project focused on the implementation of the concept in psychiatric hospitals, implementing tobacco cessation and training in brief intervention. The evidence of the implementation of the standards is reviewed in the certification process on Bronze, Silver and Gold level.

Methods An active network, setting oriented support, training and a standardised process for the certification based on peer review is implemented and evaluated.

Results Over 300 hospitals and health services participate in the ENSH Germany. Partners on professional and political level support the implementation. Data of a member survey in 2010 show significant higher quality in all standard criteria of silver and gold certified hospitals and with increasing duration of membership. Hospitals incl. mental health services working towards a tobacco free organisation. Tobacco cessation services are implemented in all hospitals. Hospitals reported that the ENSH membership and certification process was supportive for the quality improvement in health promotion and tobacco control. The results show clearly that the ENSH network supports the implementation of FCTC requirements on organizational, professional and national level. The methods, experiences and results of the implementation and certification process will be presented.

Poster presentations: Topic 1, Monday March 28 208 1.18 Approach to monitoring, ensuring transparency and denormalization of industries posing threat to public health

K. Demin, D.I.A. Demina, A. Demin, A Demin Russian Public Health Association, MOSCOW, Russian Federation

Our comprehensive approach to monitoring, ensuring transparency and denormalization of tobacco industry in Russia for public health benefit, support of WHO FCTC process envisages collection and analysis of data on: a. how the industry emerged as a public health threat in Russia, developed world and globally; b. assessment of harm, including public health, economic and other dimensions; c. structure and functioning of the industry, including relevant vital processes, such as production, distribution, export/import/smuggling, economic aspects, etc. of product posing a public heath threat; d. promotion by means of advertising, ATL and BTL, and relevant violation and circumvention of legislation; e. promotion by means of Government Relations activities of the industry and impact on legislation and other regulation; f. promotion by means of penetration in the private business organizations and using these for the tobacco industry benefit; g. promotion by means of penetration in the civil society organizations, charitable programs; h. promotion by means of use of expert community and research organizations; i. vulnerabilities of the industry; j. recommendations how the industry could be regulated for the public health benefit. This kind of analysis has been completed for tobacco industry in Russia in 2010, and was received with great interest in Russia and other CIS countries by legislators, executives, business community, civil society and research organizations, because public health approach to development and regulation of an industry posing public health threat has not been attempted before, and little is known about industry and its impact.

Collection and analysis of information, including internal industry documents, was implemented in 2009-2010 with support from IUTLD managed grant from Bloomberg Global initiative.

Among findings: emergence of Russia as the platform for global operations of the leading foreign tobacco industry companies; suspension of public health surveillance of imported raw materials at the Russian border; regional distribution of tobacco production and economy, concentrated almost exclusively in Saint-Petersburg and Leningradskaya Oblast , and to minor extent, Moscow city; dependence of budgets of two former regions on tobacco money; documented industry impact on decision making at the State Duma and Federal Govern- ment; large scale professional industry marketing research of minors; industry sponsorship of Moscow police; mass media, including ‘Health’ magazine; identification of numerous industry frontgroups and allies; cooperation with Ministry of education, etc.

Tobacco war against Russia is in full swing: 43, 9 million Russians smoke, 400 thousand die prematurely every year; foreing industry controls 93% of volume production; Russia is the 2nd largest source of tobacco smuggling; industry spends on promotion 10% of profits, or 2 bln USD annually; Russians spend 3% of GNP on tobacco.

We believe that our approach could be used for analysis of other industries posing public heath threat such as alcohol, junk food, gambling, unhealthy fashion, energy drinks, etc., for public health benefit.

Poster presentations: Topic 1, Monday March 28 209 1.19 Promotion of the Implementation process of the WHO Framework Convention on Tobacco Control in Kyrgyzstan

C.H. Bekbasarova1, M. Karataev1, M. Kasimova2, A. Toktalieva2, D. Bakash2 1Ministry of Health of the Kyrgyz Republic, BISHK…K, Kyrgyzstan 2Public Health Protection Foundation, BISHK…K, Kyrgyzstan

Despite strong resistance from the tobacco industry, Article 11 of the Kyrgyz Tobacco Control Law (TCL) mandates to implement pictorial warning since April 1, 2008 for implementation of Framework Convention on Tobacco Control (FCTC). According of TCL each cigarette package must contain the health warning in the state and official languages occupying not less than 40 % (52% including 3mm of black frame ) of main space on front and back sides as a text heading, drawings and/or pictograms.

However, the political changes in Kyrgyzstan during 2007-2010 created a favourable environment for the tobacco industry, leading to significant increase of strong tobacco lobby in Kyrgyzstan which resisted implementation process of FCTC, especially for implementation new pictorial health warnings by support of partners in the Government, including in Health system. Developed and approved during 2007-2008 9 pictorial health warnings for implementation Articles 11 FCTC and national tobacco control law by 2 Orders of the Ministry of Health of the Kyrgyz Republic (KR) were canceled both times

The following activities were carried out during 2008-2010 years for the promotion of the Ministry of Health activities for readopting and implementation pictorial health warnings in Kyrgyzstan: 1. Evidence-based education among Kyrgyz policymakers to increase their knowledge: 10 intersectoral and around table meetings at the national level among policymakers, the National conference “Tobacco or Health”on December 18, 2008. The Resolution of the - National forum was published in the newspaper were distributed among Parliamentarians, Governmental policymakers, 3 Students conferences, 4 Health Professional workshops and trainings; 2. Mass media campaigns for increasing population’s knowledge: 10 Press-conferences, 45 Publications in newspapers, Filming and Broadcasting of the 15 different video clips, 9 Audio clips, 20 TV programs and debates, Online and telephone hotlines for smoking cessation; 3. The informational and educational guidelines, bulletins for Policymakers: were developed, published and distributed in the Kyrgyz and Russian languages 12 different booklets on tobacco health warnings, Collection of the normative acts (2008, 2010), Monograph “Economic Fundamentals of National Policy and Strategy for Regulation, Control and Reduction of Tobacco Products Use”(in Russian), 4 different Bulletins for Policy-makers, 15 press releases etc. 4. The evidence based actions to build support for implementation: evidence based re search, actions, collection of Student and Health Professional petitions to new President of the Kyrgyzstan in 2010.

Unfortunately, implementation of new pictorial health warnings was not readopted by Octo- ber 29, 2010. Promoting of readopting of pictorial health warnings by Government including executing of development of the petitions, collection of signature among Health professionals and members of the National Coalitions “Smoke Free Kyrgyzstan”for support of implementation pictorial warnings in the Kyrgyzstan are continuing still.

Poster presentations: Topic 1, Monday March 28 210 1.20 Exposure to movie smoking in European adolescents: The impact of Hollywood movies versus European movies

E.A.P. Poelen Radboud University, NIJM…G…N, The Netherlands

Objectives An increasing number of studies show that exposure to smoking in movies is related to young people’s smoking (Dalton et. al., 2003, 2009; Sargent et. al., 2007). These effects have primarily been studied in the United States, with the exception of recent German research. Therefore, we do not know how strong the effects of exposure the movie smoking are in many European countries. The majority of the movies seen by European adolescents are produced in Hollywood, still a reasonable part is produced in a European country (for example about 20% of the films seen by adolescents in the Netherlands is of Dutch origin). It is not clear whether portrayal of smoking in Hollywood movies is related to smoking in European adolescents and if it is more influential than smoking portrayal in European movies. The objective of this study is to asses whether exposure to movie smoking is related to smoking in European youth, in addition, we will examine whether European adolescents are to the same extent affected by movies produced in the United States versus movies of European origin.

Methods Data of the EU funded study “Smoking in Movies”were used. Participating countries are Germany, Iceland, Italy, the Netherlands, Poland and the United Kingdom. In total 16,554 adolescents with a mean age of 13.7 years participated in the fist measurement wave of this study (beginning of 2010). Participants in all six countries filled out questionnaires on their smoking behaviour. In order to assess adolescents’ exposure to smoking in movies recent popular movies were rated for scenes containing tobacco and smoking. In the questionnaires adolescents filled out, for a random personal selection of 50 rated movies, whether they had seen the movie, in this way an exposure measure was calculated for each participant. Multilevel analyses will be conducted as data are nested within country.

Results en conclusions Results and conclusions will be presented and discussed.

Implementation If we find that smoking portrayal in movies produced in the United States is more strongly related to adolescent smoking than smoking in European movies, an implication might be that parents are made more aware of the potential detrimental impact of smoking in US movies.

Poster presentations: Topic 1, Monday March 28 211 Topic 2: Scientific evidence for effectiveness of tobacco control policies

2.1 Population’s attitude toward Tobacco control policy in Georgia

D. Bakhturidze1, G. Magradze2 1FCTC Implementation and Monitoring Center in Georgia, TBILISI, Georgia 2Tobacco Control Alliance in Georgia, TBILISI, Georgia

Objectives This study is the first multi-component survey that gives us a real picture regarding smokers’ behavior and the Georgian population’s attitude toward the tobacco control policy. The survey would assist us to promote forming the appropriate tobacco control policy in our country.

Methods This study analyzed relevant theories and research conducted in the past few years. Survey data collection was conducted in the summer of 2009. The sampling was carried out by using stratification and two-stage procedure (clustering). The observation units were households and their members aged 13-70 years. The sample size was determined as 1605 households (Fowler, 2002). Three thousand two hundred and seventy-nine people (1494-Male and 1785-Female) were interviewed. This is a descriptive study; we describe the population’s answers to our basic questions.

Results Two out of three Georgian men (65%) and one out of five Georgian women (19%) are current smokers. As we learnt from our survey, the majority of the Georgian population (68%) perceived that they were exposed to SHS on a daily basis and understood it to be harmful to their health. On average, 72% of male smokers and 76% of female smokers reported a desire to quit smoking. This proportion is substantially higher in younger age groups and declined with the age. The majority of the population (87%) supported (agree or strongly agree) a ban on tobacco advertising in the print media, on billboards, sponsorship and other forms of advertisement; this support was more frequently expressed by non-smokers, ex-smokers, older age groups, and poorer sections of the population. Nearly half of smokers (49%) thought it is necessary to increase tobacco taxes and 14% felt there was no need to change current taxes on tobacco products. Male smokers (26%) could be expected to smoke many more cigarettes in response to a price increase than women (12%).

Conclusions Different studies have found that partial bans of tobacco advertising have no effect on sales. The ideal approach to estimating the effects of comprehensive bans is an econometric model, which would hold constant all other factors that affect consumption, such as price, income, and other economic or cultural variables.

Implementation There is a need for public health information/communication campaigns and appropriate strategies. Public opinion will assist public health advocates to promote a total ban on sponsorship of tobacco products in Georgia.

Poster presentations: Topic 2, Monday March 28 212 2.2 Implication of GYTS results to youth oriented tobacco control policies and programes in Republika Srpska

S.S. Stojisavljevic Public Health Institute, Republika Srpska, BANJA LUKA, Bosnia-Herzegovina

Objective Identification of basic factors that contribute to development of smoking status among school children and youth in the Republic of Srpska and making recommendations based on results for policy and tobacco control programs oriented towards young people.

Methodology The GYTS in the Republic of Srpska is designed as a cross study of school population sample comprising 59 elementary and secondary schools, out of 60 selected schools. In order to obtain a representative sample of respondents the double cluster selection method was used. In the first phase, 60 schools were selected according to probability proportional to the size of a school while in the second phase classes were selected randomly within the previously selected schools. Research instrument was a self-administered questionnaire. Participation in the survey was voluntary and anonymous. Students themselves filled in the questionnaire, which consisted of 80 questions relating to prevalence of smoking, evidence of tobacco addiction, the presence of information about the harmfulness of smoking in the school curriculum, smoking, involuntary exposure to tobacco smoke, exposure to tobacco advertising and access of tobacco products to minors. Statistical software SUDAAN and EpiInfo 2000 were used for data processing and calculating the sample size, the value of factors in the database, standard errors and estimates of prevalence. Statistical differences are defined in regards to the rank of 95% accuracy interval (95% CI).

Results The total number of students responded to the questionnaire was 6141, or 93.66%. 37.1% of respondents tried smoking at least once or experimented with cigarettes. 41.6% of the students who had experimented with cigarettes did it before they turned 10 years. 66.8% of smokers buying cigarettes in stores, regardless their age. 56.3% of the students have heard about the harmfulness of smoking in school. 81.6% of students have stated that they are exposed to tobacco smoke in public places.

Conclusion The frequency of consumption of tobacco and tobacco products among school age children aged 12-16 years is worrying. GYTS survey results should be used for the creation and implementation of comprehensive tobacco control measures, with emphasis on developing specific programs for this population group.

Key words Youth, Smoking, Environmental tobacco smoke, Access, Tobacco control

Poster presentations: Topic 2, Monday March 28 213 2.3 The Design and Implementation of an on-Campus Tobacco Control Program in Taiwan

P. Yu1, W. Perng2, H. Chiou3, S. Chiou4, K. Chao4, T. Feng4 1Department of Health, TAIP…I, Taiwan 2Tri-Service General Hospital, TAIP…I, Taiwan 3Taipei Medical University, TAIP…I, Taiwan 4Bureau of Health Promotion, TAIP…I, Taiwan

Objectives To construct high-quality, smoke-free campus environments, the Bureau of Health Promotion, Department of Health in Taiwan has for many years promoted tobacco control programs (e.g., preventive health education and advocacy activities). This study aims to integrate existing resources, as the Taiwan Health Promoting School, to combine the campus healthcare systems and health education. With the emphasis on six domains (i.e., establishing public policies, building supportive environments, strengthening community cooperation, developing personal skills, redefining health services, and promoting creative marketing strategies), the objectives of enhanced smoking cessation and smoke-free campuses were expected be achieved in universities/colleges.

Methods In this study, 22 technical/vocational schools and 8 general universities were recruited for investigation. To assess the overall effectiveness, schools were requested to fill out self- assessment questionnaires before (March, 2010) and after (October, 2010) the implemented programs. The Likert five-point scale was used for assessment. The differences and changes in the pre- and post-tests on the six dimensions would be analyzed for comparison. By means of radar map analysis, the factors affecting the universities and colleges’ tobacco control promotions were examined. Also, experts and scholars visited the schools, counseled and offered some advice.

Results The pre-test results showed that the mean values of each of the six dimensions of the technical/vocational schools were between 3.10 and 3.87, and the means for the general universities were between 2.57 and 3.35. For both the technical/vocational schools and general universities, the higher mean value was observed on the “establishing public policies,”while the lower mean was on “strengthening community cooperation.”From the standard deviations, we observed that the standard deviations for the technical/vocational schools were between 0.80 and 1.14, while those for the general universities were between 0.45 and 0.67, with the “promoting creative marketing strategies”presented the most diverse results. Meanwhile, the highest mean value and the lowest standard deviation on the “establishing the public policies”represented the schools’ high awareness and consensus on policy making. The post-test shall be compiled upon its completion by the end of the year, and the results will be analyzed and compared with the pre-test findings. In this study, the targets of increasing the number of smoking cessation cases and the creation of smoke-free campuses can be achieved through guidance to promoting anti-tobacco health education, boosting a variety of smoking cessation services and advocacy posters, and encouraging students to produce creative anti-smoking activities.

Conclusions We found that the schools generally support and emphasize the tobacco control programs; however, the community links and cooperation are inadequate and could be further strengthened.

Poster presentations: Topic 2, Monday March 28 214 Implementation This study implemented an integrated program, promoted action research, and established a well-designed promotional model for on-campus tobacco control programs in universities/ colleges.

2.4 Do workplace smoke-free policies facilitate stopping smoking? Ukraine GATS results

T. Andreeva National University of Kyiv-Mohyla Academy, KI…V, Ukraine

Objectives Workplace smoke-free policies are known to protect employees from second-hand smoke exposure and to indirectly facilitate quitting smoking. Whether this is the case in Ukraine was considered in the proposed study.

Methods The study is based on the data of the Global Adult Tobacco Survey completed in Ukraine in 2010 with funding provided by the Bloomberg Initiative to Reduce Tobacco Use, a program of Bloomberg Philanthropies, with technical assistance from the CDC, WHO, and Research Triangle Institute.

Two questions were used to measure smoking policies at workplaces: ‘Which of the following best describes the indoor smoking policy where you work: smoking is allowed everywhere, smoking is allowed only in some indoor areas, smoking is not allowed in any indoor areas, or there is no policy?’ and ‘During the past 30 days, did anyone smoke in indoor areas where you work?’

The outcome measures were whether (1) the respondent is a recent quitter versus a smoker willing to quit, and (2) the respondent is a former versus current smoker.

Associations were controlled for gender, age, education, and place of living.

Results In bivariate analysis both outcome measures were associated with both characteristics of workplace smoking policies: 18,3% were successful quitters where smoking was not allowed, 15,4% - if allowed in some areas, and 9,7% if allowed everywhere; former smokers constituted 30,7%, 28,1%, and 20,9% respectively; 17,3% versus 12,0% were recent quitters and 31,5% vs. 22,7% were former smokers if nobody smoked at workplaces versus some- body smoked.

However, in multivariate analysis the first outcome measure based on a smaller group of smokers who were successful in quitting or not, showed no association.

The second outcome measure was associated with the second question: those who reported not to be observing anyone smoking near them within the past 30 days were more likely to be former smokers (OR=1,470 95%CI 1,113-1,941), while there was no association with workplace smoking policies.

Conclusions The study shows that there is an association between the status of a former smoker and

Poster presentations: Topic 2, Monday March 28 215 working in a worksite where smoke-free policy is enforced. The association may work both ways. Those who quit smoking are more likely to require the others not to smoke. In a smoke-free workplace it is easier to quit. While causality is not thoroughly established in this analysis, it may be another illustration that the declared policies are less likely to be effective than those enforced.

Implementation Smoke-free policies at workplaces as a tool to protect the health of smokers and non smokers need to be properly enforced. The tobacco control legislation in Ukraine is well developed and includes smoke-free policies at workplaces and public places, but its enforcement is still a challenge.

2.5 Smoking content analysis of box-office hits in six European countries in the years 2004-2009

M.M. Morgenstern1, J.D.S. Sargent2, R.H. Hanewinkel1, S.I.M. Group1 1Institute for Therapy and Health Research, KI…L, Germany 2Dartmouth Medical School, L…BANON, United States of America

Objectives Smoking in movies has been identified as a potential causal risk factor for youth smoking. Aim of the present analysis was to study time trends in the frequency of on-screen smoking.

Methods Frequency of smoking in movies was approached by counting the number of box-office hits that were smokefree. For each year of the interval 2004 to 2009 the 25 most successful movies were identified and content analysed. This analysis was conducted for six European countries (Germany, Iceland, Italy, Poland, The Netherlands, and United Kingdom).

Results The six country lists of the 25 most successful movies had a high overlap due to the fact that many of the successful movies in Europe were US Hollywood productions. From the six countries, United Kingdom and Iceland had the lowest proportion of EU productions, Italy and Poland the highest. The content analysis revealed that the proportion of smoke- free movies remained quite stable in the years 2004-2007 with about 30% of the 25 most successful movies being smokefree. The proportion of smokefree movies increased in 2008 with a mean proportion of 37% and was almost doubled in the year 2009 with a mean proportion of 65%. The highest increase of smokefree movies was found for Germany (44% absolute difference between 2004 and 2009), the lowest increase was found for Italy (22% absolute difference between 2004 and 2009).

Conclusions There seems to be a strong decline in depictions of smoking in movies. This effect is pro- nounced in US Hollywood productions, but is also found for national (EU) movies.

Poster presentations: Topic 2, Monday March 28 216 2.6 Misconceptions and knowledge about the smoke-free legislation in Denmark in 2010: A cross-sectional study

B.K. Køster, B.S.H. Harboe, I.H.C. Clemmensen Danish Cancer Society, VALBY - COP…NHAG…N, Denmark

Objective In august 2007, Denmark implemented a smoke-free legislation -’law on smoke free environments’ -that prohibits smoking in public places and workplaces. However, the legislation contains several exceptions on almost all areas (workplace, restaurants, schools etc.). Thus, smoking rooms and smoking cabins are still allowed in workplaces along with smoking in one-man offices, which means that environmental tobacco smoke (ETS) leaks from these sources. In a 2010 survey of the populations’ exposure to ETS it was shown that at workplaces 15 % was exposed daily, 35% exposed less than daily, while only 40 % never were exposed. Initiatives to inform the population of the law were sparse. We have examined the misconceptions about the Danish smoke-free legislation.

Methods A population-based sample of 5049 respondents living in Denmark aged 15+ completed a questionnaire on tobacco related behavior and exposure to ETS in august 2010. We examined the relations between knowledge on legislation and demographic factors with descriptive statistics. Data was collected from an internet panel consisting of more than 100 000 panelists. From this panel 26 401 persons were invited; 7 401 (28 %) initiated the questionnaire; 6 830 (26%) completed the questionnaire. Of the 6 830 persons 1781 were screened out. The sample was stratified on gender, age, region and education corresponding to Danish population.

Results The misconceptions with the law are large e.g. forbidden to smoke in child minding homes all 24 hours of day - correct answer No - was known by 14 % age range (10%-18%), forbidden to smoke on stairways in multiunit dwellings - correct answer Yes - 30 % age range (34%-50 %), permitted to setup smoking rooms/facilities in eating and drinking venues - correct answer Yes - 62% age range (49%-65%), permitted to setup smoking rooms/facilities in nursery homes - correct answer Yes - 11% age range (9%-13%), permitted to setup smoking rooms/facilities in schools - correct answer Yes - 27 % age range (24%-33%). Also differences on the perception of public versus private workplaces exist; permitted to setup smoking rooms/facilities in private workplaces - correct answer Yes - 74 % age range (68%-76%); permitted to setup smoking rooms/facilities in public workplaces - correct answer Yes - 48 % age range (46%-50%).

Conclusion The exceptions of the law on smoke free environments should be rejected to remove all matters of dispute and to adopt a law that protects the population efficiently. In addition initiatives to inform the population are required to achieve a better agreement between legislation and population knowledge.

Poster presentations: Topic 2, Monday March 28 217 2.7 An Exploration of Factors Affecting Success Rate of Smoking-Cessation Clinic in Taipei

L. Yu1, H. Lin1, Y. Lin1, C. Lin2, A. Chiu1, J. Liu1 1Taipei City Government, TAIP…I CITY, Taiwan 2John Tung foundation, TAIP…I CITY, Taiwan

Objective To study the success rate of Smoking-Cessation Clinics and related factors to inform future policy on smoking-cessation in Taipei.

Method All patients at a smoking-cessation clinic formed the population under study. A sample of convenience of 147 patients were surveyed by a structured questionnaire over the telephone. Subjects were interviewed after their first visit to the smoking-cessation clinic and three months later. Data collected included demographics, smoking history, degree of dependency on nicotine, past efforts to quit smoking, knowledge of adverse effects of smoking, number of visits to the clinic, and type of medication received. Data were analyzed using the chi-square test and the independent t-test.

Result The 147 subjects averaged 48 years of age and 86.4% were male. Nicotine dependency averaged 6.78. On average, the subjects started smoking at 20 years of age, smoked 23.3 cigarettes per day, and had smoked 26.7 years. 16.3% had attended smoke-cessation clinics in the past and 17.0% had used medication to quit smoking. They scored 89.4 on knowledge of adverse effects of smoking, and visited the smoking-cessation clinics 3.49 times on average. Champix alone was prescribed to 68%, Nicorette to 4.1%, Smokefree to 24.5%, while 3.4% received combination Nicorette and Smokefree. 45.6% of subjects quit smoking successfully. Statistically, the number of visits and the type of prescription factored significantly in the result, namely, those who attended the clinic for more than four weeks and those who were prescribed Campix or Smokefree alone were more likely to quit successfully.

Conclusion The success rate at this smoke-cessation clinic in Taipei was 45.6%. The number of clinic visits and the type of medication significantly influenced the outcome.

Implementation The smoking-cessation clinic service can accommodate all smokers who want to quit. Smokers should be encouraged to persevere for at least four visits to obtain a better chance of success.

Key Words Quit smoking, smoking-cessation clinic

Poster presentations: Topic 2, Monday March 28 218 2.8 An Evaluation of Parent-Child Interaction in Smoking-Cessation of the Parent

H Lin1, L. Yu1, J. Liu1, C. Lin2, A.W. Chiu1, Y. Lin1 1Taipei City Government, TAIP…I CITY, Taiwan 2John Tung foundation, TAIP…I CITY, Taiwan

Objective To evaluate the efficacy of the introduction of a parent-child interaction in smoking-cessation.

Method Primary pupils were recruited to encourage their parents to quit smoking in the 2010 Quit- and-Win campaign. Seventy-seven parents took part in a telephone survey to evaluate the efficacy of the campaign four months after its conclusion. Data collected included demographics, smoking history, how children acted, whether the parent quit smoking. The chi-square test and the independent t-test were used to assess statistical significance.

Result The parents averaged 40.9 years in age, 88.3% were male, 11.7% female. Before the campaign they smoked on average 18.7 cigarettes a day. On average, they took up smoking at 18.3 years of age, had smoked for 22.5 years and 88.3% of them had tried to quit. The pupils averaged 10.1 years in age; close to half (49.4%) were girls. They took home Quit-and-Win enrollment forms (49.4%), verbally encouraged their parents to quit (51.9%), and monitored their parent’s smoking continually (51.9%). Twenty-eight (36.4%) subjects successfully quit smoking. Whether the child monitored smoking continually was a significant factor (Pï_œ0.05).

Conclusion Primary pupils can increase the success rate of their parents’ quit-smoking efforts significantly by monitoring smoking behavior continually.

Implementation Further expand the scope of parent-child interaction in smoke-cessation campaigns. Continual monitoring of the parent’s smoking behavior contributes to the success of smoking-cessation efforts.

Key Words Parent-child interaction, smoking-cessation

2.9 Prevalence of Tobacco Use among Kyrgyzstan’s Physicians and Nurses and Their Attitudes towards Tobacco Control

C.H. Bekbasarova1, S. Bekbasarov2, A. Toktalieva2, M. Kasimova2 1Ministry of Health of the Kyrgyz Republic, BISHK…K, Kyrgyzstan 2Public Health Protection Foundation, BISHK…K, Kyrgyzstan

Objective To estimate the prevalence of tobacco use among Physicians and female Nurses and their attitudes towards tobacco control in Kyrgyz Republic

Poster presentations: Topic 2, Monday March 28 219 Methods The questionnaire of the Tobacco Use Prevalence Study among Physicians and Nurses of the Kyrgyz Republic was developed by using the questionnaires of the Global Health Professional Surveys. The respondents were interviewed anonymously. 1450 Physicians from 1700, and 1846 of Nurses from 2300 participated in the survey. Statistical analysis of the data was performed using Microsoft Excel and SPSS-12.

Results Current Prevalence of smoking of manufactured cigarettes among male Physicians aged 23-69 years is slightly higher than that data of general male population with same age group and similar educational level (49% compared to 42%). Smoking Prevalence among female physicians of Kyrgyzstan is much higher, than among women of national representative sample (6% against 2%) with a similar educational level. Smoking rate is 10 times higher than among young female Physicians in age group 25-34 years with a similar age group and educational level (11, 1% against 1%). Current smoking prevalence among Physicians lowers with the increase of the age group, the same picture is found among female Nurses. One third of Health Professionals exposed to smoking at home, 5% of physicians (65% women, and 35% men) and 50% of Nurses - in public transport, 37% and 23% of Female Nurses were exposed to smoking by their colleagues at the workplace in medical organizations. The high level of agreement of the Respondents (from 84% to 94%) was received to the question «Smoking is harmful to your Health”, nevertheless, the awareness of the harm of smoking in Kyrgyzstan was found enough low. Only, 6% of Physicians and 4% of nurses in Kyrgyzstan believe they have enough education in order to help patients give up smoking.

Conclusion The results showed that the current smoking prevalence among male physicians in the Kyrgyz Republic aged 23-69 is slightly higher than that data of general male population with same age group and similar educational level. Prevalence of smoking was significantly higher among female Physicians and Nurses than in general population with a similar educational level and age group.

Implementations These data was used for developing the national strategy for tobacco control for implementation FCTC by involving of Health Professionals for reducing smoking as among health professionals so among the general population.

Authors are grateful to the Canadian Tobacco Control Research Initiative, the American Cancer Society, Cancer Research - UK and Research for International Tobacco Control and the International Development Research Centre for their support of conducting this survey in Kyrgyzstan.

2.10 Harmonised Human Biomonitoring in Europe - measuring cotinine in a pilot study

J. Mulcahy1, A. Polcher2, C. Consortium3 1Health Service …xecutive, GALWAY, Ireland 2BiPRO GmbH,, MUNICH,, Germany 3COPH…S Consortium, MUNICH, Germany

HBM is an effective tool to assess human exposure to environmental pollutants and potential

Poster presentations: Topic 2, Monday March 28 220 health effects of such pollutants. It is seen as an essential element in a strategy aiming to integrate health and environment. In support of the European Environment and Health Action Plan European Member States scientists are developing currently a functional framework to define, organize and manage a coherent approach towards HBM in Europe. The framework aggregates experiences from existing and planned HBM activities in European countries and worldwide to investigate what is needed to support better comparability of HBM data. Such is needed to establish human biomonitoring as a tool for the control of chemical regulations (REACh) and to improve quantification of exposure of the general European population to existing and emerging pollutants. Additionally HBM can be used to determine reference values for exposure, to support policy making by e.g. evaluation of policy actions aimed at reducing exposure to potentially hazardous environmental stressors at a European level and to promote more comprehensive health impact assessments of policy options. From an inventory and analysis of existing and planned HBM studies in different EU MS similarities and discrepancies (related to environmental exposures, national environmental health concerns, analytical capacities, and political and health priorities) are identified and harmonized study protocols are prepared. All this is done by a consortium consisting of 35 partners from 27 European countries (COPHES).

The concept will be tested from 2011 on in a feasibility study which will take place in 16 European Member States as well as Norway and Switzerland. Apart from selected heavy metals the nicotine metabolite cotinine will be in the focus of investigation. More than 3600 urine samples from children aged 6- 11 and their mothers will be collected in a harmonised way all over Europe and will be analysed in order to evaluate the exposure to Environmental Tobacco Smoke (ETS). Values will show if legislation related to restrictions of smoking are effective, even if the sample size is quite limited for the European Scale. Nevertheless, the network will be in a position to provide for the first time an idea of preliminary reference values related to ETS on which further policy recommendations will be based.

2.11 Reduction in suicide risks after smokers quit smoking

C.P. Wen1, S.S.C. Chang2, Y.C.C. Chang1, M.K. Tsai1, Y.C.Y. Yang1 1National Health Research Institutes, MIAOLI, Taiwan 2University of Bristol, BRISTOL, United Kingdom

Context Many studies found increased suicide risks among smokers, but the effect of cessation on such risks is not well known.

Objective To evaluate the suicide risks of smokers before and after smoking cessation.

Methods A large medical screening institution in Taiwan. The cohort, recruited since 1996, consisted of 385,445 adults participating in a medical screening program. Cox proportional hazards regression models were used to compare suicide risks between current smokers and former smokers.

Results Old age, male, divorce, alcohol drinking, having cancer history and users of tranquilizers/ sleeping pills or major psychotropic drugs were associated with higher suicide risks. After controlling for these variables, the risk of smokers was 2.17 times that of nonsmokers,

Poster presentations: Topic 2, Monday March 28 221 (hazard ratio [HR] = 2.17, 95% confidence interval [CI] 1.37-3.45). Smokers in the cohort who quit had a 39% reduction in suicide (HR = 0.61, 95% CI 0.38-0.99). The risks of former smokers (HR=1.28, 95%CI 0.58-2.80) were not much different from those who never smoked. Similar reduction was found among heavier smokers (49%), mental patients or smokers taking tranquilizers/sleeping pills (31%).

Conclusions Smokers had 2-fold increase in suicide risks, but when they quit, the risks substantially reduced, becoming close to those who never smoked. The reduction was obvious even among the mental patients or heavier smokers. If more smokers can continue to quit, including those with mental illnesses, their risks will reduce. Although smoking cessation in general offers benefits way beyond suicide prevention, successful quitting can protect smokers from their high suicide risks.

2.12 Second-hand smoke exposure among pregnant woman in Ankara

H. Ozcebe1, I.E. Erguder2, B.D. Dilbaz3, N.B. Bilir1 1University of Hacettepe, ANKARA, Turkey 2University of Ankara Department of Biochemistry, ANKARA, Turkey 3SSK …tlik Maternity Hospital, ANKARA, Turkey

The prevalence of smoking among males in Turkey is the highest rate in the European region, therefore women and children are mainly passive smokers in the places such as car, home. It is aimed to learn smoking status and second hand smoking among pregnant women. In this study, 179 pregnant women at the last trimester, who were followed by a maternity hospital in Ankara were interviewed. Nineteen (10.7%) of the women said they smoked during pregnancy. Urine samples were taken from 89 pregnant women who are non smokers at their last visit before delivery. Among 89 non-smoking pregnant women, 45 said they were exposed to tobacco smoke, both at home or public places, and 44 were not exposed. Cotinine levels of urine samples were determined using ELISA method. As the results, the average urinary cotinine value is 78.97 ng/ml, this value is 283.5 ng/ml among pregnant who were smokers. Only one woman had 6.5 ng/ml cotinine level (which can be considered as normal). The average value of urinary cotinine was 118.7 ng/ml for the women who were exposed to second-hand smoke and 43.3 ng/ml for the non-exposed women. Second-hand smoke exposure is an important risk for everyone, but much more important for the pregnant women, both for their health and also for the baby.

2.13 Determinants of Smoking Behaviour among the Secondary School Students in Bangladesh

R. Mizanur1, A. Sk. Akhtar2, K.A.J. Jahir3 1Universiti Malaysia Sarawak (UNIMAS), KUCHING, Malaysia 2National Institute of Preventive and Social Medicine (NIPSOM), Mohakhali, DHAKA, Bangladesh 3Directorate General of Health Services, DHAKA, Bangladesh

Objectives To determine the smoking prevalence and to examine the determinants of smoking behaviour among the secondary school students in Bangladesh.

Poster presentations: Topic 2, Monday March 28 222 Methods A two-stage cluster sample was used with a selection of schools on probability proportional to enrolment size followed by stratified random sampling of government and private schools and then a random start of classes of VIII, IX and X from each school. The 70-item questionnaire included with ‘core GYTS’ (Global Youth Tobacco Survey) and other additional questions. Data analysis was performed using SPSS 17 software and the results accounted for the complex sampling design and weighting factors in the data set. A total of 60 schools were selected in which school response rate was 98.3%. Within the school, class grade VIII, IX and X were selected targeting the students aged 13 years and above. An anonymous self-administered questionnaire was filled in by all students present at the day of survey. The sample consisted of 6563 with response rate was 95.4%.

Results The prevalence of smoking was 12.3% (95% CI: 10.4%, 14.4%) among boys and 4.5% (95% CI: 3.5%, 5.8%) among the girls respectively. The mean age at initiation of smoking was 10.8 years with standard deviation 2.7 years. At least one cigarette was smoked by students per day. Logistic regression analysis revealed that boys are 2.282 (95% CI: 1.636, 3.185) times likely to be smoked than the girls and it was 1.786 times (95% CI: 0.985, 3.237) higher among the students aged 16 years and above than the younger counterpart. Smoking by teachers appeared to be the strongest predictor for students smoking behaviour (OR 2.206, 95% CI: 1.576, 3.088) followed by peer influence (OR 1.993, 95% CI: 1.184, 3.356).

Conclusion Smoking prevalence among the students is high in Bangladesh compared to the previous studies. Effective smoking prevention program should take into account within the dominant environmental influence to reduce smoking behaviour. The school curriculum items had a less impact in preventing smoking except teacher’s smoking behaviour.

Implementation Nicotine dependence typically occurs in adolescents. It is identified as an increasing public health problem. Despite established country’s tobacco control law, cigarette smoking by the young people and the magnitude of nicotine dependence among the students is alarming.

Funding source: Research and Development Unit, Directorate General of health Services DGHS), Mohakhali, Dhaka-1212, Bangladesh.

2.14 Unexpected outcomes: An ethnographic account of smoke free policy enactment in acute psychiatric settings

L.G. Grant1, J.L. Oliffe2, J.L. Johnson2, J.L. Bottorff3 1University of Northern British Columbia, PRINC… G…ORG…, Canada 2University of British Columbia, VANCOUV…R, Canada 3University of British Columbia - Okanagan, K…LOWNA, Canada

Objective Smoke free grounds policies were introduced in acute psychiatric hospital settings to help improve health among patients, staff, and visitors. However, enacting these policies has been challenging. Suspecting cultural norms around tobacco use in psychiatric settings influences policy enactment, a study was conducted to examine the recent introduction of a tobacco free policy and describe complexities about how smoke free grounds policies impact acute psychiatric units.

Poster presentations: Topic 2, Monday March 28 223 Methods A qualitative ethnographic approach was undertaken in Northern British Columbia, Canada. Data included approximately 70 hours of participant observation, document analysis, and interviews with patients (n=20), healthcare workers (n=20), and key informants (n=8) on acute psychiatric units in two hospitals. Data were analyzed using interpretive descriptive methods to inductively derive thematic findings and develop cultural understandings about the factors influencing smoke free policy enactment in these settings.

Results The study revealed various contextual factors that influence the enactment and uptake of smoke free grounds policies in acute psychiatric settings. Health care workers described lack of support and alienation from other areas of the hospital in enforcing tobacco policies, described roles of policing tobacco use, framed tobacco use as individual choice, and often privileged cultural or personal knowledge over other available knowledge while attempting to meet policy requirements. Leadership appeared to play key roles in shaping policy enactment. Patients often favoured the new policy, but smokers spoke of individual benefits of tobacco use frequently employing the notion of the right to smoke. These groups found ways to communicate about and enable tobacco use that were seen as respectful and coinciding with individual interpretations of the policy. Perceptions of increased visibility of smoking around hospitals were associated with negative attributes of stigma and litter. Disparate approaches to policy enforcement appeared magnified in smaller hospital settings and geographic distance and structural divisions operated to further entrench or support these differences.

Conclusions This study provides new systematic evidence regarding smoke free policy enactment in acute psychiatric settings including the need for strong leadership to broker the challenges, attention to factors beyond departmental boundaries, and unambiguous organizational commitment to unified approaches.

Implementation This study underscores the importance of identifying how localized contexts influence smoke free policy enactment and offers suggestions to policy makers about which contexts warrant increased attention during all stages of policy enactment within acute psychiatric settings. This study helps inform and direct future research inquiry and particularly encourages researchers to investigate further the organizational structures and knowledge biases that form barriers to effective smoke free policy enactment.

Poster presentations: Topic 2, Monday March 28 224 Topic 3: Experience with tobacco control in national contexts, with special focus on smoking bans and point of sale bans - case studies

3.1 Relationship between the smoking ban in restaurants and frequency of their customers’ visits

I. Pesic1, A.M. Dzeletovic2, N.M. Lazarevic3, B.S. Gvozdenovic4, N.R. Lazovic5, A. Jovicevic6, A. Milosevic7 1Institute for Pulmonary Diseases and TB, Clinical centre of Serbia, B…LGRAD…, Serbia 2Institute of Public Health of Serbia, B…LGRAD…, Serbia 3Ministry of Health of the Republic of Serbia, B…LGRAD…, Serbia 4AbCRO, Inc. Serbia, Belgrade, B…LGRAD…, Yugoslavia 5Medical center „dr Misovic„ Cacak, CACAK, Yugoslavia 6Institute for Oncology and Radiology of Serbia, B…LGRAD…, Serbia 7Pharmacist Faculy, B…LGRAD…, Yugoslavia

Objectives The frquency of citizens’ restaurants visits, assessment of their attitude toward smoking ban in restaurants according to their smoking status and employment.

Methods A total of 600 citizens filled the survey. The sample was randomly selected. We estimated: a) the frequency of restaurants visits; b) reasons why subjects do not go or rarely go to restaurants; c) if they agree with the complete smoking ban in restaurants and d) if they would go in restaurants more often in case the smoking is forbidden. The analysis of data was performed by means of t-test for independent samples and analysis of variance(ANOVA).

Results The mean age was 33.5 years. There were 55.8% employed and 44.2% unemployed subjects. Among those subjects who used to go to restaurants, only 3.8% go everyday, 17.3% once per week, and 18.5% once per month. The majority of subjects 60.3% do not go to restaurants. According to smoking status, there were a total of 65.8% subjects that do not smoke, and more than two thirds that do not use to go to restaurants. There were 34.2% smokers and more than half of them 53.7% also do not use to go to restaurants. These are the reasons why they do not go to restaurants: A) 26.5% of subjects said that do not like restaurants, and 10.2% of them are smokers. B) In 17.7% cases, subjects were bothered by the cigarette smoke, and there were 0.6% smokers among them with this reason(NS). C) For 49.7% subjects going to restaurants is a great expense. We found a significant difference in relation to the employment status 57.0% cases were not employed (p<0.001). D) 6.1% cases do not go to restaurants due to other reasons (do not have a free time, and go to resaturants only when family celebrations are organized, etc). There are 6.0% smokers among them and 16.0% ex smokers, and the most expected outcome 78.0% non-smokers(NS). If there will be the smoking ban in restaurants, 52.8% subjects would go to restaurants. Among them there are actually 5.6% smokers that this would be a trigger for quitting smoking. Besides that, 37.3%

Poster presentations: Topic 3, Monday March 28 225 non-smokers and 9.9% ex smokers said that they would more frequently go to restaurants if the smoking is forbidden in them.

Conclusions More than half subjects that currently do not go to restaurants declare that if the smoking is forbidden in restaurants, they would readily go there. Some smokers have such attitude and they believe that smoking ban in restaurants would help them in smoking cessation. The fact that the majority of subjects do not go to restaurants due to the big expenses could be related to the current economic crisis and unemployment.’

3.2 Evaluation of the impact of the new smoke-free law in Serbia

A. Jovicevic1, S.K. Krstev2, N.L. Lazarevic3, D.A. Dzeletovic4, I.P. Pesic5, S.U. Ukropina6 1Institute for Oncology and Radiology of Serbia, B…LGRAD…, Serbia 2Institute for Occupational Health, B…LGRAD…, Serbia 3Ministry of Health of the Republic of Serbia, B…LGRAD…, Serbia 4Institute for Public Health, B…LGRAD…, Serbia 5Institute for Pulmonary Diseases, B…LGRAD…, Serbia 6Institute for Public Health of Vojvodina, NOVI SAD, Serbia

Objectives In Serbia, the new Law on Protection from Environmental Tobacco Smoke will enter into force in November 2010, restricting smoking in indoor public places and workplaces.

A plan for the evaluation of the implementation and the impact of this law has been made.

Methods In order to monitor and evaluate implementation and effects of the new smoke-free law, a study has been launched by the Committee for Tobacco Use Prevention of the Minsitry of Health. The study will examine public support, compliance, effects on smoking cessation and health benefits related to the new legislation.

Results Data are collected before (as baseline data) and periodically after the implementation starts. Public support will be evaluated through a survey of the representative sample of the population carried out before the implementation and 3, 6 and 12 months after the implementation begins. Preliminary data have shown that 75% of general population support the smoke-free law. The number of patients and treatment results at smoking cessations services (26 registered services throughout the country) will be monitored and compared with baseline data. Compliance with the smoke-free legislation will be monitored through inspections of workplaces and indoor public places by all relevant inspections (health and sanitary, education, labor, market etc.). Health benefits will be evaluated by monitoring rates of hospital admission due to acute myocardial infarction and other cardiovascular conditions. Tobacco industry activities and media coverage related to the implementation of the smoke- free law will be monitored as well.

Conclusion Evaluation results should indicate if the smoke-free law is having expected effects i.e. effects similar to those observed in other countries that introduced smoke-free regulation. Results should help identify problems in the implementation and enforcement as well as the

Poster presentations: Topic 3, Monday March 28 226 deficiencies in the law, particularly those related to venues with partial restriction of smoking or exemptions.

Implementation By showing positive effects of the new smoke-free law, public support and support of all stake-holders could be increased. Lack of expected benefits in certain areas would be an argument for the improvement the smoke-free law and its implementation.

3.3 Negotiating access to tobacco following the increase in the age of sale in the UK

T.A. Tjelta, A. Amos, D. Ritchie University of …dinburgh, …DINBURGH, United Kingdom

Objectives To examine young people’s cigarette access strategies in two areas of deprivation in Scotland following the increase in the minimum age of sale in the UK in October 2007. The perceived impact of the age increase will be described, strategies employed in circumventing access restrictions will be identified and findings will be located in the context of national survey data to consider implications for policy, research and practice.

Methods Twenty four individual, paired and triadic qualitative semi-structured interviews were undertaken with 13 and 15 year old young people between March and November 2010 in two disadvantaged communities in Edinburgh. Interviews explored perceptions and experiences around smoking and cigarette access. Participants were recruited via youth clubs, detached youth-workers and ‘third sector’ organisations. The interviews were recorded, transcribed and analysed thematically.

Results Young people continue to experience very little difficulty accessing tobacco following the increase in the minimum age of sale, despite a high reported frequency of ID requests. Cigarettes were reported to be readily available via retail purchases, proxy purchases, social and ‘illicit’ sources. A number of specific strategies were employed in securing access, including making efforts to develop relationships with retailers and targeting particular individuals for proxy purchases. ‘Fag-houses’ were reported to supply illicit and/or counterfeit product for around half the standard retail cost.

Conclusions National surveys have shown a decline in the proportion of young people ‘usually’ accessing cigarettes from shops following the increase in the minimum age of sale in the UK. However, these have also shown an increase in the proportion of young people accessing cigarettes from social or ‘informal’ sources, and do not report on proxy purchases. Study findings suggest young people have recourse to a range of alternative sources where retail access is curtailed, and employ a range of strategies in circumventing sales restrictions. The impact of the increase in the minimum age of sale is therefore perceived by young people to be minimal.

Implementation The high reported frequency of ID requests may be attributable to sales law enforcement efforts following the increase in the age of sale, and sustained enforcement may contribute to the curtailment of retail cigarette access among under 18s. However, young people

Poster presentations: Topic 3, Monday March 28 227 reported very little difficulty recruiting friends, family and others to procure cigarettes on their behalf. Proxy sales laws may be difficult to enforce, and unlikely to impact meaning- fully on youth smoking and cigarette access without the development of community-level strategies to address prevailing norms.

3.4 Factors that influenced SHS exposure in hospitality venues in Greece before the 2010 smoking ban

C.I.V. Vardavas1, N.A. Anagnostopoulos2, C.N. Nakou3, V.D. Dramba4, M.M. Minas5, E.P. Patelarou6, G.G. Giourgouli7, M.K. Kougias2, K.G. Gourgoulianis5, A.P. Pataka3, A.A. Antoniadis4, C.L. Lionis7, D.D. Dockery8, G.C. Connolly8, P.B. Behrakis9 1University of Crete & Harvard School of Public Health, Heraklion Crete & Boston MA, Greece 2Smoking and Lung Cancer Research Center, Hellenic Cancer Society, ATH…NS, Greece 3Department of Medicine, Aristotelio University of Thessaloniki, TH…SSALONIKI, Greece 4Department of Pulmonary Medicine, General Hospital of Serres, S…RR…S, Greece 5Department of Respiratory Medicine, University of Thessaly, LARISSA, Greece 6University of Crete, Heraklion Crete, Greece 7Department of Medicine, University of Crete, H…RAKLION, Greece 8Harvard School of Public Health, BOSTON, United States of America 9Harvard School of Public Health & Hellenic cancer society, ATH…NS, Greece

Objective Secondhand smoke (SHS) is a serious threat to public health. The aim of this analysis of Wave 1 data of the Hellenic Air Monitoring Study was to evaluate which factors influenced indoor SHS exposure before the adoption of the smoke free legislation in September 2010 and to assess if opening doors and windows eradicates indoor SHS exposure.

Methods During April-May 2010, a total of 149 venues (64 cafes, 58 bars, 20 restaurants, 5 internet cafes and 2 betting parlors) were visited and assessed in 5 prefectures of Greece for their levels of indoor air pollution attributable to SHS, using particulate matter of 2.5Î_m (PM 2.5) as an indicator and according to standardized methodology with a TSI Sidepack AM 510. At least 30minutes was spent in each venue and observational data such as the existence of smokers, open doors and/or open windows as also the day/time of the week was also noted.

Results In comparison to venues that did not allow smoking, and whose average level of indoor PM 2.5 was measured at 6Î_g/m3 (range 1-14 Î_g/m3), venues that did allow smoking (n=142) had PM 2.5 levels of 182 Î_g/m3 (range 3-2480 Î_g/m3). Comparing venues with open doors/ windows (and even sliding walls) to those that were closed, the later had higher PM 2.5 levels 134 Î_g/m3 vs. 290 Î_g/m3, respectively (p<0.001). A linear regression analysis indicated that within venues in which smoking was noticed, average PM 2.5 levels were statistically dependant of the average smoker density (cigarettes per 100m3) with a Beta of 51.57 Î_g/ m3, (95%CI: 31.4 to 71.7) per one cigarette/100m3 increase and if the venue had its windows/ doors closed with a Beta of 157.9 Î_g/m3 (95%CI: 78.4 to 237.3). The time of day and the day of week were not found to statistically affect PM 2.5 levels, when all the above factors were taken into account.

Conclusions Cafes, bars, restaurants, internet cafes and betting parlors in Greece before the 2010 smok-

Poster presentations: Topic 3, Monday March 28 228 ing ban were significantly polluted with SHS, with indoor air pollution related to the number of cigarettes per cubic meter of airspace within the venue and if the venue had its doors/ windows open.

Implementation Opening doors and windows does not eliminate exposure to SHS, a fact which should be taken into account in countries with warm climates such as Greece, where opening doors and windows is incorrectly projected as a solution to protecting non smokers and employees from exposure to SHS.

Funding Source and Declaration of interest: Funding was provided by the Behrakis foundation through the HEART (Hellenic Action For Research Against Tobacco) project. The authors have no conflict of interest to declare.

Poster presentations: Topic 3, Monday March 28 229 Topic 4: Tobacco industry document research

4.1 Does repeated viewing enhance the association between exposure to smoking in films and own smoking

K. Hunt1, M. Henderson1, J. Sargent2, D. Wight1 1MRC Social and Public Health Sciences Unit, GLASGOW, United Kingdom 2Dartmouth Medical School, L…BANON, United States of America

Objective To assess whether there is a relationship between images of smoking in films and own smoking amongst Scottish adolescents; and whether this is affected by the number of viewings of films.

Methods Questionnaires were administered to a cross-section of 15-16 year old pupils (mean age 15 years and 6 months) from 13 schools within central Scotland in 2007 by trained researchers. 1,999 pupils were present on the days of the surveys (88% of all eligible pupils) and completed questionnaires in classrooms under exam conditions with no teachers present. Respondents were asked ‘in the last 12 months, how often have you smoked tobacco (cigarettes)?’ (dichotomized into ever smoked in the last year versus never smoked in the last year) (outcome measure). To estimate the amount of smoking that the respondents had seen in films (‘film smoking exposure’) we used a measure developed by Sargent and colleagues which has been described elsewhere. Information was also collected on variables that could be associated with smoking and also with film exposure, including family background and functioning, individual characteristics, media use, family rules around media use, and peer smoking status.

Results A graded relationship between smoking and levels of exposure to film images of smoking was found (gender-adjusted OR for highest quartile of exposure 1.73 (1.24, 2.41); fully adjusted OR 1.57 (1.01, 2.37)). A stronger relationship was observed when accounting for the number of viewing of films (gender-adjusted OR for highest quartile of exposure 2.19 (1.57, 3.04); fully adjusted OR 1.57 (1.04, 2.37)). Other variables associated with smoking included being female, peer smoking, lower levels of parental control, family time, and parental monitoring, and wanting to leave school early. Adolescents allowed to watch films classified as appropriate for over 18s, who watched TV often with mixed sex groups of friends, and who often disregarded parental rules about viewing were also more likely to smoke.

Conclusions This is the first study internationally to demonstrate an impact of repeated viewing of films, and the first in the UK to show an association between film images of smoking and adolescents’ own smoking behaviours. It adds to evidence suggesting that the smoking content of films should be carefully scrutinised if films are not to act as an indirect means of promoting tobacco use to children and young adolescents

Poster presentations: Topic 4, Monday March 28 230 Topic 5: Product regulation – additives, new products, e-cigarettes

5.1 Successful interventions to reduce waterpipe smoking among Danish youth

P.D.J. Jensen Danish Cancer Society, COP…NHAG…N, Denmark

Fifty pct. of all Danish 9th grade students have tried waterpipe smoking. This is more or less the same percentage as when the same group is polled on how many have tried smoking cigarettes. Demonstrably, in a short period of time the waterpipe has moved from a position outside of Danish tobacco culture to being an integral part of the phase of tobacco experimentation among youth. The same tendencies have been seen in other European countries such as Sweden and Germany indicating the emergence of a new health threat. On this background the Danish Cancer Society decided to study the rise and popularity of this new tobacco phenomenon and the association between waterpipe smoking and the risk of becoming cigarette smoker among Danish youth. During the same period of time successful interventions were effected to prevent adolescents from smoking waterpipe.

A report on waterpipe culture among Danish youth demonstrated that adolescents try waterpipe smoking due to a high social acceptance among parents and friends compared to cigarette smoking, myths about the non-damaging smoke (that it is neither damaging to health nor addictive), the alluring sweet smell of the smoke as well as the oriental aesthetic of the waterpipe itself, which makes smoking seem exciting and mysterious. However, the massive growth in the rate of waterpipe smokers would not have occurred if the tobacco industry had not chosen to distribute waterpipe tobacco and waterpipes on a mass scale through the retail and service station industry. Secondly, the key to this commercial success is of the same kind as that in the Middle East, where the tobacco industry in the 1990’s developed a new, sweetly tasting waterpipe tobacco, ‘tabamel’, as a supplement to the original, acrid variety, ‘tumbak’. Especially women and young people in the Middle East were tempted by this chemically produced tobacco product. This same tendency, especially among the very young, rapidly manifested itself in Denmark, aided, in no small measure, by the willingness of retailers to sell the product. In this perspective it was estimated that a communication initiative alone was not enough if the goal was a significant reduction on the number of young waterpipe smokers. An agenda setting media campaign was therefore followed by political initiatives such as signing contracts with supermarkets and gas stations to stop the sale of waterpipe tobacco and lobbying relevant politicians. The result was a significant reduction in the accessibility on the market, a majority of political parties voting for a ban and the Danish minister of public health proclaiming that he supported the idea of a ban and would take it to a European level. Since 2008/2009 there has been a decrease of young waterpipe smokers in Denmark.

Poster presentations: Topic 5, Monday March 28 231 5.2 Immediate respiratory effects of smoking an e-cigarette

C.I.V. Vardavas1, N.A. Anagnostopoulos2, M.K. Kougias2, V.E. Evangelopoulou2, G.C. Connolly3, P.B. Behrakis4 1University of Crete & Harvard School of Public Health, Heraklion Crete & Boston MA, Greece 2Smoking and Lung Cancer Research Center, Hellenic Cancer Society, ATH…NS, Greece 3Harvard School of Public Health, Boston, MA, United States of America 4Harvard School of Public Health & Hellenic cancer society, ATH…NS, Greece

Objective Electronic cigarettes are one of the newest potential reduced exposure products (PREP) which is marketed to smokers. However there is little, if any, knowledge on the potential risks of smoking such a product. Therefore the aim of the study was to determine whether smoking an electronic cigarette can immediately affect respiratory function among healthy young smokers.

Methods Twenty healthy subjects were recruited as asked to smoke an e-cigarette after written informed consent was obtained. Pulmonary function assessment was performed by spirometry (FEV1, PEF), body plethysmography and impulse oscillometry (IOS) measurements (R5, R10, R20, X5, X10, X20, Fres) so as to assess pulmonary function before and after smoking an e-cigarette.

Results In all measurements pre and post values were strongly correlated with each other. Spirometry assessed lung function was found to decrease after smoking an e-cigarette, however the noted differences were borderline not statistically significant (p=0.056). On the contrary, IOS measurements identified that smoking an e-cigarette had a statistical significant impact on lung resistance (R5Hz, R10Hz, R20Hz) with an increase of 15.06, 14.04 and 14.78 % in their predicted resistance (p<0.001, p<0.001 and p=0.004 respectively).

Conclusions These preliminary results indicate that smoking an e-cigarette was associated with an immediate increase in lung resistance as also a decrease in lung function. However, further research is needed so as to assess the long term respiratory effects of smoking e-cigarettes and which chemical compound(s) are responsible for this health effect.

Implementation E-cigarettes could be a threat to consumer and public health and action should be taken, to regulate their production, use and sale.

Funding Source and Declaration of interest: This project was supported by the Behrakis Foundation through the HEART project (Hellenic Action for Research against Tobacco), author CV is also supported by a Flight Attendant Medical Research Institute (FAMRI) grant (CIA 072058). The authors have no conflict of interest to report.

Poster presentations: Topic 5, Monday March 28 232 Topic 6: The tobacco pack: from pictorial warning to plain packaging

6.1 Advocacy for Early Enforcement of Effective Pictorial Health Warnings in India: NGO Initiatives

J.J. Kennedy Government of Tamil Nadu, Smoke-Free Cities projects, CH…NNAI, India

Pictorial health warnings lead to greater awareness of risks of tobacco use and encourage quitting. The Indian Tobacco Control Act notified pictorial warnings in July 2006. After repeated delays and dilutions the warnings are to be enforced from November 30, 2008. Further delay is possible due to ongoing litigations, poor political will and public awareness. Objectives: -Execute comprehensive advocacy campaigns to expedite the enforcement of pictorial warnings by engaging policy makers and media -Develop information cards for sensitization of policy makers on the necessity of pictorial warnings and counter the misinformation campaign of the tobacco industry -Undertake a paid print media campaign to form a positive public opinion for pictorial warnings Policy maker advocacy: extensive research of international and national data undertaken to develop two sets of information cards. Both sets prepared and released with a gap of 9 months, to all Parliamentarians urging them to expedite enforcement. Media advocacy: three advertisements developed (in English and Hindi), urging the government to stop further delay and dilution and ensure immediate enforcement. Advertisements published in January and April, 2008, in leading newspapers. Both advocacy tools shared with state level civil society partners for dissemination among local legislators and media, respectively. The media campaign generated positive public response evident through communications received by NGOs. Supplementary earned media coverage (print and electronic) was generated through both these advocacy campaigns. India has crossed the deadline of the FCTC to enforce this law. Aggressive advocacy is must to prevent further impediment.

6.2 Attitudes of school children in Serbia towards combined health warning on cigarette packages

V.V. Vasic1, S.S. Simic2, B.D.J. Djikanovic2 1Health Center, VALJ…VO, Serbia 2Institute of Social Medicine School of Medicine, B…LGRAD…, Serbia

Objectives The combined health warning consisted of the photograph and the corresponding text on a tobacco packages can be effective in changes of attitudes toward smoking, especially in youth population. The aim of this study was to assess perception and understanding of textual warning placed on tobacco packages in Republic of Serbia among school children, and to investigate their attitudes towards proposed European Union photograph warnings.

Methods Six focus groups were conducted with students in grade 8th (fourteen years, in average) of primary schools in city Valjevo - Central Serbia, in 2009. They participated in study based on expressing their interest. Focus groups were conducted and analyzed according to the conventions of qualitative content analysis.

Poster presentations: Topic 6, Monday March 28 233 Results Out of 47 school children who participated in six focus groups, 46 were non smokers, and only one was smoker. We noticed that smokers were reluctant to apply for participation in focus groups, most probably due to the fear of accusing or being stigmatized. Findings indicated that school children don’t pay too much attention to existing textual warnings, although they think that context are good but needs innovative approaches. Massages with photograph warnings have stronger emotional influence on them, particularly those illus- trating effects of smoking on health and esthetic appearance. Those messages contributed to better understanding of serious consequences of smoking on health and acquiring clear picture of those consequences. Out of 42 suggested photographs by EU school children selected four as the most impressive and those are also recommended by EU.

Conclusions Young people generally have positive attitudes toward the combined health warning consisting of a photograph and the corresponding text on the cigarette packages. They found them discouraging smoking. Those messages attract their attention and contribute to better informing and knowledge increase in this population group.

Implementation In the Republic of Serbia there is intention to introduce health warnings on tobacco packages consisted of the photograph and the corresponding text and to replace textual messages which exists now. Results of this study are valuable in selection of most influential photographs for youths from those recommended by EU.

6.3 Communicating Luxury through Cigarette Packaging: A’Chatter Box’ Project

E. Di Sante1, S.O. O’Connor1, R.S. Schwartz1, J.A. Andrews1, J.C. Cohen1, A.L. Lavack2, T.D. Dewhirst3, D.H. Hammond4, M.T. Tilson5 1University of Toronto, TORONTO, Canada 2University of Regina, R…GINA, Canada 3University of Guelph, GU…LPH, Canada 4University of Waterloo, WAT…RLOO, Canada 5Non-Smokers’ Rights Association, OTTAWA, Canada

Objectives The cigarette package has become one of the last available marketing and advertising avenues in Canada to communicate messages about lifestyle and strength. With restrictions in the marketing environment comes the potential for innovation in communicating messages. This study aims to provide an in-depth understanding of how luxury is communicated through cigarette package design elements including colour, graphical features, lexical choices, embossing, and foil paper. The presentation will allow for conference attendees to participate in their own brief cigarette package analysis.

Methods The study sample consisted of 79 cigarette packages from two major companies (Rothmans Benson and Hedges, RBH =38 and Imperial Tobacco Limited, ITL=41), representing 14 separate brand families. The study approach used semiotic analysis, content analysis, market research, and tobacco industry document analysis. During Phase 1 of the semiotic analysis all packages were analyzed for connotation, denotation and meaning of various lifestyle and strength themes. During Phase 2 of the semiotic analysis, the packages identified as connoting

Poster presentations: Topic 6, Monday March 28 234 luxury were further analyzed to identify which design elements suggested luxury through individual and co-variation of elements. The results from the semiotic analysis were then grounded using tobacco industry document analysis and market research.

Results Sixty eight percent of our sample of cigarette packages were identified as connoting luxury. The design elements that were imbued with messages of luxury included foil (colour, embossing), package colour (metallic, gold, silver), lexical choice (synonyms for luxury: “premium,” ”special,””fine”; associations with jewelry: “sapphire”; French culture: “de Luxe”; aristocracy: “Belmont”), and graphical features (coat of arms, monograms). Thus individual design elements are clearly being used as sites of meaning production. Apart from individual elements, a combinatory pattern emerged whereby associations among elements reinforced the luxury messaging of any given pack.

Conclusions Historically, tobacco companies have marketed brands of cigarettes as capable of satisfying a variety of consumer needs. In response, governments have prohibited the promotion of tobacco products by any means that are false, misleading, deceptive or likely to create an erroneous impression about their characteristics including lifestyle advertising. Despite the implementation of prohibitions, this research underscores that cigarette packages continue to connote lifestyle messages, which could be argued is in contravention of the Canadian Tobacco Act and the Framework Convention on Tobacco Control Specifically, tobacco companies use several design elements, individually and through combinatory patterns, which connote luxury and prestige. New regulations should consider further prohibition on design elements (for example, beyond ‘light’ and ‘mild’ descriptors).

Implementation The study contributes to the evidence base that will be needed to inform next generation tobacco control policies directed toward regulating package design elements including the option of plain and standardized packaging.

Funding Health Canada & the Canadian Tobacco Control Research Initiative

Poster presentations: Topic 6, Monday March 28 235 Topic 13: Harm reduction approaches: moving beyond fixed positions

13.1 Neighbour smoke

B.S.H. Harboe, A.L.B. Brink, B.K. Køster, I.H.C. Clemmensen Danish Cancer Society, COP…NHAG…N, Denmark

Objective Neighbour smoke is transfer of environmental tobacco smoke (ETS) between apartments in multi-unit dwellings. Neighbour smoke is an emerging public health issue and an issue of health equity. As public knowledge about ETS increases, tenants are becoming increasingly concerned about neighbour smoke. Here we describe the prevalence of neighbour smoke in a national representative sample in Denmark.

Methods A population-based sample of 5049 respondents living in Denmark aged 15+ completed a questionnaire in august 2010 on tobacco related behavior and exposure to ETS. We examined the relations between exposure to neighbour smoke and demographic factors with descriptive statistics. Data was collected from an internet panel consisting of more than 100 000 panelists. From this panel 26 401 persons were invited; 7 401 (28 %) initiated the questionnaire; 6 830 (26%) completed the questionnaire. Of the 6 830 persons 1781 were screened out. The sample was stratified on gender, age, region and education corresponding to Danish population.

Results In this sample 23% of those living in an apartment, a semi-attached house or in a college were exposed to neighbour smoke, 64% were never exposed and 13% did not know whether they were exposed or not. Thirty-nine percent preferred to live in a smoke-free building (a building where smoking is prohibited everywhere - also including the apartments), while 47% preferred to live in a building without regulations of indoor smoking and 14 % did not know. Of those exposed to neighbour smoke 56 % preferred smoke-free buildings vs. 35 % of those not exposed. Attitude towards living in a smoke-free building were associated to smoking status. Never smokers were most keen on indoor smoking prohibitions (57% of never smokers) and daily smokers were least keen (7%). But 14% of smokers (both daily and occasional smokers) preferred to live in a smoke-free building and 31 % of smokers never smoke indoor in their own home.

Conclusion Given that at least 23% of the Danish population living in multi-unit dwellings is exposed to ETS makes neighbour smoke a serious problem in Denmark. Even brief exposure to ETS is a health risk. Air sealing and ventilation treatments in multi-unit dwellings can reduce but not eliminate neighbour smoke. The only solution to neighbour smoke is smoke-free buildings. This issue requires considerations for public health but it also raises ethical concerns and practical challenges.

Poster presentations: Topic 13, Monday March 28 236 13.2 Revisiting Harm Reduction - An Update of Pros and Cons

L.M. Ramstrom1, T.W. Wikmans2 1Instutute for Tobacco Studies, STOCKHOLM, Sweden 2Research Group for Societal and Information Studies, STOCKHOLM, Sweden

Objectives To elucidate the most current scientific findings regarding the need for harm reduction as an integrated part of tobacco control policies and the feasibility, utility and possible effects of different harm reduction approaches.

Methods Review of the recent scientific literature and findings from current own studies.

Results Tobacco use is a matter of self-administering a substance, nicotine, that is strongly addictive but just modestly inducing diseases by itself. The dominating nicotine delivery device, the cigarette, does, however, deliver the nicotine accompanied by various highly toxic combustion products that incur the well-known ill-health effects. While it is obvious that the best prevention of tobacco-related harm is abstinence from nicotine, there are large groups of people who are unwilling or unable to abstain from nicotine. For them it will be beneficial to get their needed nicotine with no or substantially less accompanying toxins. The key question will be to find tobacco products that deliver nicotine in a sufficiently satisfying way but with a minimum of accompanying toxins. In the mid of last century the tobacco industry tried to deceive smokers by saying that filter cigarettes, particularly “low tar/nicotine”cigarettes were such products. Now we know that they are just as harmful, since the combustion products are still there. Therefore harm reduction products are now being sought among non-combustible tobacco products.

Conclusions There is a very wide variety of non-combustible tobacco products, some of them being very toxic as well, but there is accumulating evidence that certain such products represent disease risk levels quite close to those of no-tobacco-use and far below the risk of cigarette smoking. While these pieces of evidence have lead to a great deal of consensus that these products will be beneficial for individual health, there have been concerns that unintended side effects could be negative in a public health perspective. Recent research has provided further pieces of evidence to assess the pros and cons of harm reduction in tobacco control.

Implementation Implementation of tobacco harm reduction strategies will require 1) an evidence-based system of product regulation along the lines recommended by the WHO Study Group on Tobacco Product Regulation 2) objective public information about opportunities and limitations of harm reduction

Poster presentations: Topic 13, Monday March 28 237 Topic 14: The economies of tobacco control: cost-effectiveness studies, economic benefits, earmarking of tax revenues

14.1 The cost benefit analysis of substituting tobacco for bamboo in South Nyanza, Kenya

P. Magati, J. Kibwage Tobacco To Bamboo Research Project / Strathmore University, NAIROBI, Kenya

Objectives The broad objective of this study is to investigate and compare the costs and benefits of planting bamboo as opposed to tobacco in South Nyanza region, Kenya. The specific objectives of this study are i. To estimate the financial and economic costs of planting bamboo viz a viz tobacco in South Nyanza region, Kenya. ii. To estimate and compare the financial and economic benefits of farming bamboo and tobacco in South Nyanza, Kenya. iii. To suggest recommendations for policy makers aimed at assisting tobacco farmers shift agricultural production from tobacco to alternative crops.

Methods A multi-stage and stratified random sampling procedure was used to select 210 households from the four administrative districts in the study area. One sampling area with the highest concentration of tobacco households was selected from each district through stratification where a proportional sample was randomly selected for the study. The survey was carried out using a standard questionnaire with both structured and non-structured questions relevant to the study.

Bamboo farming study was carried out on 120 trial farms where 2420 bamboo seedlings were planted in September/ October 2006. The seedlings were planted under the same natural tobacco growing conditions. Half of the bamboo clumps were randomly selected for regular monitoring. Literature review, interviews and participant observation on tobacco and bamboo production were also conducted. The cost of bamboo seedlings was taken based on a UNIDO feasibility study on large scale bamboo farming where they estimated the costs of bamboo culms in Kenya. The revenue of bamboo was gotten from a market survey and UNIDO study.

Revenue from tobacco was computed by multiplying the average yield by the gate prices as dictated by tobacco companies. Input prices e.g. farm implements, costs of seedlings, fertilizer and the average labour rate per day in this area.

Results and Conclusions Results of the base scenario showed that bamboo farming is financially and economically beneficial to tobacco farmers since the incremental benefits are positive. This is shown by the results which indicate that whilst the financial net present value for tobacco farmers is KShs 155,445 ($1,943) that of bamboo farmers is KShs 663,272($ 8,291).

Poster presentations: Topic 14, Monday March 28 238 Bamboo farming therefore, if well managed can meet the objective of the Framework Con- vention on Tobacco Control and also the government as it seeks to find an alternative to tobacco growing.

14.2 Lung cancer mortality in Sub-Saharan Africa

V. Winkler, H. Becher Ruprecht-Karls-University Heidelberg, H…ID…LB…RG, Germany

Valid data on mortality is a very important part of vital statistics for health policy. Worldwide, lung cancer (LC) is the most frequent cancer death among men with an estimated age-adjusted mortality (ASR) of 29.4 per 100,000 in the year 2008. Tobacco smoking causes more than 90% of all LC cases in developed countries, though, WHO/IARC reports the lowest LC mortality is seen in Sub-Saharan Africa (SSA). There are two possible explanations for this observation: (i) a considerably low smoking prevalence and (ii) errors in cancer diagnosis. However, in 1995, the estimated prevalence of smoking was high in males (28%) and low in females (8%) in SSA. More recent data on smoking prevalence confirm relatively high percentages in males.

We developed and validated a method to estimate LC burden in countries where reliable cancer registration is lacking. Our model is based on smoking prevalence, estimates on LC in non-smokers, and relative risk estimates for tobacco smoking.

First, we applied this method to data from Indonesia, Vietnam and Ethiopia. We found very good agreement between our estimates and the GLOBOCAN estimates by IARC for the two Asian countries, where the quality of cause of death statistics is much better, and a strong disagreement for the African country, where our estimate was 2.5 times larger.

In a second step, we use recent smoking prevalence data from the WHO Report on the Global Tobacco Epidemic 2009 to estimate country-specific ASR and absolute numbers of LC deaths and compare the results to the recently published GLOBOCAN 2008.

Results show the LC mortality is underestimated for most SSA countries. Based on recent population figures (UN 2008) we estimate about 46,000 LC deaths for SSA per year. For 2008 GLOBOCAN estimated only 13,700 deaths. Sensitivity analyses assuming lower smoking prevalences and lower rates in non-smokers confirmed this magnitude. Even by assuming a non-smoking population within the modelling procedure we still estimate about 27,500 LC deaths in SSA.

We believe the local registries on which the GLOBOCAN estimates are based are not sufficiently reliable at present and are the main cause of the observed differences. The only African country with reliable mortality data, South Africa, has high rates according to GLOBOCAN. Since smoking prevalence is similar in many other African countries, and smoking is the dominant factor for lung cancer, similar rates should be expected

The demographic transition is ongoing in SSA and the numbers will therefore increase further. Smoking prevalence has increased over the last decades in Africa. As a result, chronic disease prevention becomes more relevant. In summary, we think the cancer burden in Africa is underestimated. More prevention efforts are therefore needed for the future, in particular tobacco control.

Poster presentations: Topic 14, Monday March 28 239 14.3 Waterpipe use is associated with progression to regular cigarette smoking among Danish youth

P.D.J. Jensen1, G.E. Engholm1, S.P.J.K. Kremers2 1Danish Cancer Society, COP…NHAG…N, Denmark 2Maastricht University, MAASTRICHT, The Netherlands

Objectives Waterpipe smoking among Danish, Swedish and German youth is increasing dramatically, indicating the emergence of a new health threat. This study assessed the association between waterpipe smoking and progression to regular cigarette smoking among Danish continuation school students.

Methods Evaluation data from a school-based anti-smoking programme implemented in 2004-2005 were used. The size of the longitudinal cohort was 2202 participants (63%) of whom 762 (35%) met the inclusion criterion of being initial cigarette smokers: tried cigarette smoking a couple of times, tried cigarette smoking every now and then, smoke cigarettes but less than once a week, or stopped after having smoked cigarettes less than once a week. Only these students were selected for further analysis, excluding all never-smokers and students who had tried smoking or still smoked cigarettes regularly (weekly or daily).

Results Approximately 10% of the initial cigarette smokers (n=80) progressed to regular cigarette smoking during the eight-month follow-up period. Among boys, waterpipe smoking frequency was predictive of being a regular cigarette smoker at follow-up eight months later (p=0.02); this was not the case for girls. Other statistically significant predictors for cigarette smoking progression among initial cigarette smokers included students aged 14-15 years (only girls), low self-efficacy (only girls) and high cigarette smoking prevalence in the school (both boys and girls).

Conclusions We found that students in Danish continuation schools, especially boys, who were also waterpipe smokers on an occasional or regular basis were more likely to become regular cigarette smokers than those who had never tried waterpipe smoking. A test for trend regarding increased risk for becoming a regular cigarette smoker with higher frequency of waterpipe smoking, showed a significant effect among boys but not girls. The results demonstrate waterpipe smoking as a potential predictor of progression from initial to regular cigarette smoking among Danish continuation school students. In addition, the relationship between frequency of waterpipe use and cigarette smoking progression demonstrates a dose-response mechanism: high frequency of waterpipe smoking predicts higher risk of smoking progression vs. low frequency of waterpipe smoking. These results support the hypothesis inspired by the Gateway Hypothesis considering waterpipe smoking as a potential gateway event for regular cigarette use among initial cigarette smokers.

Implementation The study was published in Substance Use & Misuse, 45: 1245-1261. The main results were published in Danish medias on November 2nd to lobby the Danish politicians to vote for a ban on waterpipe tobacco. On November 11th 2009 the Danish minister of public health proclaimed he supported the idea of a ban and would take it to a European level.

Poster presentations: Topic 14, Monday March 28 240 14.4 Cigarette prices and affordability in the European Union

I. Bogdanovica, A. McNeill, R. Murray, J. Britton UK Centre for Tobacco Control Studies/ University of Nottingham, NOTTINGHAM, United Kingdom

Objectives In the European Union (EU), cigarette prices vary substantially between Member States. Attempts have been made to compare affordability by adjusting for national income and purchasing power, but the optimal method of measuring affordability has not been established. We used a range of price and affordability measures to explore the consistency of differences in affordability, and the extent to which contemporary cigarette affordability varies, between the current 27 EU Member States; and hence to determine whether price is being used consistently as a tobacco control measure in the EU.

Methods We calculated and compared between EU Member States the affordability of cigarettes in the EU Most Popular Price Category (MPPC), and of Marlboro cigarettes, using three measures: the Relative Income Price (RIP) of 2000 cigarettes as a proportion of Gross Domestic Product per capita; the number of minutes of labour needed to earn the price of 20 cigarettes; and the number of cigarettes that could be purchased for the local price of a MacDonald’s Big Mac (The Big Mac index).

Results Affordability varied between Member States by about four and seven-fold. Cigarette affordability was low by all measures in the three Member States with the highest absolute prices (UK, France and Ireland), but differed substantially across different measures for other Member States. In Eastern European countries, affordability was low for RIP and minutes of labour measures, but relatively high in these countries and the Baltic States for the Big Mac index.

Conclusions The affordability of cigarettes varies substantially across the European Union depending on the measure used. Comparing affordability between countries with different cultures, economies, educational opportunities, costs of living and many other characteristics is difficult, as choices on discretionary spending, and pressures on individual and family budgets, are likely to vary markedly. The importance of differences in cigarette affordability in relation to local discretionary purchasing power remains uncertain and merits further study.

Implementation Although the relative ranking of Member States differs between affordability measures, the wide range of affordability by all measures indicates that price could be used much more extensively as a tobacco control measure across the EU.

Poster presentations: Topic 14, Monday March 28 241 14.5 Moving beyond a limited follow-up in cost-effectiveness analyses of smoking cessation interventions

R. Prenger1, M.E. Pieterse1, L.M.A. Braakman-Jansen1, J. Van der Palen2, E.R. Seydel1 1University of Twente, …NSCH…D…, The Netherlands 2Medisch Spectrum Twente Hospital, …NSCH…D…, The Netherlands

Objectives Cost-effectiveness analyses (CEAs) can be defined as the comparative analyses of alternative courses of action in terms of both their costs and consequences and are designed to improve health. CEAs of smoking cessation interventions typically use objective behavioural data, i.e. physical endpoints like biochemically validated smoking cessation. However, smoking cessation is a complex process in which several steps towards (maintained) behaviour change are taken. Delayed effects may occur after a follow-up period ends, which can lead to under- or overestimation of these interventions. As extending the follow-up period is often impeded by practical and financial limitations, available measures of cognitive determinants of smoking cessation can be modelled into the cost-effectiveness ratio to predict future smoking behaviour. Also, (cost)effectiveness results are often not comparable, as trials handle varying follow-up periods. The aim of this study is to model cognitive determinants of smoking cessation into a cost-effectiveness model of a behavioural intervention, comparing an intensive smoking cessation program (SST) with a less intensive smoking cessation program (LMIS) for COPD outpatients.

Methods The CEA of an existing RCT with a 12 month follow-up (SMOKE study) was replicated and included estimated future smoking behaviour at 24 months by means of the stage-of-change algorithm of the Transtheoretical Model measured at 12 months. Possible delayed negative effects were taken into account as well by modelling a relapse rate over the second year. Costs were adjusted for the different stages-of-change participants were in at 12 months. Probabilities to predict future smoking behaviour were obtained from the dataset and literature.

Results As in the first 12 months, the SST was highly cost-effective compared to the LMIS. Sensitivity analyses showed that the SST dominated the LMIS in approximately 50% of the cases in the first 12 months. By modelling the cognitive determinants to a future second year of follow-up, the SST appeared to dominate the LMIS in approximately 75% of all cases.

Conclusions This study demonstrated that modelling of future smoking behaviour in the CEA of a behavioural intervention led to a shift in results. Not including these psychological effects may therefore bias results in CEAs of behavioral interventions particularly. Although in case of the SMOKE study the SST merely became (even) more clearly cost-effective, it is conceivable that when a cost-effectiveness ratio is less favorable, including psychological effects in CEAs could have a decisive impact. Furthermore, extending follow-up periods in (cost)effectiveness analyses using this procedure may enhance comparability of interventions. Future studies should f ocus on alternative psychological models (and different kinds of behavioural interventions) to test the appropriateness of the theoretical models for these purposes. Ultimately, this could have important consequences for health policy development in general and the adoption of smoking cessation interventions in particular.

Poster presentations: Topic 14, Monday March 28 242 14.6 Smoking and tobacco use among Albanian students, enrolled at Nursing department, University of Vlore - Albania.

A.S. Saliaj1, A.R. Ramaj2, A.S. Saliaj2, A.S. Saliaj2 1Nursing department, University og Vlore, Albania, VLOR…, Albania 2Nursing department, University of Vlore, Albania, VLOR…, Albania

Objectives: 1 To provide regional data about smoking level among students enrolled at Nursing department, University of Vlore - Albania. 2 To compare our estimates of prevalence of Albanian students tobacco use with other countries data. 3. To raise recommendations for Albanian students over tobacco prevention and control programs based on systematic studies of literature and researches about smoking harms in other countries.

Methods There are two methods, which are used in this research. The first one is a survey about tobacco use and habits among students enrolled in Nursing department, University of Vlore - Albania. The second one is a comparative research between similar studies with students of other countries, based on an analytic assessment.

Results From the eventual data results that among the students enrolled at Nursing department, University of Vlore - Albania, the percentage of male smokers is higher than the percentage of female ones (14% to 5%). Approximately 75% of all students, who have fulfilled this questionnaire, have smoked at least once. Third year students smoke more than first and second year ones. Almost all students have sufficient acknowledges about smoking risks and tobacco harms.

14.7 Excise Taxes and Smuggling - Concerning the Credibility of the Tobacco Industry’s ‘Discarded-Cigarette-Packages-Study’

H. Effertz, M. Adams Institut für Recht der Wirtschaft / Universität Hamburg, HAMBURG, Germany

The consumption of tobacco products is one of the main causes of illnesses. An often neglected but highly eff ective instrument for fi scal and preventive purposes is higher taxes on tobacco products. The tobacco industry however claims that higher taxes have tremendous effects on smuggling activity with additional costs with regard to law enforcement. The claim appears to be substantiated by a study which collects and documents the amounts of discarded empty cigarette packs, and which is used to estimate the fraction of illegally imported cigarettes. We show that this study makes use of systematic misspecifications and impreciseness and thus seems to pursue the aim of showing an exaggerated high amount of illegally imported cigarettes. The industry’s claim that two thirds of non-taxed cigarettes in Germany are imported illegally, thus lacks any sound, well-grounded empirical corroboration.

Poster presentations: Topic 14, Monday March 28 243 Topic 15: Monitoring and surveillance of tobacco control progress

15.1 Simulation modeling of the tobacco epidemic in Ukraine in 2005-2010

T. Andreeva1, K. Krasovsky2 1National University of Kyiv-Mohyla Academy, KI…V, Ukraine 2Institute for strategic research, Ministry of Health of Ukraine, KI…V, Ukraine

Background After years of prevalence of smoking increase, Ukraine observes its decline. Between June 2005 and May 2009 prevalence of daily smoking among adults changed from 37% to 27%, in men from 62% to 49%, in women from 17% to 9%.

Objectives Simulation modeling was used to identify the prevailing processes which account for the decline in smoking prevalence.

Methods A Markov chain simulation model considered results of population surveys conducted in 2005 and 2010 as consecutive cross-sections of the same population and took into account processes of smoking initiation and cessation and probabilities of deaths among smokers and non-smokers in 5-year birth cohorts. Basic probability of death was derived from the national statistics data in age-specific form. Probabilities of smoking initiation and cessation were derived from the survival analysis results of the 2010 survey data. Age-dependent coefficients of these probabilities for different groups were modeled aimed to minimize discrepancies between the real and the calculated levels of smoking prevalence in particular age groups and number of deaths nationwide and in particular age groups.

Results Daily smoking decline in Ukraine in 2005-2010 is mostly accounted for by deaths of older smokers and less intensive substitution by new smokers. About half of smoking decline in men was due to smoking cessation, while in women this process was less widespread.

Conclusions While it is unrealistic to expect considerable cut of smoking-related deaths within two or three decades, the results of modeling demonstrate an urgent need for measures to develop smoking cessation services.

Poster presentations: Topic 15, Monday March 28 244 15.2 Assessing the prevalence of smoking in car: results of the observational study in Veneto, Italy.

L.G. Sbrogiò1, G. Frison2, L. Tagliapietra2, F. Michieletto2, F. Allegri3, R. Boffi4, R. Mazza4, C. De Marco4, A. Ruprecht4, G. Invernizzi4 1Az. ULSS 19 Adria, ADRIA, Italy 2Prevention Regional Direction, V…NIC…, Italy 3Az. ULSS 9 Treviso, TR…VISO, Italy 4Tobacco Control Unit, Istituto Nazionale dei Tumori, SIMG Italian College GPs, MILAN, Italy

Objective As smoking in car represents an exposure to extremely high levels of environmental tobacco smoke (ETS) and it is considered a special risk for children and custom vehicle drivers, the aim of the study was to estimate the prevalence of smokers inside cars or duty vehicles and the presence of children exposed to second hand smoke on board, in the NHS Local Health Authorities of Veneto Region, Northern Italy

Methods An observational study was carried out by technician personnel of the Prevention Department of the Local Health Authorities of Veneto Region (participants 19 Local Health Authorities out of 21 in the Veneto region, 90,5%) from October 1st to October 17th 2008. The observers, standing by main crossing of a sample of towns, had to record sex of the driver and of the passengers, their presumed ages, verify if drivers or passengers were smoking, and if there were any children on board.

Results A total of 5928 cars were examined at the crossings, males accounted for 61,4% of the drivers. Smoking overall by at least one person in the car was reported in 409 cases (6,9%, 12% among commercial vehicles), the driver alone smoking were in 87,3%, whereas only the passenger smoking represented 8,3% of the cases. Both the driver and passenger smoking were 4,4% of the observations. Children were present as passengers in 762 cars (12,9%); there were people smoking with children on board in 7 cars (0,9%) .

Conclusion In spite of the efforts to limit the dangers of second hand smoke, smoking in car is still a common behaviour, and represents a serious risk both for adults and children. In spite of the efforts to limit the dangers of ETS among people, smoking in car is still a common behaviour. Although observed smoking in car in the presence of children was found to be infrequent, too many children are exposed everyday to ETS in cars.

Implementation Since the percentage of smoking in car is roughly doubled in custom as compared to private vehicles, custom vehicle drivers represent a special target for smoking prevention and cessation programmes. Educational material was made in order to sensitize on the topic and to address to cessation clinics. Supporting initiative of introducing specific laws to ban smoking while driving is another key point. During the recent debate on the topic in Italy (2009-2010), the researchers presented figures and related scientific information on the national media in order to raise the problem. Focusing in research projects could help the Department of Prevention of the Local Health Authorities to increase their activities and involvement in the research field.

Poster presentations: Topic 15, Monday March 28 245 15.3 The monitoring of Italian smoking ban after five years

L.S. Spizzichino, D.G. Galeone, M.G. Giaccio Ministry of Health, Italy, ROM…, Italy

Background On January 10th, 2005, a smoking ban in all enclosed places has been implemented in Italy; it’s the first law monitored since its application.

Objective A strategy has been elaborated in order to evaluate the results every year of enforcement on exposure, prevalence, initiation and cessation of smoking and tobacco consumption.

Methods The surveillance activities of the Italian Ministry of Health involve the collaboration of different stakeholders in order to implement the strategy and collect data.

Results Prevalence of smokers reduced from 23.8% to 23%, the average number of cigarettes smoked reduced from 14.8 to 14 in 2009. Hospital admissions for Acute Myocardial Infarction show a reduction of 5% in 2005 and 4% in 2006 in people with age < 70. Italian data from the surveillance system on health behaviour (PASSI) show that 41% of smokers tried to quit but 80% failed; only 60% of smokers report their GP suggested to stop smoking and 94% quit by themselves.

Nicotine Replacement Treatments sales increased in the year after the ban but thereafter decreased to a lower (-6%) level respect to 2004. Sales of drugs like Buproprion and Varenicline rocket up to 1500%. Sales of cigarettes decrease -9,8% from 2004 to 2009 but Roll Your Own products sales increase of +139%. By year 2005 more than 16,700 controls has been conducted by police, with 1,193 infractions (7.1%) but only 447 (2.7%) to people smoking where not allowed. As consequence of a regional prevention department study, more than 2,400 public and more than 3,800 private offices has been monitored, smokers have been found in 1.5% and 2% of cases respectively; more than 90% interviewed said workers respect the law.

Conclusions Laws are more effective than voluntary agreements; the use of different sources of data and the involvement of different stakeholders allowed ministry of health to better apply his strategy.

Implementation Smoke free policy is the first ever example of strategy in Italy that has been evaluated in its application. Scientific and synergic approach to evaluation is feasible and helpful to the strategy improvement.

Poster presentations: Topic 15, Monday March 28 246 15.4 Identification and self perception of smoking status in Denmark in 2010: A cross-sectional study

I.H.C. Clemmensen, B.S.H. Harboe, B.K. Køster Danish Cancer Society, COP…NHAG…N, Denmark

Objective Smoking is the number one preventable cause of morbidity and mortality. In Denmark smoking causes 24 % of all deaths. In recent years the average smoking rate in the Danish population has been declining by approximately one percent annually. However a new group of persons who smoke but do not identify themselves as smokers; ‘Phantom smokers’ has increased concurrently. There is no lower threshold of smoking that does not cause morbidity and mortality. Here we describe this group in a national representative sample in Denmark.

Methods A population-based sample of 5049 respondents living in Denmark aged 15+ completed a questionnaire on tobacco related behavior and exposure to environmental tobacco smoke (ETS) in august 2010. We examined the relations between smoking status, identification as smoker and demographic factors descriptive analysis. Data was collected from an internet panel consisting of more than 100 000 panelists. From this panel 26 401 persons were invited; 7 401 (28 %) initiated the questionnaire; 6 830 (26%) completed the questionnaire. Of the 6 830 persons 1781 were screened out. The sample was stratified on gender, age, region and education corresponding to Danish population.

Results In this sample 19,2 % were daily smokers; 2,2 % non-daily smokers; 4,1 % occasional smokers; 32,9% former smokers and 41,6 % never smokers. Of the non-daily smokers 45 % actually smoked within the past 24 h. and 88% within the past 48 h. Of the occasional smokers 10 % had smoked within the past 24 h. and 18% within the past 48 h. ‘Phantom smokers’ exists among non-daily smokers and occasional smokers as 40 % of the non-daily smokers and 80 % of the occasional smokers do not consider themselves smokers. Perception of oneself as a smoker is related to the monthly cigarette consumption. Among non-daily and occasional smokers with a monthly cigarette consumption above 10 cigarettes 60% perceived themselves as smoker; 10 cigarettes 40%; 1-9 cigarettes 28 %; 0 cigarettes 18%.

Conclusion All levels of smoking has impact on health. The large group of phantom smokers that does not perceive themselves as smokers are at risk of increased morbidity and mortality. Information and education about phantomsmoking should be increased in the population to prevent persons of the risk associated with this phenomenon and the risk of becoming a smoker.

Poster presentations: Topic 15, Monday March 28 247 15.5 Tobacco Use among Students 13-15 Years in six Countries of Former Yugoslavia, 2007-2008

Mojca Juricic1, Dijana Mayer3, Aida Ramic-Catak4, Darko Markovic4, Agima Ljljevic5, Elena Kosevska6, Charles W. Warren2, Juliette Lee2, Veronica Lea2, Ann Goding2, Michelle Carlberg2 1Slovenia, UL Faculty of Medicine, Ljubljana 2Centers for Disease Control and Prevention (CDC), Atlanta, USA 3Croatia, Institut of Public Health 4Bosnia & Herzegovina 5Montenegro 4FYR Macedonia

Objective The purpose is to focus on youth tobacco use using Global Youth Tobacco Survey (GYTS) data.

Methods The Global Youth Tobacco Survey (GYTS) data from all six “former Yugoslavia”countries (Bosnia & Herzegovina, Croatia, FYR Macedonia, Montenegro, Serbia, and Slovenia) were used to assess differences in tobacco use. The GYTS is a school-based survey with a two-stage design - schools were selected proportional to enrollment size and classes were randomly selected within participating schools. All students in selected classes were eligible to participate.

Results Across the six countries, 15.3% currently use any tobacco product, ranged from over 20% in Croatia and Slovenia to less than 10% in Montenegro. There was no difference in gender in five of the six countries however the rate for boys was higher than for girls in Bosnia & Herzegovina.

Overall, 14.0% of the students reported current cigarette smoking, with gender differences only in Bosnia & Herzegovina where boys (14.3%) were more likely to smoke cigarettes than girls (9.4%). Current cigarette smoking like current any tobacco use was highest in Croatia (24.1%) and Slovenia (20.3%) and lowest in Montenegro (5.1%). In Bosnia & Herzegovina, Montenegro, and Serbia, over half of current cigarette smokers were identified as “experiment- ers”(1-5 days in the past month). The percent of smokers who were frequent smokers (20 or more days in the past month) was over 20% in all countries, except Montenegro (19.5%) and over 30% in Croatia (37.2%), Macedonia (38.1%), and Slovenia (38.1%). There was no gender difference in smoking intensity in any country.

Overall, 8.0% of students currently used other tobacco products; with no gender difference. Smokeless tobacco was less than 2% compared to 7.5% who smoked some form of tobacco, other than cigarettes. Across the six countries, 20.6% of students who had never smoked cigarettes indicated they were likely to initiate smoking in the next 12 months. Susceptibility was over 20% in Bosnia & Herzegovina and Slovenia, with no gender difference .

Conclusions Regarding tobacco control, all six countries have ratified the World Health Organization - Framework Convention on Tobacco Control (WHO FCTC). Intensified efforts to lessen the current harm caused by tobacco use in all six countries are needed.

Keywords Tobacco Use, Adolescents, School-based

Poster presentations: Topic 15, Monday March 28 248 15.6 Child exposure to environmental tobacco smoke during prenatal and postnatal period

P.K. Polanska, H.W. Wojciech Nofer Institute of Occupational medicine, LODZ, Poland

Background Environmental tobacco smoke exposure (ETS) is associated with poor pregnancy outcome including increases risk of spontaneous abortion, stilbirth, low birth weight, preterm delivery and sudden infant death syndrome. ETS exposure after birth can increase the risk of sudden infant death syndrome, respiratory infections, asthma, middle ear diseases or even cancer and it can cause neurodevelopmental and behavioural problems in children.

Objectives The aim of the study was to evaluate the prenatal and postnatal child exposure to environmental tobacco smoke.

Methods The study population consisted of women from Lodz, Poland among which detail questionnaires were conducted three times during pregnancy period. From all women included into the study the saliva sample was collected to verify smoking status in pregnancy. One and two years after delivery additional questionnaires were performed and urine sample from all children was collected. The cotinine level in saliva and urine was analyzed using Liquid Chromatography with Tandem Mass Spectrometry (LC-MS/MS ESI+).

Results About 22% of the children were expose to ETS during prenatal and 46% in postnatal period. Cotinine level in children’s urine statistically differentiated children from smoking mothers (geometric mean (GM) 11.4 ng/ml; 95% CI 7.1-18.3) and in exposed homes (GM 7.3 ng/ ml; 95% CI 3.6-15.0) compared with non-exposed homes (GM 1.3 ng/ml; 95% CI 0.9-1.7) (p<0.001).

Conclusions High percentages of children are exposed to ETS during prenatal and postnatal period.

Implementation Children should be more protected from ETS exposure in prenatal and postnatal period.

Poster presentations: Topic 15, Monday March 28 249 15.7 Second Hand Tobacco Smoke exposure in Switzerland

C.K.H. Huynh1, J.B.M. Moix2, A.D. Dubuis2, R.S.B. Babel3, Y.S.E. Emmenegger4, M.P. Pasche5, J.C. Cornuz6, J.C.R. Rielle7 1Institute for Work and Health, LAUSANN…, Switzerland 2 Ligue Valaisanne contre les Maladies Pulmonaires et pour la Prévention (LVPP), SION, Switzerland 3Vivre sans fumer, Centre neuchÃ¢telois d’information pour la prévention du tab, N…UCHAT…L, Switzerland 4CIPR…T FRIBOURG-FR…IBURG Centre d’information pour la prévention du tabagisme, FRIBOURG, Switzerland 5CIPR…T Vaud, LAUSANN…, Switzerland 6Policlinique Médicale Universitaire (PMU), LAUSANN…, Switzerland 7CIPR…T Genève, Centre d’information pour la prévention du tabagisme, G…N…V…, Switzerland

Objectives This study, unique in Switzerland, has established a base map on the population’s exposure to Second Hand Tobacco Smoke (SHTS).

Methods A passive sampling device called Monitor of NICotine or “MoNIC”, was constructed and evaluated by IST laboratory for determining nicotine in SHTS. Vapor nicotine was passively collected on a potassium bisulfate treated glass fiber filter as collection medium. Analysis of collected nicotine on the treated filter by gas chromatography equipped with Thermoionic-Specific Detector (GC-TSD) after liquid-liquid extraction of 1mL of 5N NaOH : 1 mL of n-heptane saturated with NH3 using quinoline as internal standard. Based on nicotine amount of 0.2 mg/cigarette as the reference, the inhaled Cigarette Equivalents (CE) by non-smokers can be calculated. Using the detected CE on the badge for non-smokers, and comparing with amount of nicotine and cotinine level in saliva of both smokers and exposed non-smokers, we can confirm the use of the CE concept for estimating exposure to SHTS. The regional CIPRET (Center of information and prevention of the addiction to smoking) of different cantons (Valais (VS), Vaud (VD), NeuchÃ¢tel (NE) and Fribourg (FR)) are going to organize a big campaign on the subject of the passive addiction to smoking. This campaign took place in 2007-2009 and has for objective to inform clearly the Swiss population of the dangerousness of the passive smoke. More than 3’900 MoNIC badges were gracefully distributed to Swiss population to perform a self-monitoring of population exposure level to SHTS, expressed in term of CE. Non-stimulated saliva was also collected to determine SHTS biomarkers nicotine/cotinine levels of participating volunteers.

Results Results of different levels of CE in occupational and non-occupational situations in relation with SHTS were presented in this study. It underscored the fact that all the Swiss people involved in this campaign (N=1571) is exposed to passive smoke, from <0.2 cig/d (10.8%), 1-2 to more than 10 cig/d (89.2%). In the area of high exposure (15-38 cig/d), are the most workers in public restaurant, cafe, bar, disco.

Conclusions By monitoring SHTS tracer nicotine and its biomarkers, salivary nicotine and cotinine, it is demonstrated that the MoNIC badge can serve as indicator of CE passive smoking. It is also demonstrated that the salivary nicotine (without stimulation) is a better biomarker of SHTS exposure than cotinine.

Poster presentations: Topic 15, Monday March 28 250 Implementation Nearly 90% of Swiss people are exposed to SHTS. 10.8% of them are exposed to more than 10-38 cig/day (workers of restaurants, coffees, bars, discotheques). By monitoring SHTS tracer nicotine and its biomarkers, salivary nicotine and cotinine, it is demonstrated that the MoNIC badge can serve as indicator of CE passive smoking.

15.8 Attitudes of Hotel Industry Executives on the Japanese TC legislation

M.K. Kitada Sapporo gakuin Uni., …B…TU, Japan

Background Japan is internationally renowned for being behind in tobacco control (TC) measures. In Japan, as of May 1st 2003, a Health-promotion law suggesting TC measures was introduced for first time. Recently, smoking restrictions in schools, hospitals and public facilities have improved and many municipalities have prohibited street smoking. However, restaurant and hotel TC measures have been left behind. This study examined the executive of Hotel industry attitude toward the smoke free policy.

Methods A cross-sectional survey of hotel executives were carried out in 2008 (240 hotels in Hokkai- do) and in 2009 (2587 hotels in 46 prefectures excluding Hokkaido). We conducted a self- administered survey of hotel industry that were contracted to a travel agency and asked questions regarding their tobacco control measures.

Results We received responses from 1102 hotel executives (response rate: 40.0%). 441 hotels (43.8%) among these hotels reported that they offered non-smoking room. The average of the ration of the non-smoking room in each hotel was only 11.1%. Restrictions in public spaces (smoke-free front desks, restaurants and cafÃ©s) have been insufficient as a whole. In particular, this study indicated that Japanese-style inns needed to promote TC as soon as possible.

Almost 70% of the hotels conducted the tobacco control implementation after the Health Promotion Law introduced within 5years. Despite the Health Promotion Law has introduced for 6 years, 161 (14.8%) executives did not know about this law. Further, only 342(31.6%) executives answered that have known about this law very well. What is more, only 128(11.9%) executives agreed with establishment penalty of Health Promotion Law. On the contrary, 423(39.2) disagree and 527(48.9) didn’t show own opinion. Moreover, 419(38.7%) answered that need to enactment the smoke-free law such as other developed countries. However, 121(11.2%) disagree and 543(50.1%) didn’t show own opinion.

Conclusion The present survey suggested that hotel industries have smoking restrictions, which are insufficient. The Health Promotion Law’s weak regulation generates a patchwork with gaps in antismoking implementation and what is more, there is a danger that the variability in antismoking measures is expanding. Hotel guests and customers will be exposed the harmful second hand smoke depending on their chosen accommodations. Moreover, the employees who work there are in more danger as they are exposed to second hand smoke more than the guests.It is necessary to enact laws that are further advanced than this weak health promotion law regulatory control to protect the health of all people.

Poster presentations: Topic 15, Monday March 28 251 15.9 Impacts of comprehensive tobacco control programming in a rural Midwestern US state.

L. Cornish, M. Lutz University of Northern Iowa, C…DAR FALLS, United States of America

Multiple strategies for reducing tobacco use have been shown to be effective, but their combined effects versus individual effects are not clearly understood. Iowa, a rural Midwestern US state, implements comprehensive tobacco control programming at multiple socioecological levels. Important strides in policy change have been made in the state, including a 2007 tax increase of $1.00 to $1.36 per pack and the passage of a statewide Smokefree Air Act in 2008. Statewide Priority Population Networks have been established to address tobacco use prevention and cessation among minority populations. Mass media interventions have been implemented across the state to raise awareness among Iowans of policies and services. Just Eliminate Lies (JEL) is a state-supported, youth-led, anti-tobacco program that promotes peer education and leadership at the local level to prevent tobacco use among Iowa youth. State-funded cessation services have provided no/low-cost counseling and pharmacotherapies to individuals. Multiple survey data sources indicate that smoking rates among youth and adults in the state have decreased. However, several important threats to the continuation of this decrease remain. The current research examines the influences of the multiple strategies that have been employed with considerable success to address tobacco use prevention and control.

15.10 Youth Smoking in Poland: results of three rounds of the Global Youth Tobacco Survey

J. Lobaszewski, K. Przewozniakk, W. Zatonski The Maria-Sklodowska Curie Cancer Center and Institute of Oncology, WARSAW, Poland

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 aged 13-15 in 1999 (N=3,209), 2003 (N=3,693) and 2009 (N=3,282)

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 neighboring eastern countries, 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. In 2001, 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 positive impact both on youth behaviors, as 40% of schoolchildren declared that they decided against taking up smoking because of the ad ban. The results of the latest study confirm a constant decrease in percentage of students aged 13-15 who had ever tried to smoke a tobacco product (62% in 1999 and 49% in 2009). Furthermore, the proportion of pupils who first tried to smoke before the age of 10, dropped from 31% in 1999 to 23% in 2009. At the same time, we have observed negative changes in smoking behaviors and attitudes of schoolchildren. This especially

Poster presentations: Topic 15, Monday March 28 252 concerns growing percentage of youngsters declaring use of tobacco products other than manufactured cigarettes. For example, percentage of pupils smoking hand-rolled cigarettes rose from 20% in 2003 to 26% in 2009 and proportion of water-pipe (shisha) users have doubled over the same period of time (from 5% to 10%, respectively). At present, current smokers are also less likely to quit (48% in 2009 compared with 77% in 1999). It may result from lower percentage of students who received any help in quitting dropped by 10% (from 61% in 1999 to 51% in latest GYTS study).

Conclusions Three rounds of GYTS study in Poland have confirmed the positive effects of tobacco control measures that have been implemented over last decade. At the same time, study results reveal new challenges in reducing the prevalence of youth smoking in Poland.

Implementation GYTS results suggest to intensify tobacco control program for youth. Most important is to control exposure of children and young people to tobacco smoke at home and ban smoking in public places, to introduce pictorial health warnings on cigarette packs, substantially rise cigarette prices and denormalize smoking as a social norm.

Poster presentations: Topic 15, Monday March 28 253 Topic 17: Successes or failures in the tobacco control advocacy

17.1 Education, Communication, Training and Public Awareness of Tobacco Control in the Republic of Serbia

M. Lazovic1, I.P. Pesic2 1Hospital, CACAK, Serbia 2Institute for pulm. Dis., B…LGRAD…, Serbia

All activities carried out in the Republic of Serbia (RS) in the past few decades have mainly resulted in the Ministry of Health’s unsuccessful attempts to solve the tobacco control (TC) problem partially, either by conducting short-term health promotion campaigns or by trying to regulate legally certain aspects of TC. The National Committee for Smoking Prevention of the Ministry of Health (NCSP), formalized in March 2003., has reviewed the need of a wide spectrum of measures and activities proposed in the European TC Strategy and WHO FCTC.

Some of strategic framework TC of the RS: education, communication, training and public awareness of harmful effects of tobacco consumption. The public awareness will include provision of comprehensive, accessible and effective programs concerning at least the following: a) providing information on health risk and addictive characteristics of tobacco consumption and exposure to second hand tobacco smoke, b) education on the benefits of smoking cessation and tobacco-free lifestyle, c) providing a wide range of relevant information on the activities of the tobacco industry, d) training on TC issues for health professionals, inspectors, community workers, social workers, media professionals, teachers, administrators and other concerned persons, e) Warning against harmful effects of tobacco production and consumption on health, economy and environment.

The organizers: Ministry of Health ( TC Office and NCSP), Ministry of Education and Sport, Ministry of Labor, Employment and Social Policy. The activities: • Workshops for policy makers, regarding the need for more smoke-free health institutions, work places, schools and public places. • Workshops for health care workers and teachers on smoking related health hazards, addiction to nicotine, tactics of tobacco industry and promotion of health lifestyles. • Media campaign for the National No Tobacco Day (January, 31.) • Media campaign for the World No Tobacco Day ( May, 31.) • International campaign “Quit and Win” • Organization of specific campaigns for the high risk population groups.

The significant activities: Support to the development of the network of smoking cessation counseling services, support to health professionals in their attempts to quit smoking, as well as training of health professionals on the primary health care to offer assistance in smoking cessation and participation in drafting legislation on tobacco control RS.

Poster presentations: Topic 17, Monday March 28 254 17.2 Gender based analysis of tobacco use and tobacco policy perception in student population of BiH/RS

J. Zivkovic1, S.S Stojisavljevic2, L.J.J. Jandric2, J.B. Bojanic2 1Public Health Association of Repubic of Srpska, SAMAC, Bosnia-Herzegovina 2PHI, BANJA LUKA, Bosnia-Herzegovina

Introduction Bosnia and Herzegovina`s entity Republika Srpska adopted national anti tobacco strategy 2004 and in the same time introduce three national laws related to tobacco - public places smoking ban, tobacco advertising ban and tobacco selling prohibition to the persons age under 18. Smoking rates in general population is 33.6% (year 2002 - household survey), but habits, rates and attitudes of students population, as one of high risk group, and their gender based perception of tobacco control strategies was not known.

Methodology Self reported cross section study among 12000 students population University of Banja Luka, randomized sample size n=2000, conducted during October 2009 with two standardized instruments - anonymous questionnaire and interview .

Results Smoking rates among students (M=27,6% , F=30%) are bit lower comparing to general population rates. 10% of student smokers start smoking during studies. Tobacco strategy and existing legislation is familiar only to the half of students. Knowledge related to tobacco control policy is insufficiently presented in this risk group. Economical, financial and political influence of tobacco industry is underestimated. There are no significant gender differences related to the tobacco use, perception and attitudes. More then half student population does not expect any significant changes in tobacco control during next year.

Conclusion There is strong need for better approach in terms of policy making, tobacco control and implementing prevention programs. Existing tobacco control policy and legislation need to be changed in order to get more influence to the specific high risk target groups.

17.3 Strengthening voice of Public Health Association of Serbia in tobacco control trough research and advocacy

S.S. Simic, S.K. Krstev, D.M. Matijevic, A.K. Kotevic Public Health Association of Serbia, B…LGRAD…, Serbia

Public Health Association of Serbia was established in 2003 with technical and financial support of the Canadian Public Health Association trough CIDA funded regional public health projects in the Balkans. Since then, the public health association movement plays an important leadership and advocacy role in tobacco control. It mobilizes public health community and gives voice to civil society’s perspective on this issue. It took initiative in important research providing for the first time in Serbia data about smoking prevalence among specific population groups.

Research GYTS was implemented in over 300 schools in Serbia in 2003, and after that was repeated in 2008 to investigate smoking prevalence, knowledge, attitudes and behavior with respect to

Poster presentations: Topic 17, Monday March 28 255 tobacco consumption and the health risk related to smoking among youth. In 2006, the pilot Global Health Professionals Survey (GHPSS) was carried out in the facilities of medicine, dentistry and pharmacy at Belgrade University. The National survey on pre-and post natal smoking was implemented in 2008 and 2009 with sample of 2721 women who gave birth from April to June 2008. This marked the first time that a study on this particular population group was carried out in Eastern Europe. PHAS has been conducting in 2009 the study Assess- ment of smoke-free policy and practice in healthcare institutions in Serbia implemented in all health care institutions and providing data about the smoking prevalence among employees in those institutions. Results of these researches indicate high smoking prevalence in youth (8.5% pupils age 13-15 are currently smoke cigarettes and 2.1% of them are daily smokers); more than a third a women (37.2%) ever smoked at some point during the course of pregnancy, whether regularly (23.4%) or occasionally (13.8%); and overall smoking rate in health care institutions is 39.9% - higher than national rate for adults (33.6%). For physicians is 29.1%, nurses 41.7% and other health staff - 42.8%.

Advocacy Significant decrease of smoking prevalence in Serbia was achieved last few years (more than 7%) with implementation of numerous activities including those underwent by PAHS in partnership with governmental and non-governmental sector. Briefings with media are regularly organized at events marking National no-smoking day (January 31st) and World no-smoking day (May 31st). To inform public and decision-makers about urgency of the tobacco control -related issue and the need to improve quality and effectiveness of smoking prevention and cessation services, facts sheets and booklets with results of studies were distributed and used as teaching aid for journalist, teachers and health professionals in series of seminars. Mobilization of PHAS members in tobacco control is constant priority of the first NGO in Serbian public health scene.

17.4 Local solution for a national problem: ‘Smoke-free Almaty’ initiative

A. Zhylkaidarova National Center for problems of healthy lifestyle development, ALMATY, Kazakhstan

Tobacco control advocates’ most notable achievement over the past couple of years occurred at the local level in Almaty, the Kazakhstan’s commercial and media capital and its most populous municipality. The initiative called “Smoke-free Almaty,”resulted from a successful grassroots campaign showcasing the determination of healthy lifestyle specialists and members of coalition “For smokefree Kazakstan”to collect irrefutable evidence for their advocacy efforts. The resulting video presentation was shown at a public hearing attended by media and several key officials in the local government. In response to this highly effective monitoring and advocacy activity, the officials acknowledged shortcomings in enforcing the national law and vowed to improve. They allocated 41 million tenge (US$315,000) for 2006-2007 and 196 million tenge (US$1307,000) to create “Smoke-free Almaty”. This marked the first such specific allocation for a tobacco control initiative by any government entity in the entire Commonwealth of Independent States.

Smoke-free Almaty, specifically geared to reduce smoking among Almaty residents, has five action priorities: 1) Rolling out education campaigns about the risks of smoking; 2) Providing smoking-cessation assistance, including the establishment of a Quit line and other support services; 3) Mobilizing key elements of society against tobacco, including youth groups; 4) Launching and sustaining a media information campaign; 5) Monitoring and evaluating the effectiveness of the overall initiative as well as enforcement of existing tobacco laws.

Poster presentations: Topic 17, Monday March 28 256 The education campaigns are the core of the initiative because education and awareness- raising are necessary elements of all the other priorities as well. Initiative organizers are working closely with coalition members to develop strategies and programs to meet the priorities. For a start, they are focusing on antitobacco messages on TV and radio; training programs for health professionals, teachers, and youth leaders; and innovative outreach efforts such as encouraging theaters to present antitobacco messages before performances.

The first results of the program have shown a vital, positive effect. Smoking rates among medical professionals have decreased from 32% till 15%, among youth - from 17% till 14%. An awareness on tobacco among target groups of the population have increased.

Advocates are using the new local government initiative as a model for other cities and regions throughout the country to adapt. Astana, Kazakhstan capital city, has supported the initiative and enforce the similar program since 2011.

17.5 Davideath vs. Davidoff: how to defeat Big Tobacco

P.A. Diethelm FCA, OxyRomandie and CNCT, G…N…VA, Switzerland

During the 4th European Conference on Tobacco or Health, in October 2007, attendees could see all over the city of Basel posters and big signboards announcing the Davidoff Swiss Indoors, with a picture of tennis star Roger Federer just below the logo of the famous cigar and cigarette brand. The Davidoff Swiss Indoors was the last tennis tournament in the world still sponsored by a tobacco company. At the 2007 conference, a petition was launched, addressed at Roger Federer and asking him to refuse that his name, image, and his huge popularity with the youth, be used to advertise tobacco. The petition subsequently was signed by over 500 eminent tobacco control and public health people all over the world. This was the first step of a fight which involved NGOs from several countries, under the coordination of OxyRomandie, and which culminated with the announcement, in August 2010, of the premature termination of the sponsorship contract between Davidoff and the organizer of the tournament. This was hailed as a major victory for tobacco control.

The way this victorious outcome was achieved contains interesting lessons for tobacco control, considering in particular that it was achieved in a country, Switzerland, with a very strong presence of the tobacco industry, which exercises intense lobbying on political decision making. Furthermore (or consequently) Switzerland has weak tobacco control legislation and will most likely be the last country in Europe to ratify the WHO FCTC.

From the outset, our approach was multi-pronged, comprising public communication, direct communication aimed at some of the stakeholders (mainly ATP) and legal actions. To circumvent lack of adequate law in Switzerland, French law and European directives were used. Pressure was put on ATP in the UK. These actions involved several NGOs, notably ASH UK, ASH Scotland, CNCT in France, all coordinated by OxyRomandie. A website (www.davideathswissindoors.ch) and a logo parodying the official Davidoff Swiss Indoors logo were created. The tobacco sponsors tried to close down the site, but their move was rejected by the Basel civil rights court. In France, television channels which had broadcasted the tournament were sued by CNCT. OxyRomandie filed a complaint against the Swiss national television, which went up to the Swiss Federal Tribunal. In England and in Scotland, the Ministry of Health was alerted and pressure was put on ATP. The issue got good international coverage in the media.

Poster presentations: Topic 17, Monday March 28 257 On 10 August 2010, the Basler Zeitung had a full page article with headline saying: “The name ‘Davidoff’ falls down: the pressure by the anti-tobacco organization was too strong.”This shows that, with proper coordination and well targeted actions, a few determined NGOs, acting internationally, and in spite of very limited financial resources, can indeed defeat Big Tobacco.

Poster presentations: Topic 17, Monday March 28 258 Tuesday March 29 2011 Intervention related poster presentations

Topic 7: Social inequalities in smoking/tobacco related health disparities

Topic 8: Strategies to reach and support/educate lower socio-economic status (SES) groups

Topic 9: Interventions for smokers with multiple risk behaviours - e.g., other addictions, co-morbidity, mental health problems

Topic 10: Novel tobacco treatment interventions

Topic 11: The role of health pr ofessionals

Topic 12: Health education and health communication - eg., mass media campaigns, health communication interventions, youth education programmes

Topic 16: Implementation of evidence based interventions in daily practice: barriers and facilitating factors

259 Topic 7: Social inequalities in smoking/ tobacco related health disparities

7.1 National research on pregnant women smoking habit

Lazovic, M., Hospital, Cacak, Serbia Vasilijevic, D.V., Cacak, Hospital Pesic, I.P., Belgrade, Institute for pulm. Dis

In a research among pregnant women, data were collected on smoking prevalence pre, during and post pregnancy, exposure to second hand smoke, successful smoking cessation and health of newborns.

Method: stratified two-stage cluster sample 2721 women, using specifically constructed questionnaire. The average age of women was 28, half of all women are primiparae, half of all women had a high school education.

Results: 35,7% smoked before conception, 37,2% smoked during the pregnancy, 10 cigarettes on average before pregnancy and 9 during the pregnancy. Exposure to SHS at home: 57,7% pregnant women exposed, 67,4% of those who smoke at home are husband, 84,6% pregnant women allow smoking at home. Successful smoking cessation: 23,2% stopped smoking during pregnancy and did not start 6 months post partum, 11,8% stopped smoking after first visit of the patronage nurse and did not start at 6 months post partum. Health of newborns (2700 were born in the study period): 3933,3 g is an average weight of newborns. Newborns whose mothers smoked before conception and during the pregnancy had lower birth weights.

Conclusion: Smoking prevalence of pregnancy and exposure to SHS is significant number. Smoking is a significant health hazard of newborns and parents, there is no safe exposure to SHS, all people must be protected from SHS and all people have the right to live and work in smoke free place. It is necessary to establish counseling for giving up smoking young women, it is need continuing education about exposure to tobacco, legal protection non-smokers.

7.2 Longitudinal assessment of smoking cessation rates across social groups in a hospital population

K. Doherty1, L.D. Daly2, A.C. Clarke2, P.F. Fitzpatrick2, C.K. Kelleher2 1St. Vincent’s University Hospital, DUBLIN, Ireland 2University College Dublin, DUBLIN, Ireland

Few longitudinal studies have examined smoking cessation in a hospital population where there is an inherent social stratification. The aim of this analysis was to examine how socio- economic inequity impacted on subsequent smoking patterns in patients admitted to a general public teaching hospital. This was a cohort study of a quasi-systematic sample of 1086 smoking inpatients, with a follow-up rate at six months of 76.7%. A baseline questionnaire was administered during

Poster presentations: Topic 7, Tuesday March 29 260 admission and a further questionnaire at follow-up. Reported smoking cessation at follow-up was biochemically validated. Education levels, employment status and entitlement to free medical benefits (General Medical Service [GMS]) were used as indicators of socio-economic status. The Fagerstrom Test was used to measure nicotine dependency.

The overall validated point prevalence smoking cessation rate was 11.4% at follow-up. The continuous smoking cessation rate was 7.3%. Multi-variate analysis identified several socio- economic factors associated with high levels of nicotine dependence during admission: low levels of education, unemployment or being unable to work due to sickness/disability. Similarly, those uninterested in quitting had lower levels of education. At follow-up, being strongly motivated to quit was associated with successful quitting (OR 2.0 [95% CI: 1.2 - 3.4]). However there was no evidence of independent relationships between the socio-economic factors and successful quitting. Patients with GMS entitlement were less likely to quit but not significantly so (OR 1.4 [95% CI: 0.9 - 2.2]).

For those with socio-economic disadvantage, smoking cessation interventions should be geared initially to increasing motivation to quit, with appropriate follow-up supportive measures.

7.3 Efforts aimed at reaching immigrant groups and immigrant associations for the purpose of preventing tobacco

O. Haglind …nvironment Administration, GOT…BORG, Sweden

About 21 per cent of the population of the City of Gothenburg, Sweden, have an immigrant background. The largest immigrant groups come from Iran and Iraq, each comprising about 10,000 people. Both international and national experience shows that several of these groups smoke more than Swedish born people.

In 2004 and 2005 a project was carried out in Gothenburg with the aim of reaching immigrant groups with Serbo-Croat-Bosnian and Arab backgrounds for tobacco preventive purposes. In 2009 the city obtained renewed funds to continue the work for two years, though now with more immigrant groups and a broader onset. Funds come from the National Institute of Public Health.

The project is founded on the goal determined by the Swedish Riksdag of halving tobacco smoking by 2014 among groups that smoke most.

The project commenced with a broad epidemiological survey of immigrant groups’ countries of origin, geographical distribution in the city and smoking habits. A list of the various immigrant associations was drawn up.

The efforts have had the goal of reaching the boards of immigrant associations and a number of discussion meetings and working meetings have been held. The immigrant associations have also had the opportunity of financial support in the form of mini-projects with the aim

Poster presentations: Topic 7, Tuesday March 29 261 of getting association members to stop smoking. Some immigrant associations have only had women members, others have several hundred members, others considerably fewer. One important part of the project has been to reach people who in their work meet immigrants that smoke and make it possible for such people to bring up the use of tobacco as part of their advisory service and support. On such occasions the contact method of Motivational Interviewing - MI - can be used. Teaching initiatives on MI have therefore been addressed to social workers that administer matters of financial support, employees of the National Insurance Office and the Employment Office, teachers of SFI, civic PR officers and interpreters.

Other important efforts have been to create smoke-free environments where immigrant groups meet, such as in connection with music and carnival events. Another initiative has been to enhance interest in stopping smoking in connection with Ramadan - when several immigrant groups are included in the prohibition against smoking in the daytime.

The project has been successful, but collaboration with the immigrant associations requires the efforts to offer mutual benefits and a working methods that inspire confidence.

7.4 East-West Gap in Smoking Prevalence in Europe

M.M. Manczuk, W.Z. Zatonski Cancer Center and Institute of Oncology, WARSAW, Poland

Objective The aim to this work is to examine differences in smoking prevalence between western (EU15) and eastern (EU10) part of European Union.

Data source and methods Data come from nation-wide surveys or census studies conducted among adults in 2002 or neighboring years in 25 EU countries and Russia. Data were submitted by collaborators from each country.

Data were cleaned and weighted by world standard population to ensure maximum possible comparability and analyzed separately for current smokers, former smokers and never smokers and separately for men and women. Data were aggregated into age groups: 20-64 years (also in subgroups: 20-44 and 45-64) and 65+.

Results The prevalence of current smoking in men aged 20-64 years is higher in the EU10 countries (42.7%) than in the EU15 countries (35.5%). Among the EU10 countries, Slovenia has a lower (30.1%), Czech Republic has a similar (35.4%), and Romania (37.6%) and Slovakia (39.2%) have a slightly higher prevalence than the average of the EU15 countries. In Latvia and Bulgaria, smoking prevalence exceeds 50%, while in Estonia, Poland, Lithuania and Hungary it ranges from 40% to 50%. The highest rates in the EU10 countries are comparable to those in Greece (51%) and Portugal (47.2%), but are still much lower than those observed in Russia (66.2%) where they reach the highest level in Europe. These patterns characterize both young adult (20-44 years) and middle-aged (45-64 years) male population.

In contrast to men, there are no major differences in women’s smoking between the EU10 and the EU15. The average prevalence of current smoking in women aged 20-64 years is slightly higher in the EU15 (27.4%) than in the EU10 (24.8%). The differences in smoking prevalence between countries are larger in the EU10 than in the EU15: Bulgaria has the high-

Poster presentations: Topic 7, Tuesday March 29 262 est prevalence in Europe (32.5%), while Romania (12.5%) and Lithuania (13.2%) have the lowest. In addition to Bulgaria, smoking prevalence in adult women exceeds 30% in Hungary and Poland, as well as in Portugal, Greece and the Netherlands. In young adult women (20-44), average smoking prevalence is higher in the EU15 (31.2%) than in the EU10 (26.3%); in Greece, Portugal and Bulgaria, the prevalence exceeds 40%. In middle-aged women (45-64 years), smoking prevalence in the EU10 (22%) is similar to that in the EU15 (21%), and Poland is the leading country in this age group (30.8%).

Conclusions Male smoking prevalence is higher in central and eastern Europe than in western Europe (EU15). In women smoking prevalence is still slightly lower in EU10 countries than in the EU15.

The study revealed considerable variability across countries in survey methods. Raw comparisons of prevalence rates are highly misleading. There is a need to develop more consistent of tobacco surveillance in Europe.

7.5 Smoking rates in pregnant women one year before and after the Irish workplace smoke-free policy

Z.K. Kabir1, H. McAvoy2, U. Reulbach3, J. Wilde2, E. McNamee4, V. Clarke1, S. Daly4, L.C. Clancy1 1TobaccoFree Research Institute, DUBLIN, Ireland 2Institute of Public Health, DUBLIN, Ireland 3Trinity College, University of Dublin, DUBLIN, Ireland 4Coombe Women and Infants University Hospital, DUBLIN, Ireland

Objectives To examine smoking rates during pregnancy among Irish mothers across selected socio- economic and demographic maternal characteristics one year before and after the Irish workplace smoke-free policy introduced in March 2004.

Methods Individual-level data on mothers’ with singleton live-births was abstracted from a tertiary-level university teaching hospital in Dublin for the years 2003 [n=7,593] and 2005 [n=7,648]. Variables included maternal age, ethnicity, marital and employment status (working and not working). Mothers who responded ‘yes’ to both “Are you an ever-smoker and do you smoke now”during their first ante-natal visits were classified as current smokers. Age-standardized smoking rates for the two main sub-groups (working vs. Not working) across the covariates available were estimated based on demography of women of child-bearing age in the 2002 Census. Age-standardized smoking prevalence ratios (PR) with 95% confidence intervals (CI) were computed overall, and for each of the covariates comparing not working mothers with working mothers for 2003 and 2005 separately. Relative Index of Inequality (RII) in age-standardized smoking rates was computed (comparing not working with working mothers) for each calendar year based on relative ranking (0 to 1) and then regressing the cumulative percentile distribution of these two sub-groups within each year. 95% CIs of RII were generated utilizing Proc GENMOD program in SAS. For comparison, aggregate-level smoking data for Northern Ireland (NI) pregnant mothers by mother’s socio-economic groups were collected for [2000 (n= 1722) and 2005 (n=1830) when NI did not have a comprehensive smoke-free policy in place.

Poster presentations: Topic 7, Tuesday March 29 263 Results Overall, there was a 12% significant decline in crude smoking rates from 23.4% [in 2003] to 20.6% [in 2005]. Age-standardized smoking rates in mothers not working and those working declined: [31.3% to 29.9%] (p=0.31) and [18.1 to 15.9%] (p=0.02), respectively. PRs were higher in 2005 compared to 2003 overall [1.73 (95% CI: 1.58-1.90) vs. 1.89 (1.71-2.08)], and also by age, ethnicity and marital status when comparing mothers not working with those working. RII for 2003 and 2005 were 0.65 (0.50-0.81) and 0.79 (0.62-0.96), respectively. A similar pattern in PRs was observed in NI: 1.72 [95% CI: 1.38-2.14] in 2000 and 1.81 [95%CI: 1.23-2.67] in 2005. Smoking rates in NI also declined [23 to 18%] (p<0.05).

Conclusions Overall smoking rates in pregnancy remain high on the island of Ireland, especially in those who were unemployed. A significant decline in overall smoking rates in pregnant mothers one year after the Irish smoke-free policy was observed. However the disparity in smoking rates observed between employed and unemployed women has widened by 22% between 2003 and 2005. Tobacco control and smoking cessation approaches must develop successful approaches to targeting unemployed women in early pregnancy if social inequalities in birth outcomes and women’s health are to be tackled.

7.6 Widening inequalities in smoking rates in the Republic of Ireland?

Z.K. Kabir1, H. McAvoy2, U. Reulbach3, J. Wilde2, L.C. Clancy1 1TobaccoFree Research Institute, DUBLIN, Ireland 2Institute of Public Health, DUBLIN, Ireland 3Trinity College, University of Dublin, DUBLIN, Ireland

Objectives To assess patterns in adult smoking rates in Ireland across two main socio-economic indicators: level of education and social class (SC), using national cross-sectional survey data from 1998 and 2007.

Methods Complete smoking-related information on adults (‰¥18 years) for 1998 [n=6,293] and 2007 [n=10,251] were analysed utilizing the SLAN (Survey of Lifestyle, Attitudes and Nutrition) survey data. Self-reported smoking data were analysed according to a set of socio-economic indicators. Age-standardized smoking rates for each of the two main indicators were computed overall and by sex based on demography of adult populations in the 2002 Census as the standard population by SC and educational levels. Relative index of inequality (RII) in age- standardized smoking rates was computed (comparing the lowest with the highest socio- economic groups) for each calendar year based on relative ranking (0=highest; 1=lowest) and then regressing the cumulative percentile distribution of the sub-classes within each year. 95% confidence intervals (CI) for RII were generated employing Proc GENMOD procedure in SAS statistical software.

Results Overall, sample-weighted smoking rates declined from 33% (in 1998) to 29% (in 2007) in the population. However, table 1 shows that the lowest SC groups recorded 51% higher smoking rates compared to the highest SC smoking rates in 1998 and this widened relatively by 37% to 70% in 2007. Smoking rates among those with lowest education widened relatively by 40% (from 35% to 49%) between the two time-periods compared to the highest groups. In general, smoking rates in lower socio-economic group females have increased more relative

Poster presentations: Topic 7, Tuesday March 29 264 to their male counterparts between the two time-periods.

Conclusions Overall, smoking rates have declined in Ireland over a 10-year period but using ‘a’ relative index of inequality measure, social inequalities in smoking rates have significantly widened in lower socio-economic groups during the same time-period, worsening further among disadvantaged females. Tobacco control policy and specifically the treatment of tobacco dependence need to target this population and be combined with socio-economic interventions to address these inequalities.

7.7 The contribution of betel quid chewing to the smoking attributable mortality in Taiwan

C.P. Wen, H.T.C. Chan, M.K. Tsai National Health Research Institutes, MIAOLI, Taiwan

Background and objectives Chewing betel quid became increasingly popular ever since cigarette market was forced open by the U.S. in 1987 Now, one third of smokers chew betel quid in Taiwan, nearly 2 million adults, and the habit is sustained by the continuation of smoking. While smoking attributable mortality (SAM) has been reported for 2001, the role of betel quid chewing remains to be assessed.

Method The cohort, 430,087 adults from a standard medical screening program since 1996, was followed up till 2007 in Taiwan. Questionnaire on smoking and betel quid chewing were collected at the initial visit. Hazard ratios (HR) were calculated by Cox model. Deaths information was ascertained as of 2007.

Results The cohort was followed up during 1996-2008 and 9,858 deaths were identified. The smoking rate was 44% for males and 5.5% for females while the chewing rate was 19.3% in males and less than 1% in females. All cause risk for current smokers was 1.69 but those with chewing, 2.29, doubled the excess risk in smoking. More than 20,000 deaths a year in Taiwan were attributable to the combined effect of smoking and betel quid chewing by the 1.5 million male adults. Another 11,350 deaths were attributable to smoking by 3 million smokers without chewing betel quid.

Conclusion One third of all male deaths (36%) in Taiwan, 31,171, were smoking/betel quid related, consisting 65% from chewers and 35% from non-chewers, even though chewers constituted only one third of smoking population. The devastation and aggravation by betel quid chewing have not been fully appreciated in the tobacco control field in Taiwan.

Poster presentations: Topic 7, Tuesday March 29 265 7.8 Gender difference in pacient with BPOC from Romania

I.M. Munteanu, D. Mihaltan Marius Nasta Institute of pneumology, BUCHAR…ST, Romania

The aim was to analyze the association between the number of packages year and other markers of severity of COPD that can lead to hospitalization in emergency system in Romanian for identify specific issues, to decrease the number of days of hospitalization and improving quality life.The study group was composed of 151 cases, 107 men and 44 women, given that the two cases were missing information on the degree of COPD, the final study sample included 149 cases,105 men (70.5% of study sample) and 44 women (29.5% of the sample) Because we spoke about patients with COPD most of the subjects included in the study, approximately six of 10 subjects were smokers (87 cases, 59%). About one third were former smokers (48 cases, 32%) and only one of ten subjects were smoking (14 cases, 9.3%). Overall average lot packages year smoked was 39.3 ± 22.18. The analysis, however, exposure to active smoking by gender reveals that:smoking prevalence was lower in men than in women (56.2% to 63.6%): share of former smokers is higher in men than in women (39.0% to 15.9%); ne in five women do not ever smoking (20.5%), while only 4.5% in men (as one of ten cases) were non smokers ; men smoked on average 20.7 ± 41.83 packs year, compared with 33.15 ± 24.4 in women as is the media package:differences between the two subgroups (women and men) are significant statistically (Ï‡2 test, p <0.05).Only 7.4% (11 persons) of the cases included in the study said they had a lower cumulative exposure to smoking 20 packs - years, and about four in ten subjects (61.7%) were smokers with substantial exposure equal 50 packs or more - years. Inspection data using descriptive statistics indicate a prevalence of large and medium smokers (more than 40 pack-years) slightly higher among men than women.

Conclusions 1. The increase in smoking prevalence in the world in general and developing countries, like Romania, in particular, is the most important cause of increasing prevalence of COPD. 2. This increase is especially women who have COPD at earlier age than men. 3. Cumulative exposure to smoking was high, 61.7% of the patients studied were smokers, average consumption was over 43.4-year package, which shows a high degree of nicotine dependence. 4. For patients smoking exposure was correlated statistically significant levels with severity of COPD .

7.9 Tackling illicit tobacco - initiating a normative shift in our communities

A. Crossfield1, D. Wiggins1, A. Rutter2, P. Hodgson3 1Smokefree North West, MANCH…ST…R, United Kingdom 2Fresh- Smoke Free North …ast, CH…ST…R L… STR……T, United Kingdom 3Smokefree Yorkshire & the Humber, L……DS, United Kingdom

Buying and selling smuggled and fake tobacco is ingrained behavior in many of our communities, and its easy availability seriously undermines all the efforts to cut smoking prevalence and in particular to tackle tobacco related inequalities in poorer communities. It drastically reduces the price incentive to quit, encourages people to smoke more, and makes it easier for children to take up and maintain the habit.

Poster presentations: Topic 7, Tuesday March 29 266 A social marketing campaign to initiate a normative shift against illicit tobacco at community level is underway across the North of England. It has been commissioned by the North of England Tackling Illicit Tobacco for Better Health Programme, which brings together the three tobacco policy teams in the North of England, trading standards, HMRC, police and other interested agencies. Evaluation of the first phase of activity has been positive and has resulted in a significant increase in intelligence and enforcement.

The overall aims of the Programme are twofold - to reduce the supply of illegal tobacco through increased intelligence and enforcement activity, and to cut demand by increasing the belief in communities that the trade is not a victimless crime.

This conference presentation will provide an overview of the steps taken to build an evidence base on which to build the social marketing campaign, its creative development and integration with work at a national level, evaluation of impact and its further development.

The overall illicit tobacco Programme was highlighted as an example of best practice in ‘A Smokefree Future. A Comprehensive Tobacco Control Strategy for England’ published in February 2010 (now subject to review by the Coalition Government formed in May 2010).

The learning and experience of those involved in the Programme and its social marketing campaign is now helping with the development of similar activities elsewhere in the UK.

Poster presentations: Topic 7, Tuesday March 29 267 Topic 8: Strategies to reach and support/ educate lower socio-economic status (SES) groups

8.1 The design of a smokefree home leaflet and home pack: a Guernsey case study

V.K. Amey Guernsey Adolescent Smokefree Project, ST P…T…R PORT, GU…RNS…Y, CHANN…L ISL, United Kingdom

The beliefs and attitude of young mothers in relation to smokefree homes and passive smoke were explored in Guernsey and they were encouraged to contribute to the designing of a smokefree home leaflet and pack aimed at young mothers. Semi-structured interviews were conducted with 11 participants (aged 17-23 years). Most participants were smokers, however they all knew what passive smoke was and asserted that their homes were smokefree. Even if they were unable to list specific impacts of second hand smoke on children, they all agreed that children should be protected. Few described the difficulties in telling people not to smoke around their children in other people’s homes and cars. Moreover, some young mother said that they found it hard to persuade their partners not to smoke around the children. They believe that the following ideas could promote smokefree homes to young mothers: providing information about passive smoke during parents craft sessions preferably after the baby is born, giving out a pack with giveaways linked to smokefree homes, being assertive to friends and family who try to smoke around children and getting partners to be involved.

8.2 Attitudes among professionals towards socially vulnerable people and smoking cessation

H.S. Stuart, B.C. Christensen Public Health Office Copenhagen, KØB…NHAVN N, Denmark

Objectives Smoking cessation among socially vulnerable people (drug addicts, mentally ill, homeless people) pose a challenge to both public health professionals and social workers. As part of a national intervention project in Denmark, we conducted a survey on attitudes among professionals and socially vulnerable towards smoking cessation.

Methods A questionnaire with 25 questions relating to smoking patterns and attitudes towards socially vulnerable people and smoking cessation was distributed nation-wide at 76 treatment facilities and activity centres. The study population included a total of 1059 leaders, staff members, and socially vulnerable citizens. This study is followed by a qualitative study based on interviews with the socially vulnerable and members of staff regarding the relationship between the two groups when smoking cessation is introduced at the facilities and centres.

Poster presentations: Topic 8, Tuesday March 29 268 Results The prevalence of smoking is a much higher among the socially vulnerable, 61% in our survey compared to 21% of the general population in Denmark. However, just as among the general population, 33% of the socially vulnerable express the wish to quit smoking. Among leaders and staff members, only 19% believe that the socially vulnerable wish to quit smoking and as few as 16% of staff members believe that socially vulnerable people are able to quit smoking. Particularly those members of staff who themselves are smokers express attitudes that could potentially run counter to successful implementation of smoking cessation programmes. 54% of smoking staff members express the opinion that smoking together with the socially vulnerable is a tool that can be used purposefully in working with the vulnerable to improve their lives.

Conclusions Many socially vulnerable express a wish to quit smoking, but structural conditions at treatment centres and activity centres often do not facilitate smoking cessation. One of the most important barriers is attitudes among staff members, in particular staff members who themselves are smokers. This calls for a more professional attitude among staff toward the socially vulnerable regarding smoking cessation, which in turn requires leaders to take responsibility.

Implementation The results of the survey will be used by the national intervention project; firstly, as part of an argument to integrate smoking cessation activities in the daily practices of treatment facilities and activity centres; and seceondly in the development of a train the trainer concept whereby smoking cessation counsellors train local staff members to encourage the socially vulnerable to reflect upon their smoking behaviour.

Interactive possibilities We would like to invite the audience to engage in dialogue with us regarding the complexities of the relationship between the socially vulnerable and staff members.

8.3 A smoking cessation service in a disadvantaged neighbourhood: an evaluation of its reach and effectiveness

F.E. Benson1, V. Nierkens1, M.C. Willemsen2, K. Stronks1 1Academic Medical Center - University of Amsterdam, AMST…RDAM, The Netherlands 2STIVORO, the Dutch expertise centre for Tobacco Control, TH… HAGU…, The Netherlands

Objective In the Netherlands, like in the rest of Europe, approximately 20% of all deaths can be attributed to tobacco use. Quitting results in short-term effects, such as improvements of pulmonary functions and long-term effects, like lowering risk of a large number of cancers and CVD. However, a recent trend-analysis revealed that reductions in the total percentage of smokers in the Dutch population are predominantly due to smoking cessation among high educated smokers, which might explain that in the Netherlands (as well as in other countries) smoking prevalence is higher among lower socioeconomic (SES) groups. In addition, low SES smokers are less likely to use efficacious cessation aids. It is therefore crucial that effective cessation support be made more fully available to low SES smokers.

Therefore, several public health care organisations in the Hague, the Netherlands, have decided to start an experiment with a smoking cessation service in a deprived neighbourhood, i.e.

Poster presentations: Topic 8, Tuesday March 29 269 the ‘Schilderswijk’ in which the financial barrier has been removed. In this intervention smokers will be reached via several recruitment strategies, like referral by de GP and social network strategy. The smoking cessation service provides evidence based behavioural counselling and support to smokers wanting to quit, complemented with the use of Nicotine Replacement Therapy (NRT) and bupropion (Zyban). Behavioural support will be provided in group sessions and through personal counselling.

The aim of this study is to assess the reach and the effectiveness of a service on smoking cessation in the multi-ethnic population in this disadvantaged neighbourhood in The Hague.

Methods In this project both reach of smokers and effectiveness of the smoking cessation service will be assessed. To assess the reach we will use action research, i.e. continuously collect data on satisfaction, needs and reach (defined as the proportion of smokers who receive smoking cessation support) to provide public health organisations involved in the pilot feedback. To assess the effectiveness, a pre-post-test design will be used. Primary outcome measures will be the number of successful quitters and quit attempts relative to the number of smokers entering the smoking cessation service, at 4 weeks and 1 year after the intervention. Secondary outcome is the number of quit attempts during and after the intervention. Data will be collected by registration forms, structured interviews, in-depth intervies, focusgroup interviews and observations.

Expected results Datacollection will take two years untill January 2013. First data about reach are expected at the end of 2011.

Conclusion The results of this study will contribute to the knowledge regarding the reach and effectiveness of smoking cessation services in a mulit-ethnic disadvantaged neighbourhood.

Implementation The results of this study can be used to aid the wider implementation of smoking cessation activities among deprived groups.

8.4 Reaching socially disadvantaged women - policy approaches to reduce smoking during pregnancy in Germany

H. Fleitmann1, U. Sonntag2, C. Rustler3, S. Ullbricht4 1Indepent Consultant Tobacco Control, DORTMUND, Germany 2Landesvereinigung für Gesundheit Niedersachsen e.V., HANNOV…R, Germany 3Deutsches Netz Rauchfreier Krankenhäuser, B…RLIN, Germany 4…rnst Moritz Universität, GR…IFSWALD, Germany

Findings from the “ Marmot Review 2010, Fair Society, Healthy Lives” show that smoking is responsible for half of the difference in life expectancy between lowest and highest income groups and that smoking related death rates are 2- 3 times higher among low socio economic groups. On the other hand the Framework Convention on Tobacco Control emphasizes the need for a gender specific approach to increase quality and cost-effectiveness of tobacco control measures. In Germany 13% of women continue smoking during pregnancy. Average smoking rates of 20% were recorded with students, apprentices and blue collar workers compared to only

Poster presentations: Topic 8, Tuesday March 29 270 9% of white collar workers and 4% of academics. Latest available figures for the Region of Mecklenburg Vorpommern with high unemployment rates show that 46 % smoke before pregnancy, 24% still smoke during the 4 month and 20% before giving birth. If all pregnant women were non smokers 10% of perinatal cases of death, 35% of new borns with low birth weight and 15% premature birth could be avoided. Parallel to this, figures show that 50% of 17 year olds live with one parent that is smoking, 20% live with both parents smoking and 30% of parents do not leave the appartment to smoke. Developing a comprehensive policy to reduce smoking during and after pregnancy would have great public health benefits.

The German Association of women against tobacco ( FACT - Frauen aktiv contra Tabak e.V. www.fact-antitabak.de) organized a multidisciplinary workshop to identify implementation strategies on how to reach pregnant women and to increase involvement of health professionals. 28 high level representatives from welfare, medical, professional and women’s health organizations signed a common manifesto requesting policy makers, professional organizations and sickness funds to urgently take concrete measures. These include systematic and proactive identification of smoking status and offers for support, integration of tobacco prevention/ cessation in primary care, comprehensive education and training and structures for reimbursement of services. The presentation will give detailed information on how to better reach pregnant women, to increase the sense of responsibility of health professionals and social workers and how to initiate innovative approaches.

Reduction of smoking rates of mothers and reduced exposure to environmental tobacco smoke of children are closely related. Only though measures that take into account the needs and life circumstances of women especially living in socially deprived communities, will we be able to reduce smoking rates and contribute to a reduction of social inequalities in health on a wider level.

Poster presentations: Topic 8, Tuesday March 29 271 Topic 9: Interventions for smokers with multiple risk behaviours – e.g., other addictions, co-morbidity, mental health problems

9.1 Barriers for successes in smoking cessation in women

I. Pesic1, B. Bulajic-Subotic1, N.R. Lazovic2, V. Zugic1 1Institute for Pulmonary Diseases and TB, Clinical centre of Serbia, B…LGRAD…, Serbia 2Medical center „dr Misovic„ Cacak, CACAK, Yugoslavia

Objectives More than two thirds of the smokers that visit our Department are women. This review represents the evaluation of the barriers for successes in smoking cessation in woman in 2009.

Methods Before the inclusion in the smoking cessation program, women performed the physical examination. The analysis of data was performed by means of t-test for independent samples and analysis of variance (ANOVA).

Results Out of 217 women that performed the physical examination, the relapse was present in 38.3% of cases. Women was ready for the quitting (44%). Motives for smoking cessation were: personal health, family, freedom from the dependence, beauty.... Almost two thirds of the subjects (62%) have grown with parents who smoked, and now 82% of them live with smokers. Women with relapse had the average index pack/years (p/y) of 34.6. The average level of subjects’ nicotine dependence assessed by Fagerstrom test (FNTD) was 7.3. Those women were heavy smokers and dependents. In the evaluated group, high percent of them have had ilensses related to smoking, both in family (63%) and anamnesis vitar (41%) - carcinomas, COPD, stroke. The relapses occured in the period from 0.19 to 11 months, and most started within the first six months.The relapses were significantly more frequent in the first month (56%) than later p<0.001. The average age of women with relapses was 43 years. According to the treatment program, the highest number of relapses were present in women who underwent only the program of behaviour changes (45.2%), and on the other side, the least frequent relapses were in the group with combined behavioral and pharmacologic program (16.1%). Most of the investigated women did not comply the program and leaved the treatment before its end, with belief that thay have already finish the cessation process.

Conclusions After 12 and more months of the personalized program, regular follow-ups, timely interventions in the period of crisis and help via telephone contacts, intensive monitorings, the relaps occured in 38.3% of women. Although there was seriously impaired health, both in the family members and themselves, this fact did not denied more than third of the investigated women to come back to smoking. Seriously barriers were the women who unfortunately lived with parents who were heavy smokers, and later thay also became the heavy smokers. The arguments are: the age and the actve smoking - p/y very high, according to FNTD - heavy smokers,

Poster presentations: Topic 9, Tuesday March 29 272 did not comply the program and leaved the treatment before its end. Moreover, these were the women that did not have the support in their faimilies. Evaluated women live in the families with strong nicotine provocation, that are the barriers why most of them relapsed in the first month.’

9.2 What makes the difference - tobacco free or not - a study among adolescents.

I. Edvardsson, L.L. Lendahls Landstinget Kronoberg, VÄXJÖ, Sweden

Objectives The aim of this study was to identify which factors of protection that co-variates for tobacco free pupils, and if these factors differ between smoke free and snuff free pupils and if there are any differences between genders.

Methods A questionnaire study was performed on all pupils in year two in upper secondary school (17 years old) in the county of Kronoberg in southern Sweden, autumn 2009. More than 2200 pupils completed the questionnaire regarding health and life habits anonymously. Analyses were done using uni-variate and multiple logistic regression models controlling for gender, and if the pupils were smoke- and snuff free.

Results The response rate was 84 percent. The prevalence for smoke free was 80 percent for girls and 83 percent for boys. Snuff free was reported by 97 percent of the girls and 74 percent among boys. While data analyses are still being conducted we can not give the result today. The results will be presented at the conference.

Conclusions Increased knowledge about how tobacco use develops, and how different factors affect tobacco use among children and adolescents, is an important tool in health promotion and preventive activities against tobacco use for young people. That work could benefit greatly from these findings.

Implementation Knowledge about positive factors that are significant to remain tobacco free can be spread through the Department of Public Health to schools, which is the main target group.

9.3 Successful implementation of Smokefree Criminal Justice in Sweden

A.C. Algevik1, B. Holm Ivarsson2 1Swedish Prison and Probation Service, Norrköping, Sweden 2Psychologists against Tobacco, STOCKHOLM, Sweden

Objectives The smoking prevalence among prisoners and employees in prison an probation services is known to be very high and in Sweden estimated to be over 70 percent for prisoners and 50 percent for employees compared to 13 percent in the population, with a lot of smoking taking place in indoor areas. In Januari 2008 Smokefree Criminal Justice was implemented

Poster presentations: Topic 9, Tuesday March 29 273 throughout the Swedish system of prison and probation service. The main reasons to enforce restrictions on smoking were 1) to protect employees and prisoners from passive smoking in the environment, 2) to decrease the fire incidents, 3) to promote the health of employees and prisoners by decreasing the prevalence of smoking, 4) to raise work security and effectivity by prohibiting smoking during working hours for employees and 5) to underpin the work to lessen the use of illegal drugs within the prison system.

Methods After extensive discussions with different groups of employees and prisoners a tobacco prevention policy was adopted by the general director which included the following restrictions on smoking: 1) no employee or prisoner are allowed to smoke indoors, 2) prisoners are only allowed to smoke in daytime in designated areas and never in their cells, 3) prisoners who don’t want to quit smoking are supplied with free nicotine replacement products (nicotine gum, plasters) when locked up in the cells, 4) employees are not allowed to smoke during paid working hours (only lunch hour), 5) all prisoners and employees who want to quit smoking or snuffing are offered tobacco cessation therapy including free medication for cessation.

Results Several evaluations have been undertaken. The environment is almost completely smokefree. Many prisoners and employees have quit smoking. Satisfaction and compliance is high. Problems and complaints are few, and fewer among prisoners than among employees. The interest in quitting smoking and the support of the regulations has been surprisingly great among the prisoners. Results will be presented.

Conclusions Many did not believe it would be possible to enforce regulations to restrict when and where to smoke and make the environment smokefree in a tough culture like the criminal justice, but we have shown that it is definitely possible. The protests, barriers and problems have been fewer than expected although some problems remain to be solved.

Implementation Crucial factors for success: make people aware of the coming regulations long before they are actually implemented and allow questions and dicussions, a strong leadership on all levels, involvement of the employees, frequent information, networks, structured work, evidence based methods for cessation, good education and information material and endurance.

9.4 Smokeless tobacco and coronary heart disease: risks among non-smokers in Bangladesh

Objectives To determine the association between smokeless tobacco (SLT) use and coronary heart disease (CHD) among non-smoking adults in Bangladesh.

Methods A case-control study of non-smoking adults aged 40-75 years, residing within Dhaka City

Poster presentations: Topic 9, Tuesday March 29 274 Corporation areas, was conducted in 2010. Cases of CHD were selected from two cardiac hospitals; controls were selected from both hospital and community settings. Cases were classified as incident cases (diagnosed within last one-year) of CHD if diagnosed as such by the hospital cardiologists. Neighbourhood residents of the CHD cases not known to have any cardiac disease were selected as community controls. Hospital controls were those patients who attended the cardiac outpatient departments but on examinations were declared as not suffering from CHD by the hospital cardiologists. Four community controls were matched to each case on age (±5years), gender, residential area and socioeconomic status; one hospital control was matched to each case on age and gender. Data were collected through structured interviews. Analyses of association were adjusted for age, hypertension, diabetes, family history of heart disease, physical activities and acute psycho-social stress.

Results The sample comprised 302 CHD cases, 1208 community controls and 302 hospital controls (male: female 50:50 mean age 53 ±8.5years). Forty percent of the study subjects were current users of or had used SLT in the past. Defining current SLT use as any use in last one-year, 36% of the subjects were current users. Current use of SLT was similar among cases (33%), community controls (33%) and hospital controls (32%). The majority of SLT users were heavy users (used at least once a day) and long term users (duration >10years). Current use of SLT was not associated with increased risk of CHD when community controls were used (adjusted OR 0.87, 95% CI 0.63-1.19, p>0.05), or hospital controls were used (adjusted OR 1.00, 95% CI 0.63-1.60, p>0.05), or when both controls were combined (adjusted OR 1.00, 95% CI 0.74-1.34, p>0.05) in analyses. Similarly, when we analysed the data specifically focusing on individuals who had quit SLT (no use for >1year), quitting was not associated with increased risk of CHD. Risk of CHD did not increase with use of individual type, frequency and duration of each SLT product.

Conclusions In this study, there was no statistically significant association between SLT use and CHD among non-smoking adults in Bangladesh.

9.5 Usefulness of NNAL as a Biomarker of Exposure to Secondhand Smoke

H-J. Ryu, S.J.K. Kang, M.W.S. Seong, D.H.L. Lee National Cancer Center, GY…ONGGI-DO, South-Korea

Background Secondhand smoke (SHS) as well as active smoking is presents major risks to human health, and they contribute to the development of various human cancers, respiratory illnesses, and other diseases. Nicotine and cotinine are specific to tobacco but not to disease itself. Recently, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a potent carcinogen in tobacco smoke was introduced as a useful biomarker of carcinogen exposure. Here we introduce the preliminary results related to exposure to tobacco-specific carcinogens by secondhand smoke.

Poster presentations: Topic 9, Tuesday March 29 275 Methods The urine samples were collected from seven non-smokers at following intervals, before exposure, at three hours and the next-day after exposure to SHS, respectively. The samples were extracted using hexanoate derivatives and reconstituted in 125 uL of 10% methanol containing 12 mM HCl. The concentrations of urinary NNAL were measured using liquid chromatography-tandem mass spectrometry.

Results Urinary NNAL concentrations were significantly increased the next-day after exposure to secondhand smoke compared to those before exposure (0.1~3.1 vs. 1.02~8.6 pg/mL). Urinary cotinine concentrations after exposure also showed a similar increase pattern (0.02~2.7 vs. 3.1~22.6 ng/mL) in a higher rate. However, the urine NNAL concentrations after three hours exposed to secondhand smoke showed different pattern each.

Conclusions These results show that urinary NNAL as well as urinary cotinine can also be a sensitive tool for assessment of exposure to secondhand smoke, and evaluation of health effects of a tobacco-specific carcinogen.

9.6 Effects of a web-based multiple tailored smoking cessation programme

E.S. Smit, C. Hoving, H. De Vries Maastricht University, MAASTRICHT, The Netherlands

Objectives To investigate the effects of a multiple computer tailored smoking cessation programme delivered through the Internet.

Methods Adult smokers were recruited from December 2009 up until June 2010 mainly by advertising our study on the web. After being recruited for participation in the study, adult smokers motivated to quit smoking (N=1125) were randomized into either the experimental or control group. Respondents in the experimental group received the web based smoking cessation programme, consisting of computer-generated feedback letters tailored to several respondent characteristics, such as gender, beliefs, intention to quit smoking and smoking behaviour. Respondents in the control group received no intervention. After six months, the effect of the intervention on 24 hour point prevalence abstinence, 7 day point prevalence abstinence and prolonged abstinence was assessed using logistic regression analyses.

Results Experimental condition significantly predicted 24-hour and 7-day point prevalence abstinence after six months. Respondents in the intervention group significantly more often reported to be abstinent for the past 24 hours (OR 1.94; 95% CI 1.14-3.29) and for the past seven days (OR 1.73; 95% CI 1.01-2.98) than respondents in the control group. No effect of the intervention was found on prolonged abstinence. Intention-to-treat analysis showed a similar effect, though solely on 24-hour point prevalence abstinence (OR 1.67; 95% CI 1.06-2.65).

Conclusions The web-based computer-tailored smoking cessation programme had a significant effect on short-term abstinence reported after a six-month period. No effect was found on prolonged abstinence, which might be a result of the programme mainly focussing on the initiation of

Poster presentations: Topic 9, Tuesday March 29 276 behaviour change while limited attention was paid to maintenance of these changes.

Implementation As the intervention has been fully developed and is delivered via the Internet, implementation on a larger scale would be relatively easy and not bring about many additional costs. In addition, the online character of the intervention has several advantages for its users: it is highly accessible, can be used as a stand-alone intervention or combined with other interventions, and can be used at any time that is convenient for the user. However, in order for the programme to result in permanent smoking cessation, future studies should focus on the possibility of incorporating intervention components specifically focussed on relapse prevention.

9.7 Smoking among employees of the University Clinical Center of Kosova, 2010

B.S. Sllamniku1, A.B. Baraku2, A.S. Sllamniku2, F.U. Ukaj3, A.H. Haziri4, A.R. Rushiti4 1Iliria College, PRISHTIN…, Kosovo 2College Iliria, Institute for Scientific Research, Medical sciences, Rezonanca, PRISHTINA, Kosovo 3Clinic of Otorhinolaryngology, Head and Neck surgery, University Clinical Center, PRISHTINA, Kosovo 4College Iliria, Medical faculty, Rezonanca, PRISHTINA, Kosovo

Objectives Studies show that smoking among health professionals of the developed countries is lower than among health professionals of the Eastern Europe. The aim of this study was to obtain lacking information regarding prevalence of smoking among medical employees in University Clinical Center (UCC), Prishtina, Kosova for the purpose of initiating programs for smoking cessation in medical environment, and establishing comparison data.

Methods The targets were the employees of the third level of medical care (doctors, nurses and non- medical personnel). A randomly distributed questionnaire was distributed in four clinics (ORL, General surgery, Lung and Internal diseases). Statistical parameters (percentage, average and standard deviation) and statistical differences (T-test of proportions, Chi-square test and Fisher exact test) were analysed for prevalence of smoking with regard to demography (gender, age and marital status), work (clinic and employee level) and smoking characteristics (habit, length, severity, attempt for cessation, respect of prohibition of smoking and smoking awareness).

Results From 137 respondents (out of 585 employees) from the four clinics, 29.9% were regular smokers. Smoking was more prevalent within females (31.5%) comparing to males (28.1%). From 114 married respondents, 27.2% were smokers, in comparison to unmarried respondents (43.5% smokers). Smokers were, on average, younger than non-smokers, with smokers having 41.4 years of age (SD=9.2) while non-smokers 43.4 years of age (SD=11.0). 97.1 % of respondents declare that they are aware of the damage caused by smoking, with no difference between smokers and non-smokers. Prevalence of smoking was the highest among respondents from Internal diseases clinic (37.8%) and General surgery clinic (31.1%) in comparison with ORL (21.7%) and Lung clinic (12.5%), with significant difference between Lung clinic and all other clinics, p<0.01. Smoking was least prevalent among doctors (21.1%), while most prevalent among non-medical per-

Poster presentations: Topic 9, Tuesday March 29 277 sonnel (39.1%). An average number of cigarettes smoked per day is 17.4 (SD=7.9), with variation from 5 to 50 cigarettes per day. The average length of smoking is 14.4 years (SD=7.4). 43.9% of smokers have made unsuccessful attempts to stop smoking. 87.8% of smokers declare that they respect the prohibition of smoking in working areas.

Conclusions The prevalence of smoking among medical employees of the UCC is high; similar to prevalence of smoking in Kosova but lower than of medical personnel from South Eastern Europe. In UCC, smoking is prevailing among employees from: Internal diseases clinic and General Surgery clinic; females; unmarried; and non-medical personnel. It is optimistic that smokers declare that they respect smoking prohibition in work area, despite the lack of implementation of tobacco law.

Implementation Severity and length of smoking requires immediate need for intervention towards smoking cessation. The strategy would contain law implementation, community education and application of methods for offering support within the working environment to stop smoking.

9.8 Influence of tobacco smoke on ethanol metabolism in animal model

K. Florek1, J. Kulza1, P. Piekoszewski1, J. Gomolka2, A. Chuchracki3 1Uniwersity of Meducal Sciences, Laboratory of …nvinronmental Research, POZNAN, Poland 2Laboratory of Analytical Toxicology and Therapeutic Drug Metabolism, KRAKOW, Poland 3Central Laboratory of Gynecology-Obstetrics Hospital, POZNAN, Poland

Objectives Tobacco smoke changes the rate of biotransformation of different xenobiotics, leading to the changes in their biological activity. The main enzyme, which metabolises alcohol is the cyto- plasmic alcohol dehydrogenase, however some alcohol is metabolised by microsomal enzymes - CYP 2E1. Tobacco smoke components, which may impact the activity of CYP 1E2 is the nicotine, which increases the activities of the liver and brain CYP2E1 in rats, and the observed effect depends on the time of exposure. Apart from the compounds increasing the activity of drugs metabolising enzymes, tobacco smoke contains also such compounds as carbon monoxide, cadmium, some pesticides, cyanides and acrolein, which can inhibit them

Methods The goal of the studies was to evaluate the impact of tobacco smoke on the pharmacokinetics of ethyl alcohol and its toxic ethanol metabolite such as acetic aldehyde and on the level of other volatile organic compounds (acetone, n-butanol, methanol, n-propanol).

Rats were divided on two groups, the first group were treated with alcohol (2 g/kg) and the second group were exposed to tobacco smoke (6 h per day, for 5 days), and treated with alcohol (2 g/kg). Ethanol and other compounds of interest were determined by gas chromatography after head space solid phase microextraction.

Results Five days exposure to tobacco smoke has an insignificant impact on the elimination of alcohol, causing only a significant increase in the volume of distribution, which could be driven by an increase in the first-pass effect. On the other hand, the inhalation of tobacco smoke induced tendency to decrease in the concentration of the acetic aldehyde during the first

Poster presentations: Topic 9, Tuesday March 29 278 hour after administration of alcohol. In both groups, the time profile of the concentrations of acetone, methyl alcohol, n-propyl alcohol and n-butyl alcohol were not statistically significantly different.

Conclusion It can be concluded, that earlier exposure to relatively high level of tobacco smoke (1500 mg CO/m3) does not influence significantly on biotransformation of ethanol and other volatile compounds.

Implementation The lack of influence of tobacco smoke on alcohol metabolism directed the next study to check influence of acute an chronic alcohol administration on nicotine biotransformation.

9.9 How can we motivate young smokers to participate in smoking cessation interventions? The ACCESS project

S.F. Floeter, S.F. Fleitmann, A.B. Bühler IFT Institut fuer Therapieforschung, MU…NCH…N, Germany

Background and Objective There are numerous effective smoking cessation programmes for adolescents. However, recruitment of young people into these programmes poses a big challenge to providers. Two of three smoking teens want to quit, but they prefer to do so on their own or with the help of their friends and in consequence, success is very limited: 90% of those who quit turn back to smoking within six months. Professional cessation programmes are seldom used by adolescents. Possible reasons are that young smokers do not know about existing interventions, are prejudiced against such programmes and/or do not expect them to be successful. Aim of the ACCESS project therefore was to gain knowledge on how to motivate adolescent smokers to participate in existing cessation programmes.

Methods An international literature review was carried out to identify existing scientific evidence on recruitment strategies. In addition, 8 European countries collected good practice examples of utilised motivational strategies from providers of youth smoking cessation programmes. National networks, composed of experts in the fields of adolescent smoking cessation and youth development in general, were implemented and asked to develop new ideas on access strategies.

Results Nine basic principles have been identified to guide providers and policy makers in the development of comprehensive recruitment strategies. These principles address (1) the need to establish non-smoking as a social norm and state that (2) effective youth-specific smoking cessation interventions must be available and that (3) recruitment strategies should be evidence based. They further suggest that cessation interventions (4) need to benefit from positive branding, (5) need to be proactive and (6) to have a personal touch. It is necessary to (7) choose the right language, (8) incentives may be an option and (9) partnership with stakeholders in youth health matters is an important asset. Beyond that, strategies that support these guiding principles were abstracted from the good practice examples and grouped into five categories: interpersonal communication, marketing, tailoring, behavioral learning techniques and structural change. A range of existing recruitment activities was identified and grouped according to settings where adolescents spend their time.

Poster presentations: Topic 9, Tuesday March 29 279 Conclusions The results of the project can support providers, developers, funding bodies and policy makers in the development of effective recruitment strategies to increase the impact of youth smoking cessation interventions. However, there are still many gaps in the research on effective recruitment strategies. Recruitment campaigns are an effective instrument to improve participation rates in smoking cessation interventions, but this instrument is under-used and has not been implemented sufficiently so far. It is urgent that recruitment is recognized by society as a self standing element of any tobacco cessation strategy and a priority task for educators, health professionals, researchers and policy makers alike.

9.10 A Profile of Smoking and Health in Wales

E. De Lacy1, S. Whithead2 1ASH Wales, CARDIFF, United Kingdom 2Cardiff Institue of Society and Health, CARDIFF, United Kingdom

Background Smoking remains the largest single preventable cause of ill health and premature death in Wales, causing around 5,600 deaths a year. Although smoking among adults in Wales has declined in recent years, data from the Welsh Health Survey suggests that since 2007 the prevalence has remained at 24%.

Objectives To examine the profile of current and ex-smokers in Wales, compared to those who have never smoked, in relation to selected health conditions and health-related behaviours.

Methods Data presented in this report were taken from the 2008 Welsh Health Survey (WHS), relating to data collected between January and December 2008. The WHS is an annual survey . It is based on a representative sample of people living in private households in Wales. During the 2008 period, a household interview was obtained with 74% of eligible households in the sample, and self-completion questionnaires were obtained for 78% of adults, giving a total sample size of 13,313. Questions asked in the survey focussed on the following topics: health service use, medicines, illnesses, general health and well-being, smoking, alcohol, fruit and vegetable consumption, exercise, carers, sex and age, height and weight, ethnicity, and qualifications. Percentages were examined by reporting the illness or health-related behaviour of interest according to smoking status. Significant differences between groups for each illness / health behaviour were worked out.

Results Smoking was found to be associated with a number of poor health conditions, especially among women, including a number of heart conditions, respiratory conditions, arthritis, diabetes, mental illnesses, and long term limiting illnesses. Ex-smokers also reported high levels of ill health in this report, particularly for all heart conditions including High Blood Pressure, respiratory conditions, arthritis, diabetes, long-term limiting illness. In addition, they also were the most likely to report being overweight or obese. The findings from this report also demonstrate a clustering of health-related behaviours, with current smokers being more likely than non-smokers to report excessive alcohol consumption and poor diet.

Conclusions For many illnesses and health behaviours smokers have a worse profile than those who have

Poster presentations: Topic 9, Tuesday March 29 280 never smoked. Differences between smoking groups are often greater for women than for men. The picture is slightly less clear for ex-smokers. Smoking and associated illnesses and poor health behaviours remain a problem for Wales

Implementation investment in and focus on health prevention and promotion policies that will have long term benefits is needed. There needs to be a move from a reactive health service treating ever more and more patients suffering the adverse health effects of smoking, to a more proactive public health service, promoting and protecting people’s health throughout their lives and preventing the uptake of smoking in Wales.

9.11 Should smoking cessation experts become experts in smoking cessation?

P. Bartsch*, M. Delvaux**, M. Ansseau*** * Chest Diseases Dpt. Smoking Cessation Unit (SCU) ** Psychologist (SCU) *** Psychiatry and Psychology Unit Liege Univertsity Hospital

To measure depression prevalence in more than 100 consecutive patients seeking help for smoking cessation in a specialized university center.

This retrospective study uses clinical data, Hospital Anxiety and Depressioin Scale (HADS) and records the use of antidepressants before smoking cessation help is delivered in a reimbursed consultation.

More than 50% patients show at least a depressive mood characterized by a HADS score > 10 for anxiety and/or depression, or are currently treated with antideprsssants.

We conclude that health care professionals should be prepared to use not only smoking cessation validated drugs, but also to master different classes of drugs available for the treatment of depression,a disease which is by itself heterogeneous. If depression is one of the reasons for being dependent, other comorbidities seen when taking history or examining the patients should not be underestimated.

9.12 TOWARD A SMOKE FREE MINISTRY OF HEALTH IN ITALY

L.S. Spizzichino, D.G. Galeone, S.M. Mele, L.P. Pagliari Ministry of Health, Italy, Rome, Italy

Objectives In 2009, Italian Ministry of Health promoted an initiative targeted its employees aimed to promote compliance with the smoking ban and provide support for any smokers who wanted to quit, by providing free of charge tobacco cessation programmes, available during working hours and in the workplace, for all smoking employees who agreed to participate in the programme.

Methods Activities included: • An information seminar for employees on the risks of smoking; • A questionnaire-based survey on the smoking habits of employees in the Ministry of

Poster presentations: Topic 9, Tuesday March 29 281 Health headquarter; • The launch of “Groups to discourage smoking”run by personnel from the Italian anti- cancer league (LILT)

Results The programme is still ongoing, but some results can already be highlighted: The seminar held on February 9, 2009, was attended by over 200 employees; all employees of the Ministry of Health received an information booklet on the damage caused by smoking; the survey on the smoking habits of employees was completed.

Out of the 1,244 questionnaires distributed, 1,030 were returned (participation rate 82.8%), analyses were carried out on 994 of them.

Data showed that 25.1% of employees are smokers, smoking an average of 13.3 cigarettes a day; 43% of them are heavy smokers. Sixty-three percent of smoking employees claim they want to quit, but only 40% of them were advised to do so by their physician.

Non-smokers account for 50.5% of employees, and former smokers 24.4%; second-hand smoke is a serious nuisance for 61% of them. It is interesting to note that 36% of non-smokers is exposed to second-hand smoke in different places within the Ministry, including their own room and other rooms (in 2% and 6% of cases respectively)

Four tobacco cessation courses were launched in May 2009. A total of 74 employees (29% of smoking employees), signed up. Of these, 57 participated to three of the first four meeting and, after having completed the course, 32 (56%) quit smoking and 25 (44%) smoked fewer cigarettes a day.

Follow-up activities six months after the completion of the course are currently ongoing, and the rate of abstention from smoking is above 37%, in line with data reported in the literature.

A new course has been launched in January 2010. Over 20 employees have already signed up.

Conclusions The program has been quite a success, law that bans smoking together with cessation program, free of charge and during working hours, are useful to protect non smokers from passive smoking and to help smokers to quit.

Implementations Ministry of Health together with LILT is implementing this identical programme in different public and private company like Ford (cars), ACEA (water and electricity), INAIL (national institute for work accidents), for a total of 3,600 employees involved.

Poster presentations: Topic 9, Tuesday March 29 282 9.13 Does use of smokeless tobacco among adolescent cigarette smokers predict cigarette use in the future?

Objective To examine whether current use of smokeless tobacco in addition to current use of cigarettes is related to continuing smoking one year later among adolescents.

Results Among current cigarette smokers at Wave I, 14.5% used smokeless tobacco. The proportion who reported continued cigarette smoking at Wave II was slightly lower among smokers who also used smokeless tobacco (73.5%) compared to those who did not use smokeless tobacco (78.3%) (OR =0.71 [95% CI 0.52-0.98]). Individuals who reported using both products (cigarettes and smokeless tobacco) were more likely to be male (81.8%) than cigarette-only users (44.1%). Among users of both cigarettes and smokeless tobacco at Wave I, 37.0% continued to use both products at Wave II, 36.6% used cigarettes-only at Wave II, 8.6% used smokeless tobacco-only at Wave II, and 17.9% quit both cigarettes and smokeless tobacco at Wave II. Among cigarette-only users at Wave I, 73.4% used cigarettes-only at Wave II, 1.6% used smokeless tobacco-only at Wave II, 5.0% used both smokeless tobacco and cigarettes at Wave II, and 20.0% quit cigarettes at Wave II. Smokers who also used smokeless tobacco at Wave I were less likely to continue smoking at Wave II (adjOR =0.71 [95% CI 0.52-0.98]) than cigarette-only users at Wave I.

Poster presentations: Topic 9, Tuesday March 29 283 9.14 How are subjective social status and materialism associated with teenage smoking?

H.N. Sweeting, K. Hunt, A. Bhaskar UK Medical Research Council, GLASGOW, United Kingdom

Objectives Smoking has been described by some authors as a fashion accessory, linked with teenage identity formation and conspicuous consumption. Among teenagers, particularly females, it has been associated with high peer status, sophisticated social skills, good looks and coolness. In addition, the handful of studies on associations between measures of materialism and risk behaviours suggest higher substance use among more materialistic people. In this study, based on a sample of contemporary European teenagers, we examine the associations which subjective school-based social status and measures of materialism and consumer involvement have with smoking, and whether these change after adjustment for age or family affluence or in mutually adjusted analyses.

Methods Data were obtained in 2010, via a schools-based self-completion survey of 2,937 Scottish 12-14 year olds. The questionnaire included: seven images of 10-rung ladders on which pupils rated their own status, compared to their school year-group on a number of different dimensions (e.g. the extent to which they felt they were ‘popular’, a ‘trouble-maker’, ‘sporty’ etc); a list of material possessions (e.g. ‘Xbox 360, PS3 or Wii’, ‘ipod touch or iphone’); and a series of items representing consumer involvement. Analyses suggested three dimensions of subjective social status: ‘peer status’ (ladders representing ‘popular’, ‘powerful’, ‘respected’, ‘attractive or stylish’, ‘trouble-maker’); ‘sports status’ (‘sporty’); and ‘scholastic status’ (‘doing well at school’, ‘[not] a troublemaker’). They also identified four consumer involvement factors: ‘brand awareness’ (e.g. ‘like clothes with popular labels’); ‘dissatisfaction’ (‘feel like other kids have more stuff than I do’); ‘consumer orientation’ (‘usually have something in mind that I want to buy or get’); and ‘anti-consumerism’ (‘don’t mind what kind of car my family has’). Two definitions of smoking were employed, indicating whether pupils were ever and current smokers.

Results Among males and females, both ever and current smoking were positively associated with ‘peer status’ and negatively associated with ‘sports’ and ‘scholastic status’. Smoking was also more likely among those with more material possessions, higher ‘dissatisfaction’, greater ‘brand awareness’ and ‘consumer orientation’. These associations were not explained by age or family affluence. In mutually adjusted analyses, associations with subjective social status were largely unchanged. Those with materialism were somewhat reduced, but ‘brand awareness’ and ‘dissatisfaction’ remained associated with ever smoking and, among females only, ‘brand awareness’ with current smoking.

Conclusions These results emphasise the importance of identity and imagery to young people’s smoking uptake.

Implementation The teenage years represent a crucial time for both establishment of identity and uptake of smoking. Although direct tobacco advertising is restricted, smoking imagery is still widely available to young people. Policy makers therefore need to reflect on the particular impact of stereotypical tobacco images and modern materialism on this age group when considering the promotion of alternative behaviours.

Poster presentations: Topic 9, Tuesday March 29 284 9.15 Do both individual and group-level social status matter for teenage smoking?

H.N. Sweeting, R. Young UK Medical Research Council, GLASGOW, United Kingdom

Objectives It has been suggested that studies of adolescent smoking should consider aspects of peer relations other than peer smoking, particularly peer interaction, social status and attributes of peer networks (Ennett et al, 2009, Prevention Science 9:88-98). During adolescence there is an emergence of groupings sharing the same identity and reflecting social status (such as popular, academic or athletic ‘crowds’). Smoking has been associated with self-report and peer-rated ‘popularity’ (although not necessarily liking by others) and ‘coolness’, but also with low-status groups, isolate or dyad status. Further, while disengagement from education and rebelliousness may be a risk factor for adolescent smoking, sporting activity may be protective. This study examined how both individual self-report measures of school-based social status and group-level data derived via social network analysis were associated with teenage smoking.

Methods Data were obtained from 15-year olds (N=3,194; 81% of those eligible) in a representative sample of 22 Scottish schools. Pupils rated their own social status, compared to their school year-group via images of 10-rung ladders. Analyses suggested three subjective social status dimensions: ‘peer’ (ladders representing ‘popular’, ‘powerful’, ‘respected’, ‘attractive or stylish’, ‘trouble-maker’); ‘scholastic’ (‘doing well at school’, ‘[not] a troublemaker’); and ‘sports’ (‘sporty’). Pupils also named up to six friends. Friendship data (based on reciprocated links) were imported into the SNA Ucinet 6 and Netdraw software packages. A clustered algorithm identified discrete groups and the resulting school sociograms (charts of friendship relations) were inspected manually in conjunction with participant descriptions of their group and obvious misclassifications corrected. Groups were categorised as isolate (1 member), dyad (2), small (3-5), average (6-11) or large (12+). At the group-level, gender was represented as all-female, mixed, or all-male, and socio-economic status as the percentage from non-manual socio-economic backgrounds. Group-level ‘peer-’, ‘scholastic-’ and ‘sports-status’ were the average of each of these dimensions across all group members. Analyses adjusted for individual gender, social class, family structure and parental care/control.

Results In mutually adjusted analyses, current smoking was significantly higher among dyads (compared with those in average-sized groups) and those in all-female or mixed (compared with all-male) groups. It was positively associated with both individual and group-level ‘peer-status’, and negatively associated with both individual and group-level ‘scholastic-’ and ‘sports-status’. The strongest associations, at both individual and group-level were with ‘scholastic-status’. Results based on stricter definitions of smoking (weekly; chain) were similar.

Conclusions These results suggest the importance of both individual characteristics and social context (group-level characteristics) for teenage smoking.

Implementation Teenage anti-smoking programmes should aim to reduce the perception of smoking as a form of social bonding among certain groups. It is also important that teachers are aware

Poster presentations: Topic 9, Tuesday March 29 285 that engagement with education is associated with reduced smoking as well as enhanced life chances.

9.16 Smoking prevalence and willingness to quit in newly screened Danish patients diagnosed with airway obstruction

J.D. Dollerup1, P.B.P. Poulsen1, C.S.U. Suppli Ulrik2, A.L. Løkke3, J.H. Holt4, J.L.J. Lykke Jensen4, K.K.A. Kaa Andersen5, R.D. Dahl3 1Pfizer, BALL…RUP, Denmark 2Card.-Pulm. depart., Hvidovre Hospital, HVIDOVR…, Denmark 3Pulm. Dept. Aarhus University Hospital, AARHUS, Denmark 4Boehringer Ingelheim Denmark, COP…NHAG…N, Denmark 5Technical University of Denmark, LYNGBY, Denmark

Objectives Up to 436,000 Danes suffer from chronic obstructive pulmonary disease (COPD) with only one third diagnosed. Tobacco smoking explaining 80-90% of cases (1). To reduce the risk factor implies incentives to and initiation of smoking cessation (SC) as primary activity managing COPD. Secondary pharmacotherapy, rehabilitation activities, e.g. physical training and patient education, to prevent disease progression (1,2) should be offered. The Danish National Board of Health recommends early detection of COPD focusing on the following population: 1. Age above 35 years. 2. At least one pulmonary symptom. 3. Smokers/ex-smokers or occupational exposure (2). The objective was to evaluate the smoking prevalence and willingness to quit smoking in a population of newly screened patients with airway obstruction, indicating COPD, in primary care in Denmark.

Methods Following the recommendations issued by the National Board of Health with focus on smokers/ ex-smokers or occupational exposure the participating GPs (n=335; 10% of the Danish GPs) offered consecutively spirometry to patients with no previous diagnosis of obstructive lung disease. Besides demographic and spirometry data, additional data on smoking status, smoking history and willingness to quit smoking was recorded in an internet based database by the GP. The present study evaluated the population indicated having COPD, when screened, focusing on smoking status and smoking cessation.

Results Overall 3,498 patients had a spirometry with 1,295 patients (37%, 61 years, 48% females) diagnosed with obstructivity (FEV1/FVC-ratio < 70 %). With significant more women than men (P=0.03) in total 64% (824), diagnosed with obstructivity smoked (37 pack years, 17 cigarettes/day). There was a tendency that smoking prevalence decreased with the indicated COPD severity (66% mild, 63% moderate, 60% severe/very severe). Nearly two-thirds of smokers had a history of previous cessation attempts and 54% have used medication as part of the cessation. Being newly screened, 62% of the smokers would like to quit, but only 11% intended to start immediately. Indicated COPD severity and willingness to quit was not correlated.

Conclusions Many patients identified with airway obstruction, indicating presence of COPD, are current smokers. There is willingness to quit smoking in the majority of the patients, but only a small group intend to do initiate cessation immediately, though guidelines recommend smoking

Poster presentations: Topic 9, Tuesday March 29 286 cessation as primary intervention.

Implementation The importance of information on smoking and SC initiatives immediately after diagnosing COPD is highlighted.

References: 1. GOLD. 2009. 2. KOL (National COPD recommendations). National Board of Health, 2007.

9.17 Defining a target profile for promoting smoking cessation in Italy

L.S. Spizzichino1, D.G. Galeone1, G.F. Ferrante2, V.M. Minardi2, S.V. Vasselli1, C.B. Bietta3 1Ministry of Health, Italy, ROM…, Italy 2National Institute of Health (ISS), ROM…, Italy 3AUSL2 dell’Umbria, P…RUGIA, Italy

Background In Italy, smoking cessation programmes rarely consider the characteristics of people who make quit attempts during life (independently from quitting or still smoking) as an useful starting point for effective intervention.

Objective To evaluate the percentage of people who reported smoking cessation or at least an attempt once in the last 12 months; to investigate the association between the attempt and sociodemographic, behavioural and clinical variables.

Methods Data collected in 2008 from PASSI, the Italian behavioural risk factor surveillance system based on telephone interviews of residents aged 18-69 years, were analyzed to identify factors associated to quit smoking attempts.

Results Sample analyzed included 18,281 current and ex-smokers. Around two out of three people (11,881) tried to quit smoking and among them 3,911 (34%) failed the attempt.

A multivariate analysis showed that smoking cessation attempt was more likely among males, elder (50-69 years) and married people; among those living with children (<14 yrs), with a temporary job, without economic difficulties and with a high level of education; among those with cardiovascular risk factors (hypertension, hypercholesterolemia, obesity) and those affected by chronic diseases (almost one among cancer, diabetes and myocardial infarction). On the other side, sedentary people and those with good perceived health status are less intentioned to quit.

Stratification by sex showed a different strength of association between the outcome variable and other variables in males and females, but most important that education and perceived health status are not associated with the attempt to quit smoking among women.

Conclusions Population-based surveillance system tracking the characteristics of ex and current smokers, who tried to quit, may offer a lot of information, otherwise not available, for planning,

Poster presentations: Topic 9, Tuesday March 29 287 implementing and evaluating promotion and prevention interventions to support people who try to quit smoking.

Implementations Behavioural risk factor surveillance systems can provide information about sociodemographic and health profile of smokers who express intention to quit smoking and therefore represent a potential target of cessation treatment and health promotion intervention.

9.18 SMOKE FREE MUMS

L.S. Spizzichino1, D.G. Galeone1, M.T.M. Menzano1, M.T.S. Scotti1, L.S. Sbrogiò2, A.S. Schiavinato2 1Ministry of Health, Italy, ROM…, Italy 2ULSS 7, TR…VISO, Italy

Background The number of young women smokers in Italy has been stable for years at around 20%; the same percentage smokes early in pregnancy. Epidemiological studies tell us that only 71% of women smokers stop smoking during pregnancy and 70-80% of these start again after the birth of their child. More than half of children have at least one parent who smokes.

Objective The purpose is to encourage a standardized approach by obstetrics personnel to motivating pregnant women and their partners to give up smoking and supporting them also in the post-nursing period when there is a marked tendency to take the habit up again.

For this reason Ministry of Health has assigned the ‘Smoke-Free Motherhood”project, a national anti-smoking counselling program, to the Veneto Region.

Methods “Smoke-Free Motherhood”is coordinated by the ULSS 9 local health authority in Treviso and has been set up in collaboration with the Lega Italiana per la Lotta contro i Tumori (LILT, or the Italian League for the Fight Against Cancer) and the Federazione Nazionale dei Collegi delle Ostetriche (FNCO, or National Federation of Obstetrics Colleges). In anti-smoking policies, controlling exposure to passive smoke in the domestic environment is considered to be a fundamental strategy.

Results During 2009, in three courses of three days each (Venice-Rome-Rome), 102 obstetricians were trained as trainers; these are in addition to the 80 already trained for the Veneto Region and the 50 trained by the FNCO. The materials prepared, both for didactic purposes (guidebook and CD-ROM for the obstetricians) and for information purposes (posters, leaflets, flyers to post on doors, booklets for families) were forwarded to those Regions that are participating in the Program. The participating Italian Regions and Provinces are the following: Abruzzo, Basilicata, Province of Bolzano, Calabria, Campania, Emilia Romagna, Friuli Venezia-Giulia, Latium, Liguria, Lombardy, Marche, Molise, Piedmont, Puglia, Province of Trento, Sardinia, Sicily, Tuscany, Umbria, Aosta Valley, Veneto.

Conclusions Controlling exposure to passive smoke in the domestic environment is a part of the Italian strategy against smoking. Promote the counselling by the obstetricians during pregnancy

Poster presentations: Topic 9, Tuesday March 29 288 seems to be an effective instrument for quitting smoking of both parents.

Implementation The next step in the program was when the obstetricians who had received the training in their turn trained other personnel in their local environments and distributed the relevant material. Participation in the Program was arranged by agreement with the Regions, the HPH network, FNCO and LILT.

9.19 A BLIND STUDY ON THE CONSUMPTION OF THERAPEUTIC PSYCHOTROPIC DRUGS OF PATIENTS WHO QUIT SMOKING

C. Martin1, J. Bernal2, F.J. Ayesta2 1Univ. Cantabria, SANTAND…R, Spain 2Fac. Medicine, Univ. Cantabria, SANTAND…R, Spain

Introduction Psychiatric pathology is more prevalent in those who smoke. Its presence may be indirectly detected by the level of consumption of drugs used to treat psychiatric symptoms.

Most of the population of our region, Cantabria, is covered by a public health insurance. Drugs prescribed for most diseases or symptoms (but not for smoking cessation) are financed -either partially (60%) or totally- by this insurance. A centralized record of prescriptions is kept by the regional Government.

Aim and Methods Our aim was to analyze the prescription of therapeutic psychotropic drugs (anxiolytics, antidepressants and neuroleptics) of those people treated in of those attended in our Smoking Cessation Unit. All patients attended during the first half of 2008 and who started pharmacological treatment (n:159) were included in the study. After obtaining a written permission from the ethical committee of the region (CEIC), during 2009 a blind observer looked for which drugs -and how much of each- had been prescribed to all our patients. The prescription period analyzed was the year before initiating treatment and the following-up period (six months). Prescription results were crossed with the drug employed for smoking cessation (either NRT, bupropion or varenicline) and abstinence rates (measured at six months with a CO monitor)

Results 52 patients (32.7% of the population) had consumed any psychotropic drug in the previous year to smoking treatment initiation.

10 of these patients decreased their consumption of therapeutic psychotropic drugs after smoking cessation. 8 of them remained abstinent. This decrease was associated with a higher abstinence rates at 6 months (OR: 6.50; p:0.031).

Those who received varenicline (n=11) had more chances of reducing their use of therapeutic psychotropic drug than those who received NRT of bupropiÃ_n (n=41): 45.4% vs. 12.2%; p=0.025, OR: 6.00. Their abstinence rates at six months were also higher: 9/11 vs. 15/41); p: 0.015, OR: 7.80.

Poster presentations: Topic 9, Tuesday March 29 289 9.20 BODY SHAPE QUESTIONNAIRE (BSQ) SCORES IN SMOKER AND NON-SMOKER FEMALE ADOLESCENTS

M. Rodriguez1, M. Otero2, L. De la Rosa3, F.J. Ayesta4 1UNIV. CANTABRIA, SANTANDER, Spain 2Conselleria de Sanidade, SANTIAGO DE COMPOSTELA, Spain 3Consejería Sanidad, VITORIA, Spain 4Univ. Cantabria, SANTANDER, Spain

Previous results from our group and from other groups have already suggested that female adolescent smokers, especially those who initiated their smoking before they were 14, might consider smoking as a way to control their weight or their figure. In order to analyse this possibility, the Body Shape Questionnaire (BSQ), was applied to 1534 adolescents, both boys and girls, 12 to 16 years old, studying in either a primary or secondary school who were asked whether they smoked, they had smoked or they wanted to become smokers in a year time.

Whereas no differences were found between non smokers and smokers in boys, differences in girls were significant for those who consider themselves smokers and especially for those who either smoked or wanted to smoke in a year time. In these results were:

• BSQ total score: 22.4±1.8 vs. 45.9±5.9 (p<0.0001) for those 12- 13 years old; and 30.8±2.2 vs. 40.6±2.7 (p=0.006) for those 14-16 years old.

• The odds ratios of scoring above 136 (the usual cut-off line for a disorder) were 12.0 (4.2-34.8; p>0.0001) for the younger group and 3.2 (1.02-9.77; p=0.05) for the older one.

These results show disorders in body perception are higher in those girls who start to smoke earlier and that they may be using smoking as a mean to control their weight or figure. They also underlie the importance of considering intention to smoke when analyzing young adolescents smoking.

9.21 Selected factors influencing weight gain during smoking cessation

A.K. Kmetova1, E.K. Kralikova1, L.S. Stepankova1, Z.B. Bortlicek2, K.Z. Zvolska1, M.M. Maly3 1Centre for Tobacco Dependence Treatment, PRAGU…, Czech Republic 2Institute of Biostatistics and Analyses, BRNO, Czech Republic 3Institute of Public Health, PRAGU…, Czech Republic

Objectives The weight gain during quitting smoking is often being perceived as a barrier towards cessation.

Aim To assess the correlation of the weight gain with selected factors as FTND, BMI at the beginning of the treatment and other factors.

Methods Data of patients of our Tobacco Dependence Centre collected between 2005 - 2010, after one year follow-up, abstinence validated by carbon monoxide measurement.

Poster presentations: Topic 9, Tuesday March 29 290 Results We analyzed sample of at least 500 patients - abstainers one year after the intervention. The mean weight gain after one year of the quit date was approximately 5 - 6 kg. We identified the correlation of selected factors with weight gain. Further details will be shown.

9.22 Depressive symptoms & CDI scores in Spanish adolescent smokers

F.J. Ayesta1, M. Otero2, L. De la Rosa3, M. Rodriguez1 1Univ. Cantabria, SANTAND…R, Spain 2Conselleria de Sanidade, SANTIAGO D… COMPOST…LA, Spain 3Consejería de Sanidad, VITORIA, Spain

Previous results from our group suggest that adolescent smokers, especially those who initiated their smoking before they were 14, may present more depressive symptoms. In order to analyse this possibility, the Children Beck Depression Inventory (CDI) was applied to 2038 adolescents, both boys and girls, 12 to 16 years old, studying in either a primary or secondary school.

Differences between smokers and non smokers were found in the total CDI score. Smokers, both boys and girls, scored higher than non smokers. These differences were seen both in the youngest group (12-13 y/o) and in the oldest one (14-16 y/o):

Young girls: 10.4±1.4 vs. 6.0±0.4 (p<0.0001); Old girls: 12.2±1.2 vs. 7.8±0.7 (p=0.0014);

Young boys: 9.7±1.6 vs. 5.7±0.3 (p=0.0001); Old boys: 11.9±2.6 vs. 6.2±0.6 (p=0.0012).

Significant differences could also be observed in the odds ratios of being above the 12-point cut-off in the girls: 5.0 (2.4-10.3; p<0.0001) for the youngest group and 2.5 (1.4-4.3, p=0.001) for those 14-16 years old

These results show that depressive symptoms (measured by the CDI) are higher in smokers than in non smokers and suggest either that those who start smoking earlier are more vulnerable to depression (high CDI score) or that those with high CDI scores are more vulnerable to smoking.

9.24 Arab Americans Acculturation and Smoking Behavior

H. Al-Omari1, M. Scheibmeir2 1The Hashemite University, ZARQA, Jordan 2Washburn University, TOPICA, United States of America

More attention has been given during the last few years on smoking among Americans from different racial and ethnic minority groups. One of the minority groups that has not been investigated thoroughly are the Arab Americans. The limited information available about Arab Americans smoking behavior has limited the planning and development of tobacco control programs specific for this population. An important concept that is essential to understanding the complexity of adjusting to a new culture is acculturation. During the acculturation process individuals may modify or change their social life, communication style, and lifestyle.

Poster presentations: Topic 9, Tuesday March 29 291 The purpose of this study was to investigate the possible relationship between Arab Americans smoking behaviors and acculturation. Design: this was a cross-sectional exploratory correlational study designed to elicit information from 96 smoker and ex-smoker participants. Results: multivariate regression analysis evaluated: a) acculturation themes, b) years of living in the U.S., and c) exposure to tobacco on the stages of change. The proportion of variance was twenty one percent, R2 = .212, F(4, 87) = 5.842, p < .001. There was a difference in using experiential processes of change among smokers in the precontemplation and contemplation stage. Significant correlations were found between specific acculturation behaviors and cons of smoking. Conclusion: Family and friends are the most important factors contributing to tobacco use among Arab Americans. Implementation: There is a need to investigate and understand the nature of family and peer support for Arab Americans continued smoking behavior.

9.25 Middle Eastern female university students’ attitudes towards tobacco smoking: investigating a taboo

A.A. Al Hamiz1, E.B. Breton2 1Zayed University, ABU DHABI, United Arab …mirates 2École des hautes études en santé publique, R…NN…S, France

Background Due to religious and cultural prescriptions, figures on the prevalence of smoking among women in the Arabian/Persian Gulf region are remarkably low. However there are strong suspicions that the same prescriptions may actually keep women from disclosing their use of tobacco. There is ground for concern considering that anecdotal evidence points toward a rising trend in waterpipe smoking and toward social norms that see it as an acceptable alternative to cigarette smoking. This research aims to explore female university student’s perceptions towards tobacco use in the context of the smoking prevalence we previously estimated for this group.

Methods In March 2010, 399 female students enrolled in a federal university of the United Arab Emirates were randomly selected and invited by email to fill out an anonymous online survey. The survey included questions on smoking initiation and tobacco use, on tobacco use in the family, on perceived social norms and on knowledge and attitudes toward smoking. The questionnaire was based on previous studies conducted in different countries and on two focus groups conducted with students (n=9). At the end of the survey, students were also given the opportunity to write their comments.

Results 58.9% (n=235) of the students invited answered the survey, of which 74 opinions were given. Respondent stated opinions in the survey and focus groups fall into the following topics: consequences of smoking on health, freedom, stigma of women smoking in society, customs and traditions of people in the Arabian Gulf, and reasons to the rise of tobacco smoking. While it shows that smoking is still seen through the lens of religious and cultural prescriptions a sanitary and women’s rights perspective has also permeated the vision of this group of women.

Conclusions The results of this study, that is the first of its kind conducted in the Gulf region, provide valuable insights on the perceptions of women on tobacco use. The authors conclude by identifying strategies to improve prevalence estimates in Arab women and gaps in research that need to be addressed.

Poster presentations: Topic 9, Tuesday March 29 292 Topic 10: Novel tobacco treatment interventions

10.1 Smoke-Free Living Study: Effectiveness of Extended Interactive Voice Response Added to varenicline

B.M. McNaughton, J. Frohlich, A. Graham, F. Bass, Q-R. Young, G. Bondy, A. Ignaszewski, S. Cockell, M. Li, S. Samadian St. Paul’s Hospital, VANCOUV…R, B.C., Canada

Background Previous studies indicate that there is a significant resumption of smoking in the three months following successful smoking cessation with the use of the medication varenicline. We hypothesized that there will be a significant increase in participants who do not smoke at one year if extended Interactive Voice Response (IVR) is used after 12 weeks of varenicline and IVR treatment. The automated IVR uses algorithms and sophisticated speech recognition to engage smokers on the telephone; gather information, provide reinforcing messages and triage them to a study nurse for call-back within 2 working days if either the smoker or the nurse identifies help is required. No study to date has assessed the effectiveness of a combination of IVR and varenicline.

Objective To determine whether smokers who quit after 12 weeks of treatment with varenicline and IVR (on quit date, day 3, 8, 11, and then every 2 weeks) maintain greater abstinence rates (defined as not a single ‘puff’ of a cigarette) when receiving extended IVR support from weeks 13 to 52.

Outcomes Primary outcome is self-reported continuous abstinence of smoking and exhaled carbon monoxide levels less than 10 ppm as measured and recorded by the research nurse at weeks 12 and 52. Secondary outcome is the self-reported date of smoking and number of cigarettes smoked from weeks 13 to 52.

Methods Of the 100 participants from the community, 42 stopped smoking after 12 weeks of varenicline and 9 IVR calls and were randomized into two groups matched by level of motivation and level of addiction. The intervention group continued to receive IVR support every 2 weeks for 9 months while the control group no longer received IVR support. Weight, waist circumference, pros and cons of change, stop-smoking self-efficacy, and psychological distress were recorded at the initial and 52 week visits.

Results At 52 weeks, 27 participants (27%) were smoke-free. 14 of these participants (51%) had received extended IVR calls from weeks 13 to 52.

Conclusions IVR calls from weeks 13 to 52 did not significantly affect the quit rate for smokers who had received varenicline and IVR for the first 12 weeks of the study.

Poster presentations: Topic 10, Tuesday March 29 293 Implementation IVR is useful as a screening tool to assess smoking cessation progress but does not appear to be significantly useful as a method of counseling for smoking cessation.

10.2 Smoking cessation counseling clinics in Estonia. Assessment and networking: Estonian experience

T.H. Harm …stonian Institute for Health Development, TALLINN, …stonia

Objective Prevalence of smoking in Estonia. According to Health Behaviour Study among Estonian Adult Population, 2008, there are 26% of 16-64 years old population daily smokers (39% males and 17% females). In 2006 the precentage was 28 and in 2004 - 33. Smoking behaviour is strongly connected with the education level: 16% males with higher education are daily smokers, compared with 50% of males with basic education. Also 66% males and 33% female unemployees are daily smokers (2008). According to Estonian Medical Birth Registry 2008, 11% of pregnant women continue smoking during pregnancy (2006 - 10% and 2004 - 9%). According to Estonian school-based survey of students in 13-15 age (Estonian GYTS, 2007), there was 31% of students (32% boys and 30% girls) who currently smoke cigarettes or use some other tobacco products. 35% of them initiated smoking before age ten. 28% of never smokers are likely to initiate smoking next year. 43% live in homes where others smoke in their presence.

Methods Smoking Cessation Clinic (SCC) assessment and networking: Estonian Network of Health Promoting Hospitals and Health Services was established in 2000. Estonian HPH Network joined the European Network of Smoke-free Health Care Services (ENSH) in 2005. Estonian HPH Network is a partner in e.SCCAN (European Smoking Cessation Clinic assessment and networking ) project (2010-2011). Estonian SCC country profile: 1 340 415 inhabitants, 34% smokers, total tobacco ban 2007. Density of SCC - 1 clinic for 60000 inhabitants. The tendency is to move from the hospital setting into community setting (primary health care). In the frame of National Strategy for CVD prevention (2005-2020) and National Strategy for Cancer (2007-2015) was established the network of 21 SCC (2005-2009), incl 3 SC centres for children and adolescents and 2 - for pregnant women. Since September 2010 SC clinics for 16-64 years old population are financed by European Social Foundation programme (2010-2011).

Results 240 healthcare professionals (medical doctors, nurses, midewives) passed 16 hours education and training programme on tobacco consumption and cessation. The smoking cessation counseling service is free of charge for patinets. On average, 16-19% of the quitters are staying as non-smokers after 1 year. The guidelines for smoking cessation and good practice exist. Accupuncture, hypnose, phytotherapy without any medication is excluded from SCC list.

Poster presentations: Topic 10, Tuesday March 29 294 Conclusions The HPH and ENSH networking process give to the health care organisations the opportunities to exchange experiences, good practices and to accelerate the know-how process. It is only through collaborative action that we can truly come to grip with smoking as killer No.1.

10.3 Do material rewards work? Results from an incentive-based smoking cessation programme for pregnant women

D. Eadie1, S. MacAskill1, A. Radley2, D. Tappin3 1Institute for Social Marketing, STIRLING, United Kingdom 2NHS Tayside, DUND……, United Kingdom 3University of Glasgow, GLASGOW, United Kingdom

Background Recent evidence indicates that as few as 20% of pregnant smokers in Scotland referred by routine antenatal carers actually engage with conventional specialist smoking cessation services. There is an emerging body of evidence demonstrating the value of financial incentives to recruiting smokers to quit programmes and to supporting abstinence during pregnancy. However, whilst reward-based programmes have been shown to help initiate and support quitting, it is recognised that to realise their full potential there is a need to develop consumer understanding of how incentives can be integrated with other forms of structured support in order to sustain the behaviour. Implementation: In view of the developing evidence base in 2007 NHS Tayside launched Give It Up For Baby, a smoking cessation scheme specifically designed to help pregnant women living in deprived communities in the Tayside region of Scotland. The scheme combined weekly behavioural and pharmacological support, with financial incentives for remaining smoke free.

Objectives The paper reviews the findings from an impact and process evaluation of the scheme’s pilot phase to assess quit rates and to understand the psycho-social and service related factors responsible for predicting retention.

Methods The impact evaluation involved monitoring of quit rates at one month and three months after ‘quit date’ and three months post-partum of those who registered with the scheme over the full intervention period, 2007-2009 (n=361). The process evaluation involved in-depth interviews with services users stratified by level of engagement with the scheme, supplemented by community pharmacists responsible for delivering support (n=26).

Results Routine monitoring data of participants in the scheme indicate point prevalence abstinence rates of 55.1% at one month and 31.0% at three months after ‘quit date’ and 14.4% three months post-partum, This represents a one month quit rate of 7.8% for the target population in Tayside, (the highest of any health board in Scotland), compared to a national rate of 3.0% for all health boards offering specialist or equivalent cessation services. Process results reveal the monetary incentives helped to promote programme engagement and as currently configured worked best with those moderately dependent on the reward who require a structured approach to quit.

Conclusions Preliminary results from the pilot phase indicate that material rewards can play an important

Poster presentations: Topic 10, Tuesday March 29 295 role in encouraging pregnant women to quit, in both initiating the quit attempt (providing a reason to act differently from the established social norm) and in helping to sustain attendance (providing an added incentive to engage in structured support).

Poster presentations: Topic 10, Tuesday March 29 296 Topic 11: The role of health professionals

11.1 Treatment of tobacco dependence: National Smoking Cessation Services in Italy

A.D. Di Pucchio, I.P. Palmi, C.M. Mortali, L.M. Mastrobattista, S.D. Di Carlo, P.Z. Zuccaro Italian National Institute of Health (Istituto Superiore di Sanità), ROM…, Italy

Objectives This investigation was carried out by the Italian Epidemiological Observatory on Tobacco, Alcohol and Drugs of abuse of the Italian National Institute of Health, and describes the principal structural and organizational characteristics of Smoking Cessation Services (SCS) set up within the Italian National Health Service.

Methods The principal coordinators of 284 SCS were interviewed by telephone or email. A standard interview reporting information on locations, access modalities, smoking cessation programs, staff and number of smokers treated in 2009 was established. All data were collected between February and April 2010 and analyzed by SPSS 17.0 software.

Results • All of the 284 coordinators responded to our survey. • The majority of the SCS are in Northern Italy (55.6%), 22.5% and 21.9% in Central and Southern Italy, respectively. • SCS are available in local health units (58.3%) and hospitals (39.9%) within the Department of Drug Addiction (38.9%) and the Department of Lung and Breath Care (30.4%). • The majority of the SCS (74.5%) started up their activity under specific Regional and Health Agency Action regulations. Notably, the first SCS has been operating since 1982 and 75.3% SCS since 2003. • Although pharmacotherapy is used in 95% of the SCS, a combination of therapeutic treatments is highly preferred. Indeed, 51.4% of the SCS provide pharmacotherapies associated to individual counselling and group therapy followed by pharmacotherapies and individual counselling (31.7%), and pharmacotherapies and group therapy (6%). • Costs to access tobacco-use cessation programs differ among SCS, and no free or low cost cessation medications are available. Indeed, 48.2% of the SCS requires patient’s contribution (e.g. ticket), 26.8% is cost-free and 21% a combination of both. • The SCS staff is composed of different professionals such as physicians, nurses and psychologists. The majority of the SCS have a multidisciplinary staff including physicians, nurse and psychologists (38% SCS); in 47.5% SCS at least one physician operates in team with a nurse assistant (22%), clinical psychologists (21.5%) or other professionals (3.9%). • In 2009, more than 18,000 smokers received at least one treatment with an average of 77 smokers per SCS.

Conclusions In the last years, Italian SCS have established themselves well and developed a wide range of treatment programs. To facilitate service development and smoker access, additional resources to offer comprehensive quit smoking services, training of dedicated staff and free or low cost cessation medications should be organized.

Poster presentations: Topic 11, Tuesday March 29 297 Implementation Our study led to the development of a monitoring activity of structural and organizational characteristics of SCS enabling a comparison at both national and international level. Our results are also expected to identify a monitoring activity on qualities and efficacy of differential therapeutic treatments provided by SCS leading to an improvement of smoking cessation programmes.

11.2 Italian national programme of midwifes’ counselling ‘Smoke free moms’

L.G. Sbrogiò1, D. Galeone2, S. Campostrini3, F. Michieletto4, M. Padovan5, S. Porchia3, A. Schiavinato5, L. Tagliapietra4, E. Tamang6, M.T. Villanova7 1Az. ULSS 19 Adria, ADRIA, Italy 2Dipartimento generale Prevenzione e Comunicazione, Ministry of Health, ROM…, Italy 3Dipartimento di Statistica Università Ca Foscari, V…NIC…, Italy 4Prevention Regional Direction, V…NIC…, Italy 5Az. ULSS 9 Treviso, TR…VISO, Italy 6Az. ULSS 15 Alta Padovana, CAMPOSAMPI…RO (PADOVA), Italy 7Italian League Against Cancer, TR…VISO, Italy

Objectives 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”. 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, distribution of specific educational material, monitoring and effectiveness evaluation.

Results A follow-up at two years after delivery conducted on 600 women in 2005-2007 in Veneto Region proved that women and partners who received anti-smoking counselling have better percentage of abstinence compared to a control group (pilot project data). At a national level, main process results are: 20/21 Regions formally adopted the programme; 4 National Courses were conducted in the years 2008-2009, forming 100 midwives as local training coordinators, who have already trained 1500 other midwives (over a target of 5000 by the end of 2011). The total amount of local activities related to the implementation of the programme has generated a web phenomenon: 2.230 quotations for “mamme libere dal fumo”in Google (October 2010). Finally, the programme is now part of the National Cancer Plan (2010-2012). National effectiveness analysis proved that midwives “coordinators”improved their knowledge and put into practice anti-tobacco counselling.

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.

Poster presentations: Topic 11, Tuesday March 29 298 Implementation By the end of 2011 the evaluation of counselling activity will be extended to all midwives trained; a follow-up at six months and one years after delivery will be conducted in order to know the percentage of abstinence in a sample of women and partners in 8 Regions. The final goal is to train all Italian midwives, starting when at college, in anti-tobacco counselling (about 20.000).

11.3 Smoking prevalence among health care professionals as a challenge in the professional role.

K.B.N. Kosic Bibic1, D.A. Dzeletovic2, P.R. Pavic3, K.S. Krstev4 1Institute of Public Health of Subotica, SUBOTICA, Serbia 2Institute of Public Health of Serbia, B…LGRAD…, Serbia 3Primary Health Care of Subotica, SUBOTICA, Serbia 4Institute of occupational medicine of Serbia, B…LGRAD…, Serbia

Goal To investigate the prevalence of smoking among health care workers of the Primary Health Care of Subotica and its impact on the professional role in implementing tobacco free regulation.

Method The survey was carried out by standardized methodology and on a representative sample regarding smoking prevalence in the health care institutions of Serbia in 2009. This paper will present results of a research conducted on the health care workers in Subotica’s Primary Health Care that was included in the survey sample. The response rate in The Primary Health Care of Subotica was 86.4%.

Results 425 workers got back the questionnaire, two thirds of them were health workers: doctors, dentists, nurses (321), including 102 doctors/dentists and 219 nurses. Smoking prevalence among doctors/dentists is 27,5%, whereas among nurses is 36,1%. On national level smoke 29,1% doctors/dentists and 41,7% nurses. On average, doctors smoke 19 cigarettes daily, and 4 cigarettes during the working hours; whereas nurses smoke 16 cigaettes daily, and 4 cigarettes during the working hours (p>0,05). The largest number of smokers (41,1%) want to quite smoking, and almost a third of them to reduce number of smoked cigarettes (30,8%). 99,4% of health care workers in The Primary Health Care of Subotica are familiarized with the Law on Ban of Smoking in Enclosed Premises, and 97,2% of them declared that smoking was prohibited in the health institution. The Primary Health Care of Subotica regularly participates in health promotion campaigns and in the celebration on the occasion of a tobacco free days. The institution thas not have counseling for quit smoking, but it sent a team to be educated in.

Conclusion There is a high rate of smoking prevalence among health care workers inspite the droping the prevalence rate when compared to the year of 2003., when the survey was first carried out. Smoking prevalence rate is on national level. Health care institutions and health care workers play the key and leading role in numerous activities and measures in tobacco control within population, such as to provide smoke free workplaces as well as to cessation activities to help people who want to quite smoking. A serious problem to professional working is high prevalence of smoking among health professionals.

Poster presentations: Topic 11, Tuesday March 29 299 Implementation The results of this survey enable the recognition of the challenges in professional role of health care workers related to the inplementation of tobacco controle measures. In order for the health care workers to performe their professional activities without behaviour barriers, they need to accommodate their behaviour with professional ethics; this implies targeted trainings for health care workers.

11.4 Recording smoking cessation brief intervention fails: A cross-sectional study in a Portuguese teaching hospital

S.B.R. Belo Ravara1, J.M.C. Calheiros1, P.A. Aguiar2, L.T.B. Taborda Barata1 1Faculty of Health Sciences, University of Beira Interior, LISBON, Portugal 2National School of Public Health, Universidade Nova de Lisboa, LISBON, Portugal

Objectives Hospital-based health care providers (HCP) are in a unique position to motivate smokers to quit and assist inpatients with cessation. However, little is known about hospital-HCP’ smoking cessation attitudes and practices, and few studies targeting multiple HCP have been done in hospitals. In November 2007, a smoking survey was conducted in a Portuguese teaching hospital. An additional questionnaire for the HCP-subsample was undertaken to survey cessation attitudes, self-reported cessation practices and record-keeping procedures, training programs attendance and self-confidence to intervene.

Methods Cross-sectional questionnaire-based study, including all eligible staff. Chi-squared tests were used to compare HCP’s characteristics to cessation variables. Multilogistic regression (MLR) was performed to examine factors associated with cessation variables.

Results Study-subsample includes 426 HCP: 65.6% females; mean age 38.6±10.08; 51.7% response rate. Most HCP had positive attitudes to proactive smoking counselling (89.6%) and even more positive attitudes to being role models (97.2%). The majority of physicians (Ask: 83.3%; Advise: 88.6%) and nurses (Ask: 63.6%; Advise 69.1%) reported asking and advising (“2As” cessation practices) “always or often”. However, other HCP reported “2As”low frequencies (Ask: 11.5%-26.4%; Advice: 30.7%-48.2%; p<0.001). Additionally, a significant percentage of physicians and nurses did not report “2As”systematic practices. Systematic “Asking”was less reported than systematic “Advising”by all HCP. The great majority of HCP did not record either “2As”(Ask: 24.1-32.6%; Advice: 11.3-12%) or tobacco use diagnosis (11.3%). Most HCP had not attended undergraduate (77.5%) or graduate (92.9%) training programs and 67.5% considered they did not need further training. Nevertheless, 63.9% reported being self-confident to intervene. MLR showed that undergraduate training, being a physician or a non-smoker were beyond the factors that most influenced cessation practices. Undergraduate training and being a nurse predicted self-confidence to intervene.

Conclusions Hospital-based HCP do not follow cessation guidelines: recording is the most fallible step.

Implementation Automatic electronic systems should become mandatory in health care as they promote systematic record-keeping and increase cessation interventions. Training programs must be given higher priority in Hospitals’ tobacco control policies, involving the whole health care

Poster presentations: Topic 11, Tuesday March 29 300 team, and especially nurses. Tobacco Control and cessation skills should be a core curriculum content of all health sciences schools.

11.5 Girl Power: Women Media Profiles and Health Professionals parnter to Combat Tobacco Marketing in Sweden

L.S. Sjöberg1, G.B. Bolinder2, M.N. Nilsson3, M.P. Pantzar4, Y.W. Wiklund5, M.R. Roos1, I.T. Talu6, A.P. Post7, M.H. Haglund4, F.S. Söderhielm8, S.S. Sanchez1 1Health Professionals Against Tobacco, Sweden, STOCKHOLM, Sweden 2Karolinska Sjukhuset, STOCKHOLM, Sweden 3Umeå Universitet, UM…Å, Sweden 4National Institute of Public Health, ÖST…RSUND, Sweden 5Psychologists Against Tobacco, STOCKHOLM, Sweden 6Teachers Against Tobacco, STOCKHOLM, Sweden 7Nurses Against Tobacco, STOCKHOLM, Sweden 8A NonSmoking Generation, STOCKHOLM, Sweden

Health Professionals Against Tobacco Sweden (NGO) organized a round table luncheon on World No Tobacco Day with the objective to discuss and develop action strategies to combat tobacco marketing against women in Sweden. The event engaged media profiles and health professional students and/or those new in their careers to come together and discuss and implement strategies to halt tobacco industry marketing. The moderated round table discussion followed a manuscript which covered: identifying present marketing strategies in Sweden, examining the current legislation and discussing ways to combat marketing using collective resources such as the media and health professional channels.

World No Tobacco Day 2010 themed “gender and tobacco with an emphasis on marketing to women”brought to light this critical strategy used by the tobacco industry to make profits. It is well documented that a key tobacco use prevention strategy is to inhibit any type of marketing including more discreet methods such as sponsorship by the tobacco industry. Health Professionals against Tobacco which is and umbrella organization of Doctors, Dentistry, Nurses, Teachers, Pharmacy and Psychologists/Sociologists against Tobacco partnered with A Nonsmoking Generation to invite media profiles and health professional students to ultimately develop ways in which to eliminate tobacco industry marketing toward women in Sweden.

In Sweden the number of women smokers has exceeded that of men. The amount of young women starting to smoke and use oral tobacco has increased over the years is alarming. Deaths by lung cancer among women is rising and is higher than breast cancer. Although Sweden has made progress in inhibiting tobacco industry marketing, there are still weak points in the legislation which risk addicting new tobacco users. For example, the tobacco industry invests in promoting tobacco at point of purchase, package design, brand stretching and in corporate social responsibility initiatives. Furthermore, the manufacturers of snus are aggressively targeting women and adolescents in Sweden as this remains a market to be exploited.

The result of the May 31st event revealed that although the legislation in Sweden is comprehensive, there are still candid ways in which the tobacco industry markets its products to young women. The discussion focused on ways to close loopholes that permit marketing and including eliminating tobacco displays at point of purchase, plain packaging and advocacy directed to organizations to avoid accepting corporate social responsibility awards. Another

Poster presentations: Topic 11, Tuesday March 29 301 result of the day is the formation of a network of activists working toward eliminating marketing of tobacco in Sweden. Action to date includes the writing of a manifestation, articles in blogs, magazines and newspapers as well as meetings with businesses to combat marketing.

This event was funded by the HELP for a Life Without Tobacco Campaign and the National Institute of Public Health in Sweden.

11.6 Can Serbian health institutions be smoke-free after the implementation of total smoking ban?

S.K. Krstev1, J.M. Marinkovic2, S.S. Simic3, A. Jovicevic4, L.M.D. Markovic-Denic5, A.K. Kotevic6 1Serbian Institute of Occupational Health, B…LGRAD…, Serbia 2Institute of Medical Statistics and Informatics, School of Medicine, University, 11 000 B…LGRAD…, Serbia 3Institute of Social Medicine, School of Medicine, University of Belgrade, 11000 B…LGRAD…, Serbia 4National Institute of Oncology and Radiology, 11 000 B…LGRAD…, Serbia 5Institute of …pidemiology, School of Medicine, University of Belgrade, 11 000 B…LGRAD…, Serbia 6City Institute of Public Health Belgrade, 11 000 B…LGRAD…, Serbia

Objectives The new Law on Protection from Second-Hand Smoke will enter into force on November 11, 2010 and will ban smoking in all health institutions (HIs), including backyards and front doors. Having in mind that the prevalence of smoking in adults in Serbia is pretty high - 34% (men 38%, women 30%), we wanted to assess the smoking prevalence in all employees of various HIs in Serbia.

Methods In this nationwide study, a stratified random cluster sample of HIs was selected from all 4 geographical areas of Serbia and 4 types of institutions (primary healthcare centers - PH- CCs, university hospitals, general hospitals and institutes of public health). Among them, 3 670 employees (physicians, nurses, other health professionals, technical staff and maintenance) were included (response rate 79.6%). Predominantly, study subjects were women 74.5%; the mean age was 42.5 years for women and 43.4 years for men (p=0.019).

Results Overall smoking prevalence in employees was 39.9% (95% CI 38.3-41.6); among men 38.5% (95% CI 35.2-41.8) and among women 40.0% (95% CI 38.0-41.9), being the lowest among physicians (29.1%), followed by nurses (41.7%), other health professionals 42.8%, technical staff (43.1%), and maintenance (45.2%). The highest proportion of smokers was in general (44.1%) and university hospitals (43.1%), followed by public health institutions (38.5%) and PHCs (34.9%).

More than a half of all employees stated that smoking presented a problem at their workplaces (56.0%; 95% CI 53.0-59.0), the least among technical staff (53%), and the most among maintenance (61%). Regarding the type of HI, smoking at work was a problem in 52% smokers in general hospitals and 59% in PHCs. Less than a half of daily cigarette consumption was smoked at work (7.0 vs. 18.4 cigarettes). Roughly 1/3 of all smokers would like to quit (32.2%), mostly physicians (40.8%), and the least technical staff (25.2). Other 1/3 of smokers (37.2%)

Poster presentations: Topic 11, Tuesday March 29 302 would like to reduce the daily number of cigarettes.

Conclusion We observed a high smoking prevalence in employees of HIs in Serbia, more in women than men, reflecting the high prevalence among nurses; the lowest in physicians and high in all others employed in HIs. More than a half of all smokers reported that smoking was a problem during the work, although they smoked significantly less cigarettes at work. Overall smoking in HIs was a problem and implementation of the new Law would be a challenge.

Implementation A guide with basic information on tobacco control and brief instruction for implementation of new Law in HIs were published and disseminated to all HIs in Serbia; and education for smoking cessation teams in PHCs has been organized regularly in order to engage more health professionals in tobacco control and obtain their support for smoke-free health institutions.

11.7 Effect of cigarette smoking on blood lead levels in pregnant women

M.C.H. Chelchowska1, K.J.S. Jablonka-Salach2, J.G. Gajewska1, J.A. Ambroszkiewicz1, T.M. Maciejewski1, E.B. Bulska2, T.L.K. Laskowska-Klita1 1Institute of Mother and Child, WARSAW, Poland 2Faculty of Chemistry, University of Warsaw, WARSAW, Poland

Objectives Tobacco smoking create health problems which apply not only to individuals and family but also to different age and social groups as well as to national economy. The epidemiology studies conducted in Institute of Mother and Child indicated that in Poland 25-30 % women smoke during pregnancy. Lead exposure from cigarette smoke may have a negative effect on transplacental transpire of micronutrients and resulting in adverse influence on growth and fetal development. The aim of the study was to estimate the effect cigarette smoking on serum lead levels in pregnant women.

Methods Forty healthy pregnant women, attending the Institute of Mother and Child in Warsaw were asked to cooperate in this study. All pregnant volunteers signed a written informed consent form, approved by the Institute’s Ethical Committee. At the first visit, a history of smoking was obtained by directly questioning the pregnant women. Smokers were defined as those women who reported their smoking habit as maintained at a rate of minimum five cigarettes per day during pregnancy and non-smokers as those who had never smoked either. The classification was confirmed by measurement of cotinine concentration - the major metabolite of nicotine in serum of pregnant women.

Venous blood samples were collected from women in I (median: 12 wk), II (median: 22 wk) and III trimester (median: 33 wk). Concentrations of lead were analysed using inductively coupled plasma mass spectrometry on spectrometer analyser ICP MS Elan 6100 (Perking Elmer, Germany). Levels of cotinine in serum were determined by Cotinine one-step ELISA test; (IDS Corp USA).

Results In group of smoking mothers the mean serum cotinine concentration was 72.5 Î_g/L, whereas in group of tobacco abstinent was present only in trace amount. The concentrations of lead in plasma of smoking women were 4.0 Î_g/l in first, 3.7Î_g/L in second and 4.1Î_g/L in

Poster presentations: Topic 11, Tuesday March 29 303 third trimester of pregnancy. In non-smoking group the levels were lower and amounted 2.0 Î_g/L, 1.4 Î_g/L and 1.1 Î_g/L respectively. The differences were statistically significant in each trimester of pregnancy (p<0.01). In group of smokers we observed significant positive correlation between number of cigarettes daily consumed and serum cotinine (r=0.75; p<0.0001) as well as lead level (r=0.41; p<0.05). The same was observed in the case of association between lead and cotinine concentrations (r=0.49; p<0.01).

Conclusions Tobacco smoking during pregnancy affect in maternal blood lead concentrations. Additionally the elevation of serum level of lead correlated with degree of cigarette smoking intensification.

Implementation Recognize relationship between tobacco smoking and lead exposure during pregnancy. Describe the standardized survey questionnaire for assessing exposition of pregnant women on tobacco smoke. Develop an educational care plane for women to quick smoking tobacco during pregnancy.

11.8 Effect of initial nicotine and cotinine replacement on long-term smoking abstinence rate: a TDM approach

M.B. Baraldo1, C.P. Cojutti2, D.A. Duscio2, F.M.T. Feruglio2, R.I. Rosa3, F.M. Furlanut2 1Anti-Smoking Centre, Institute of Clinical Pharmacology and Toxicology, UDIN…, Italy 2Institute of Clinical Pharmacology and Toxicology, UDIN…, Italy 3SOS of Prevention, Protection and Health Surveillance, UDIN…, Italy

Introduction Nicotine Replacement Therapy (NRT) associated with counselling leads to a 12 months continuous abstinence rates ranging from 14.1 to 34.5%: the great interindividual variability in nicotine and cotinine plasma concentrations, and therefore the degree of replacement required, could obviously explain these unsatisfactory results. The use of a therapeutic drug monitoring (TDM) approach to NRT treatment is appealing but has never been applied in clinical practice. In a group of ambulatory patients with different levels of nicotine dependence, we have studied the relationship between the 1 week nicotine and cotinine replacement values and smoking abstinence assessed at 12 months after smoking cessation.

Methods We have retrospectively studied 94 cigarettes’ smokers (cigarettes/day: 24.1±9.6; age: 51.4±11.5 yrs; weight: 74±15.5 kg) visited between 2002 and 2009. Baseline nicotine and cotinine concentrations have been obtained while smokers were smoking at their usual rate. Blood sampling was performed in the afternoon, at least after 6 hours from wake-up and after 2 hours from the last cigarette smoked. Plasma nicotine and cotinine concentrations had been analyzed by means of a validated HPLC method. Patients were then prescribed an initial nicotine patch dose according to the plasma nicotine and cotinine concentrations observed.

One week later, after steady-state plasma concentrations were attained, plasma nicotine and cotinine concentrations have been rechecked, nicotine and cotinine replacement calculated and nicotine dose eventually modified.

We have then divided all our patients in three groups according to the baseline cotinine levels (A: <200 ng/ml (n=19), B: 200-300 ng/ml (n=34) and C: >300 ng/ml (n=41)), as

Poster presentations: Topic 11, Tuesday March 29 304 suggested by Hurt DR et al. [1]. In each group, we verified the mean nicotine and cotinine replacement at first week and observed the 12 months abstinence rate.

Results 46 out of 94 patients (mean: 49%) have remained abstinents at 12 months. Abstinence rate for group C is significantly lower than for group A and B (32, 63 and 62% respectively).

Nicotine and cotinine concentrations assessed after 1 week from starting NRT are higher for group A (112±85% and 85±18%) and B (105±85% and 76±26%) than for group C (61±28% and 63 ±29%).

Conclusions Our results have shown that the likelihood of long-term abstinence is related to the degree of the 1 week cotinine replacement values: the higher the replacement during the first week, the higher the 12 months abstinence rate. Therefore nicotine and cotinine TDM seems a valuable tool in order to identify the initial nicotine replacement dose and to tailor nicotine dose during the treatment.

1. Hurt RD, Ebber JO, Taylor JH et al. Treating Tobacco Dependence in a Medical Setting. CA A Cancer J Clin 2009; 59: 314-326

11.9 Awareness of young health professionals on tobacco control advocacy programs in Oyo State, Nigeria

O.J. Ogunnika, A.A. Atanda …ducare Trust, Nigeria, IBADAN, Nigeria

Objectives Tobacco use is a risk factor for six of the eight leading causes of death in the world. Intervention greatly increases quit rates among tobacco users. The role and image of health professionals is essential in promoting tobacco free lifestyle and cultures. Warnings from health professionals who are generally highly respected about the risks of tobacco use are usually well received. However, it requires that health care professionals be knowledgeable, well equipped and motivated to provide advice.

This study is designed to assess the knowledge as well as the awareness of young health care professionals regarding tobacco control advocacy programs in their State.

Methodology Cross sectional survey involving 172 respondents who were randomly selected and interviewed using a questionnaire. Study location was the College of Medicine, University of Ibadan, Nigeria. Data was analyzed using descriptive statistics in terms of percentages and numbers.

Results The risks associated with tobacco use was generally perceived as high and 8 out of 10 health care professional reported to have told at least someone of the risks associated with tobacco. 89% of the respondents do not have any formal education on tobacco control.79% of the respondents admit not to have heard or attended any tobacco control advocacy programs. 83% of the young health professionals who are current tobacco users have not heard or attended any tobacco control advocacy events.

Poster presentations: Topic 11, Tuesday March 29 305 Conclusion Majority of health care professionals in Nigeria have a low awareness of tobacco control advocacy programs. It is imperative that health care professionals are knowledgeable and have a high awareness of tobacco control advocacy to equip them in effectively splaying their role in tobacco control.

11.10 HOSPITAL WORKERS ATTENDING A TOBACCO CESSATION PROGRAME. A DECADE´S REVIEW

E. Alonso, R. Hernandez, B. Moreno de vega, D. Trujillo, A. Tapias, D. Rodríguez, C. Sánchez Hospital Sonsoles, VALLADOLID, Spain

Background and aims Hospital workers are a key population in tobacco cessation for their role model and example for the rest of population. We decided to review some key facts of a tobacco cessation programme aimed at these workers, including patients for the last ten years (2000-2010). If we better understand how these smokers behave regarding tobacco cessation, we could improve their results and indirectly the whole population’s attempts.

Methods 332 smokers, attending a six months tobacco cessation programme, were included in our study: They belonged to all the strata working in our tertiary teaching hospital including: doctors, nurses, auxiliary nursing personnel and workers not directly involved in health care (technicians, kitchen and cleaning staff, transport workers, office personnel). This programme was openly offered to any hospital worker willing to quit, and included 7 follow up visits. We studied each group’s records, and specifically their results, attrition rate, adherence to the programme, addiction level (Fagerstrom score) and motivation (Richmond score) and demographic variables like age and sex. A p level >0.05 was considered significant in the correspondent statistics tests.

Results The mean overall age was 43 years (SD 8 years), Auxiliary nursing personnel 44.7 years (SD 8 years) St. T= 1. 9 (p=0.04). The mean score was 6.7 points (SD 1.8 points). The mean Richmond score was 6.9 points (SD 1.8 points) 281 women (84.4%) started our programme. 70 smokers (21%) completed it. 142 smokers (42%) were registered as success in our records although only 58 (17%) registered as success could complete our programme. Success rate per group was: Doctors (46%), Nurses (51%), Auxiliary (32%) Ï‡2= 7.5 (p =0.02), Others (41%). Mean follow up visits were 3.8 visits (SD 2.1). Nurses mean visits 4.2 (SD 2.1) St. T= -2.35 (p=0.01). Men mean follow up visits was 3.2, while women mean follow up visits was 3.9 St. T= 1.95 (p=0.05)

Conclusions Women were the main users of this tobacco cessation programme. Nurses obtained the best success rate. There was a tendency in women, to attend more follow up visits than men, and this tendency was significant in nurses, Auxiliary nursing personnel were the older group and obtained the worse success rate. No other differences like addiction or motivation scores were found among the groups

Poster presentations: Topic 11, Tuesday March 29 306 11.11 ‘Smoking is treatable’ Project

K.J.K. Janik-Koncewicz, W.Z. Zatonski Cancer Center and Institute of Oncology, WARSAW, Poland

Tobacco smoking is the major single preventable cause of premature deaths in Poland. Smoking-attributable cancer mortality in male population is high and concerns 55% of premature deaths from cancer. In women, the proportion of tobacco-related deaths constantly increases, however is still at a much lower level than in men. Every year about 70.000 Poles die from active tobacco smoking and about 2.000 from second-hand exposure to tobacco.

Treatment of tobacco dependence and involvement of health professionals, especially medical doctors, are very important factors of tobacco and cancer control. Therefore, in 2009 the Health Promotion Foundation started implementation in Poland of the 2-year project entitled “Smoking is treatable”within the Global Health Partnerships Program.

Project’s goal was to develop and implement training modules on treatment of tobacco dependence for medical students and physicians (general practitioners and specialists) in Poland. The whole concept of the program treatment was evidence based and followed recommendations of Cochrane Library reviews and NICE guidelines. Project used also Polish Consensus on diagnosis and treatment of tobacco dependence. Each module was targeted at a different health professionals group and provided participants with knowledge aimed at enhancing their motivation to start treating patients from tobacco dependence, information on characteristics of tobacco dependence, its diagnosis and methods of treatment.

Presented data describe the project implementation and its results.

11.12 Smoking Cessation in Primary care - Implementation Training (SCIP-IT): Influencing practice and beliefs of general practitioners

M.E.A. Verbiest, M.R. Crone, M. Scharloo, N.H. Chavannes, V. Van der Meer, A.A. Kaptein, W.J.J. Assendelft Leiden University Medical Centre, L…ID…N, The Netherlands

Objective Development of a tailored implementation training that aims to influence Dutch general practitioners’ (GPs) beliefs and attitudes towards smoking cessation care (SSC), identification of opportunities to overcome barriers to SCC and solutions to reach an optimal implementation of SCC in regular GP practice.

Methods The tailored implementation training (6 I-model) is based on behavioural change techniques. The training consists of 6 steps in which: 1) an Inventory is made of the barriers to SCC in GP practice, 2) Information is provided to the GP about the effectiveness of SCC, 3) the level of motivation of the GP is Identified, 4) the less motivated GP is Inspired by using Motivational Interviewing techniques, 5) the GP is Instructed on knowledge and skills related to SCC implementation, and 6) Intervision will provide follow-up and feedback opportunities to provide additional implementation support. The effects of the implementation training will be tested in a cluster-randomized controlled trial. 34 GPs in both the intervention and control condition will fill-out a tracking list for two periods of six workdays in which they indicate their smoking cessation activities during those days. Alongside this tracking, patients will be asked about

Poster presentations: Topic 11, Tuesday March 29 307 the SCC of their GP and about their willingness to stop smoking. Between these two tracking periods, GPs in the intervention group will be visited by a skilled ‘stop-smoking prevention representative’ who provides the tailored implementation training based on the 6 I-model.

Results Because the intervention period is from December 2010 until July 2011, we are able to present the preliminary results at the time the conference takes place. The effectiveness of the intervention is established by comparing intervention and control group on the number of weekly stop-smoking advices given by the GP as measured by self-report, patient-ratings and entries in patient files (main outcome measure). Primary hypotheses are that the intervention will lead to better scores on a) entries in patient files about smoking status, b) GPs weekly number of stop-smoking advices, c) advice about nicotine-replacement therapy, d) the number of referrals to stop-smoking programmes and e) the number of prescriptions of nicotine replacement therapy or specific stop-smoking medication. Secondary hypotheses are that the effect on the outcome measures is mediated by more positive GP beliefs and attitudes towards SCC. Also patients of GPs in the intervention group will be more motivated to quit smoking.

Conclusions This study will provide knowledge on the beliefs and barriers that cause GPs not to act according to guidelines and provides possible solutions to overcome these. This information can be used directly to optimize strategies to assist GPs with routinely incorporating SCC for all smokers in their practice.

Poster presentations: Topic 11, Tuesday March 29 308 Topic 12: Health education and health communication – eg., mass media campaigns, health communication interventions, youth education programmes

12.1 The children of Guernsey help the children working in tobacco fields in Malawi

V.K. Amey Guernsey Adolescent Smokefree Project, ST P…T…R PORT, GU…RNS…Y, CHANN…L ISL, United Kingdom

Introduction The Guernsey Adolescent Smokefree Project (GASP) is a charity whose aim is to raise awareness about the evils of tobacco and hence reduce smoking amongst young people. The children of Guernsey have been sensitive to the plight of children working in tobacco fields in Malawi and they have been involved in fund raising activities to finance a pilot project, Ana A Topa (which means the children are tired).

Aims The initial aim of the project carried out jointly by GASP and Tobacco Tenants and Allied Workers Union of Malawi (TOTAWUM) was to help 44 small holders to grow maize instead of tobacco to then use the profits to make the project sustainable and assist 5 more families per year.

Methodology The children of Guernsey and Overseas Aid funded £10,000 towards Ana A Topa. The money was spent on buying fertilisers and maize seeds, administration fees, executive and awareness meetings. The farmers were trained on environmental friendly farming methods as well as on the evils of tobacco.

Results 23 tobacco farmers plated non-tobacco crops during 2008-2009. The participants had a surplus of food and have been able to be self-sufficient this year. The project aroused the interest of several village members living close of the project participants in maize production and 20 families are taking part in the phase two of the project instead of 5 over 2010-2011.

Conclusion The project shows that through education, awareness campaigns and most of all, financial support, tobacco farmers can embrace the cultivation of alternative crops.

Poster presentations: Topic 12, Tuesday March 29 309 12.2 Social media for promotion of idea free from tobacco society

D.G. Sundeev1, S.Y. Sundeeva2 1Kyrgyz- Russian Slavic University, BISHK…K, Kyrgyzstan 2Adult Training Center, KARA-BALTA, Kyrgyzstan

“ The technology takes away authority from editors, publishers. The authority now belongs to people” Rupert Murdoch, Global Media …ntrepreneur

Objectives Knowledge of innovative tobacco cessation methods and strategies and prevention initiatives to practice by way of social media.

Use abilities of social media (internet society, blog, social networks) for providing tobacco control.

Results Old methods of promotion of any idea or business don’t work now:90 % of people turn off TV advertising, Only 14 % of people trust advertising, 90 % trust familiar’s recommendations, 70 % trust opinions found in the Internet, More than 60 % of users trust networks, more than 40 % trust stories. And in fact it is possible and it is necessary to use for promotion of idea of a society without tobacco by way of social media!

Conclusions Unilateral communication with clients and partners - business of the past. Social media - means to establish bilateral communication with clients and partners. 83 % of users of social networks search for dialogue. The basis of dialogue in social networks - to help people to know about harm tobacco, ways for quit.

To use for promotion of idea of a society without tobacco by way of social media.

Implementation 1. before you start determine the purposes: a. That you want to inform up to a target audience b. Than the target audience is interested c As you can reach a target audience It is necessary to leave for frameworks of your health service and to tell that can interest in connection with your service

2. conversation with your audience- blog. a. Discussion by that interesting to your audience b. The message of interesting news c. The helpful information And... Traffic on your site!

3. Social Networks a. 83 % of users of social networks search for dialogue b. 81 % consider advantage *1 opportunity ‘to be lighted’, further - increase in the traffic at a site and an establishment of partnership c. More than 60 % of users trust networks, more than 40 % trust story

Poster presentations: Topic 12, Tuesday March 29 310 4. Facebook a. For 2009, the group of 35-54 years has grown on 276 % b. The group is more senior 55 has grown on 194.3 % c. Fan Pages are created by you or your clients: Video, Competitions, Photos, Discussions

5. YouTube a. And SO, want to advance social health service? b. Create a site with the static information c. Create on a regular basis updated story d. Participate in social networks to receive traffic on story and a site e. Use Twitter for dispatch renovation and receptions of traffic on story and a site

Results Free from tobacco society is really!

12.3 Teenagers as a tool against tobacco smoking, not model for tobacco industries

O. Omiyefa1, F. Osoba2, F. Akinyode3 1Youth Action On Tobacco Control and Health, LAGOS, Nigeria 2University College Hospital, IBADAN, Nigeria 3PHC Coordiator, SAKI W…ST, Nigeria

Introduction For over twenty years, the tobacco industry has made marketing and distribution of tobacco products to youths a core of its marketing strategy in Nigeria and has recruited thousands of teenagers as smokers.

Objectives This paper will try to educate and expose some of the secret parties of British America Tobacco and how to prevent students and youths from their tricks and secret parties.

Method Tobacco Control advocates in Nigeria lodged in a hotel which the BATN secret party was held this recent event was organized to promote the Pall Mall brand. It was organised in all the six geo political zones in the country and was heavy on young people. Invitation cards were secretly given out in secondary schools and colleges. Young girls were encouraged to attend. A seminar was organized by the tobacco control advocates for the same students from the different high schools in Ogun and Lagos State to sensitize them on the harmful effect of tobacco smoking and to reveal lies of tobacco industries.

Result Attendees at the workshop were surprised at the lies of the BATN and many of the high school students were not aware of the chemicals included in cigarette, this facts made students who had intentions to start smoking stopped. Most of the teachers and school head who also attended the workshop realized the damages caused by smoking.

Conclusion Teenagers in the developing countries should be encouraged to advocate for the tobacco control industries making them role models instead of smoke models.

Poster presentations: Topic 12, Tuesday March 29 311 12.4 Effects of the national campaign on passive smoking and challenges for implementation of the law

A.M. Dzeletovic1, N.K.B. Kosic Bibic2, I.P. Pesic3, A. Jovicevic4 1Institute of Public Health of Serbia, B…LGRAD…, Serbia 2Institute of Public Health of Subotica, SUBOTICA, Serbia 3Institute of Pulmonary Diseases and Tuberculosis Clinical Center of Serbia, B…LGRAD…, Serbia 4Institute of Oncology and Radiology of Serbia, B…LGRAD…, Serbia

Goal The work shows main achievements, that is, effects of the national campaign on passive smoking and opinions about the new Law on Protection of the Population from Tobacco Smoke Exposure.

Method A year-long national campaign on passive smoking started in December 2008, with the goal to inform the population about the new Law. Research on effects of this campaign was conducted in January 2010 on a representative sample, including the population of 18+. Apart from general questions (sex, age, education, region, type of settlement, smoking status), results on effects of the campaign and opinions of the new Law were used in this work. While the research was still ongoing, the Draft Law was adopted prohibiting smoking in enclosed work and public spaces.

Results More than one half of Serbian citizens (58%) remembered the campaign against passive- smoking in the past year, while more than two thirds of them (78%) remembered it after being reminded. One half of the citizens are of the opinion that anti-smoking campaigns have effect on raising awareness on dangers of tobacco smoke and reduction of smoking, and that they are useful. Most trust in anti-smoking campaigns put persons who have stopped smoking (67%), but more than one third of smokers also think that these campaigns may be efficient. Citizens who remembered this campaign of their own accord (55%) had a significantly more positive attitude towards its effectiveness. More than one half of the citizens (52%) who remembered the campaign said that the campaign had a personal effect on them. Results of this research showed that almost 80% of the citizens supported the new Law, even 56% of everyday smokers.

Conclusion The campaign has been noticed by majority of the citizens, and when reminded of the used slogans, the number of people who remembered the campaign grew. The campaign had effect and influenced citizens on a personal level. The effects of the campaign may be labeled as encouragement, to make people think about dangers coming from tobacco smoke and smoking, and, at the same time, it may be support for the new Law; this support is strongest among people who have never smoked. It is very intriguing that more than one half of smokers, who smoke on a daily basis, support this Law.

Implementation Results and effects of the national campaign on passive smoking help review the challenges in implementation of the new Law on Protection of the Population from Tobacco Smoke Exposure, and provide defining of new measures and activities in implementation of tobacco control on the national level.

Poster presentations: Topic 12, Tuesday March 29 312 12.5 Children’s concepts of cancer and its change after an intervention

I.Z. Zaloudikova, D.H. Hrubá Masaryk University, BRNO, Czech Republic

Objectives The issue investigated in this study is children’s concept and believes of cancer and its changes after an intervention using methodology that had been already applied (Schonfeld et al. 1999, 2001; Chin, Schonfeld et al. 1998; Oakley, Bendelow et al. 1995; Pridmore, Bendelow 1995; Onyango-Ouma, Aagaard-Hansen, Jensen,2004; Piko, Bak 2006). We have done this research in the social and cultural context of our location in the Czech Republic. The aim is also to test the effectiveness of the new primary cancer prevention programme ‘Non-Smoking is a Norm”, which was used for an intervention. We asked questions like: What do children know about cancer? What does cancer mean to them? Has the concept of cancer changed after the intervention? Is the programme effective?

Research Methods The ‘draw-and write’ technique and a semi-structured interview were used for an evaluation. A pre-test was conducted before the intervention. A post-test after the intervention was completed in the experimental and the control group. The statistical significance of their differences was evaluated in the EPI Info 6.09 programme by the chi_-square test and its modification according to Yates and Fischer.

Results Children’s concepts of cancer are absolutely unique subjective interpretations. They associated cancer often with death, serious threat to health, a disease affecting multiple organs, most frequently the lungs, heart and brain. Some also believe that cancer is contagious, an infectious disease, and recommend to avoid contacts with cancer patients. Smoking was cited by the children as by far the most frequent cause of cancer followed by alcohol, drugs, bad foods and environmental factors. Changes in the post-intervention concept of cancer were demonstrated in an increasing number of drawings depicting affected organs (mainly the lungs and the heart). Children were more likely to list various types of organs affected by cancer. A change in the level of cognitive dimension of the concept of cancer also occurred in the children’s belief that cancer is a disease of the lungs and other organs, and, at the same time there was a decrease in the number of those who did not know the answer. There also was an increase in the number of children who understood the cause of cancer in smoking, unhealthy food and environmental factors. These results confirm the intervention effectiveness.

Conclusions There was a change in the concept of cancer after the intervention. Results have confirmed the effectiveness of the primary preventive programme.

Implementation The primary preventive programme Non-Smoking is a Norm was tested positively and could be implemented in to the school curriculum in the health education.

Poster presentations: Topic 12, Tuesday March 29 313 12.6 Health awareness of students of smoking and impact of health education in Kazakhstan and Uzbekistan

O. Otani Osaka University, MINOH CITY,, Japan

Objective This paper looks at the awareness of tobacco harm of the college students, mainly under age 20, Republic of Kazakhstan, and Republic of Uzbekistan, and impact of health education using the Kano Test for Social Nicotine Dependence (KTSND) and essays before and after the lecture on tobacco and smoking.

Methods KTSND survey was conducted before and after health education lecture at several universities in Almaty and Astana in Kazakhstan as well as in Tashkent in Uzbekistan in year 2007-2008.

Results At all the universities in both countries, the total score of KTSND declined, that is improved, after the health education lecture. In each group, the score for the smokers were higher than that for non-smokers, but it declined in all groups.

Students answered as the most impressive issues in the health education lecture was that it made them aware of health harm of smoking, not only on throat and larynx but also for the whole body including sexual organs and fetus, hazardous impact of second-hand smoking (passive smoking). Many students in the Republic of Kazakhstan and the Republic of Uzbekistan were interested in the statistics of world atlas, beyond their own countries, such as the smoking rates of countries, as well as the actual example of non-smoking campaign posters in foreign countries especially of other European countries.

Conclusions Repeated health education on smoking harm should be arranged at schools and stronger measures should be taken for tobacco control policy at the campus of universities. Tobacco control kits of international standards should appeal but culturally sensitive modification is recommended.

12.7 A qualitative study on barriers to implement a smoke-free home

A.L. Brink, I. Clemmensen Danish Cancer Society, COP…NHAG…N, Denmark

Objective Environmental Tobacco Smoke (ETS) causes premature death and disease in children and adults. In 2008, 28 % of the Danish population (15+) were exposed to ETS in their home. We explored attitudes and practices regarding smoking within the home.

Method Study participants were men and women aged 20-69 years. Word of mouth was used to recruit smokers, former smokers and never-smokers. A total of 20 semi-structured interviews were conducted from June to August 2008. Questions covered attitudes about smoking, smoking behaviours, and approaches and barriers to reduce ETS exposure within the home. Interviews were tape recorded and transcribed verbatim. Two researchers read the interviews

Poster presentations: Topic 12, Tuesday March 29 314 and a categorization analysis were conducted. Discrepancies were resolved through consensus.

Results Most participants attempted to reduce ETS exposure in the home. Although different approaches were used most of them were ineffective (table 1). Many smokers had a misperception as to what extent they were exposing others to ETS when they, for instance, smoked under the cooker hood. Some participants described that they had a smoke-free home but exceptions were often present.

There were several barriers to implement a smoke-free home: • Several participants believed that a little ETS do no harm. It was a common misunder standing especially among smokers and former smokers that only adults with asthma or another chronic disease and children need protection against ETS. • Many never-smokers and former smokers found it difficult to ask family and friends not to smoke inside. Some reported that it would spoil the friendly atmosphere or that it would be impolite. Some were afraid that family would not want to visit anymore. • Many smokers and former smokers were afraid that if they implemented a smoke-free home they would be regarded as hysterical or as someone applying double standards.

Conclusion and implementation Most participants attempted to reduce ETS exposure in the home, but ineffective strategies were prevalent and barriers to create a smoke-free home were often present. Many people are unaware that ETS are adsorbed to walls and furniture and re-emitted into the air (thirdhand smoke). Information about this invisible thirdhand smoke along with more health messages about the harmful effects of ETS may be an important element in encouraging smoke-free homes. However, the analysis also showed that it is difficult to ask family and friends not to smoke inside. Future campaigns need to target smokers and the smoking behaviour they display in other people’s home.

12.8 Hungarian League Against Cancer Tenders against smoking for youth in 2008-2010

G.B.K. Gaálné Bogdány Hungarian League Against Cancer, BUDAP…ST, Hungary

Premises The ‘Joseph Fodor’ School Health Association in Hungary made a survey at 31 schools on cancer related mathematics examples solve has or has not effect on knowledge about cancer. Evaluation of survey made clear that usage of mathematics is successful. The survey professionally was managed by Prof. Dr. Tamas Simon, who nowadays is the president of the Hungarian League Against Cancer. Based on his idea we made posters to address the youth through their visual world.

Most recent tendencies about smoking in Hungary • 11% of children has smoking episode before his/her 10th year. • The 39.6 percent of the children at kindergartens is passive smoker

The declining trend is due to consider the Hungarian League Against Cancer is extremely important to set out tobacco control activities among young people. Prevention should begin in early childhood, it is best if young people did not even blonde. Our goal is to disseminate credible information about cancer and mitigate the taboo subject and about that cancer is

Poster presentations: Topic 12, Tuesday March 29 315 preventable.

In the context of different subjects - the active participation of children - raise more effectively the awareness of the harmful consequences of smoking, such as the external information and notices. This is especially true for young adolescences at the time when the peer group becomes the most authoritative. In Hungary trained medical students works with most influential secondary school students trained they anti-smoking peer helpers in more than 60 municipalities of the country. These helpers may be able to counteract the negative peer pressure.

In 2008, we wrote off competition for children to prepare anti-smoking posters. We received 2400 ones. Preparing the posters the children was opportunity to think about the harmful effects of smoking.

In 2009 we wrote of competition for all Hungarian primary and secondary school on anti smoking mathematics. We received 3200 items from all part of the country,

The children are very honest in their work it includes their fears, shocks and their decisions, like: ‘I never will smoke’, or ‘I would be happy if my father would quite smoking’. Hundreds of examples included calculations about comparison the money spend on tobacco products and healthy food, community activities, etc. The high rate of works calculated with the price of products, what means that the most effective tool against smoking is the increasing their price.

We would like to prepare an example book what includes selected works, useable at regular mathematics and at health promotion programs.

In 2010, spring time, near to end of school year we wrote off competition on bulletin board ‘Smokeless wall tacepao’, what will be repeated by fall.

We hope: our competitions will activate many youngsters and more and more of them will quit the smoking.

12.9 Tobacco consumption in teacher students of primary education: cognitive biases and modelling for consumption

C.A.P. Aguirre-Pérez, S. Yubero University of Castilla-La Mancha, CU…NCA, Spain

The goals of this paper are mainly descriptive and are intended to identify cognitive biases associated with tobacco consumption patterns in order to design more specific strategies for tobacco control and to guide the intervention on college students that are a priority group for intervention, Teacher students of Primary Education. We assume that they are a priority group for the role they play in modeling the behavior of tobacco consumption among their future pupils.

Smoking is a known risk factor for developing cardiovascular and neoplastic diseases and is currently the leading cause of avoidable mortality. Tobacco is the first addictive substance that adolescents and school-children have contact with, although initially the use is occasional, a transition usually occurs to other more intensive consumption patterns, since nicotine is a substance with a high addictive. Tobacco, along with alcohol, is the psychoactive substance most abused by schoolchildren in Castilla-La Mancha. The age of experimentation usually

Poster presentations: Topic 12, Tuesday March 29 316 coincides with early adolescence. The onset of tobacco use at such young ages is a serious problem of national public health.

However, the major increase in the consumption of tobacco takes place starting from the age of 18 and, in the university stage, between 20% and 30% of those defined as daily smokers after graduation start in consumption

The aim of our study is to determine the influence of cognitive biases in the answers given by young people about their tobacco consumption behaviour. This will allows us to target prevention interventions more specifically in response to basic cognitive processes for the adoption of appropriate models of health.

We will make a cross-sectional study during the 2010/2011 academic year in which the students of the Faculty of Education of Cuenca will be surveyed. The study variables will be attitudes and tobacco consumption, characteristics and history of tobacco consumption, subjective assessment of health status, perceived risk and perception of danger about the percentage of smokers

12.10 ‘No smoking is a norm’; Effects and limits of the programme

D. Hruba1, I.Z. Zaloudikova2 1Medical Faculty, Masaryk University, BRNO, Czech Republic 2Faculty of …ducation, Masaryk University, BRNO, Czech Republic

Objectives Schoolchildren from 6th to 9th grades are the target population for majority of the school- based anti-smoking educational programmes. In the Czech Republic, the programme ‘No smoking is a norm’ was prepared for 1st to 5th grades (age 6-11 years).

Methods For each grade, the manual was prepared and methods of intervention were tested in the pilot study before their using in the wider controlled study. The effect of the follow-up intervention was evaluated twice in each school year. The knowledge about health risks of smoking, attitudes towards smoking, children´s exposure to passive smoking and their smoking behavior were assessed by self-reported data obtained from the interventioned and control groups. The limited reading and writting skills of such young children were respected in the methodology.

Results The best effect had the intervention on knowledge. Pro-/anti-smoking attitudes and behavior were influenced by the family smoking/no- smoking environment. The total bans of smoking at homes were reported by 52% of children, another 27 % are exposed occasionally by smoking visitors, 31% of children are exposed daily. Approximately 75% of children have smoking parents or other relatives. The frequency of children experimented with smoking has raised from 7,5% at 2nd grade to 32,6% at 5th grade. Smoking parents and other relatives were the main sources of the first cigarette.

Conclusion Smoking environment lowered the effect of intervention. School-based anti-smoking education has the crucial role, especially for children of smokers.

Poster presentations: Topic 12, Tuesday March 29 317 Implementation The programme has been recommended by the Czech Ministry of Education for wide using.

12.11 Fashion industry – tools for tobacco campaigns

M.T. Rautalahti, V. Laivisto Cancer Society of Finland, H…LSINKI, Finland

Background The purpose of the campaign was to discourage initiation of smoking by emphasizing the tobacco effects on appearance and skin health.

Objectives Cancer Society of Finland has done a series of studies between 1999 and 2010 to look more closely into the ways tobacco is present in the lives of the youth. It soon became evident that youth cannot be addressed as one entity, but age and sub-culture specific approaches are needed. We explored the operational arenas for youth health education further. One of the most interesting of the many approaches involves the fashion industry.

Methods Based on these observations we launched a multi-phased collaborative approach. The basic idea builds on a multi-message, cross-communication campaign that utilises all the available media. Messages form “bundles”and appear also in unexpected or unusual places and forms. The different media support each other and we have a specific internet site as the common convergence point.

Results The first phase included recruitment of one the most famous Finnish fashion designer, creation of SkunkGirlclothesline, and collaboration with the Finnish Top Model competition on TV. One of the programs was designated to the theme of tobacco effects. The participants posed for poster photos wearing the SkunkGirl -clothes and made a set of antitobacco to-be-continued -spots for the tv-channel. These were then later shown at the beginning and end of commercial breaks. The second phase included production and sale of the clothesline in a fashion store chain. The SkunkGirl project continued in collaboration with a manufacturer of cosmetics. This included production of the world’s first smoke-free makeup set and a search of a face for marketing this set. This was accomplished on a popular, general internet site. The makeup set was sold, together with appropriate information concerning the effects of smoking on skin health, in major department stores across the country. This and earlier phases of the campaign were widely covered in both general media as well as in social media, e.g. fashion blogs.

Conclusions The SkunkGirl campaign addressed certain specific issues in the realm of tobacco effects on health. These are not on top of the list of major problems, but they may the ones that appeal to the young ones.

Poster presentations: Topic 12, Tuesday March 29 318 12.12 Study into smoking behaviour six months after participation in the Swiss ‘Quit and Win’ competition.

V.F. El Fehri1, H.K. Krebs2 1Swiss Association for Smoking Prevention, BERNE, Switzerland 2Communications and Public Research, ZURICH, Switzerland

Background Every year, the Swiss Association for Smoking Prevention holds a Quit and Win competition. This evaluation concerns the year 2009. By the 3rd of June 2009, over 2200 people had applied to take part in the Quit and Win competition. Participants were required to be Swiss residents as well as being daily consumers of cigarettes or other tobacco products. They were also required to stop smoking between the 4th of June until the 3rd of July 2009, basically meaning the implementation of a 4-week smoking ban.

Objectives The evaluation should provide data on the number of competition participants who, six months after the study, have managed to actually stop smoking or change their smoking habits, as well as considering opinions as to the rewards of stopping.

Methods The external institute Link carried out the study using CATI on behalf of the Swiss Association for Smoking Prevention. A representative cross section of 505 prospective stop-smoking competition participants was taken.

Results A third of the competition participants (33%) had maintained their smoke-free status by January 2010. Those participants who had continued to smoke had markedly reduced their tobacco consumption since the beginning of the competition. Two-thirds of the participants described the stop smoking competition as either ‘important’ or ‘very important’ as a criteria in their efforts to stop smoking. 62% of the competition participants used one or more smoking cessation aids, mainly medicinal products. The detailed results and also the impact of these results for further years of the competition will be discussed.

12.13 Patterns of tobacco use among men in Uzbekistan

G.T.U. Usmanova1, M.B. Baras2, Y.N. Neumark2 1GTZ (German Development Cooperation), TASHK…NT, Uzbekistan 2Braun School of Public Health and Community Medicine, Hebrew University, J…RUSAL…M, Israel

Background Smoking patterns often vary, although not necessarily consistently, across a wide range of demographic factors including education, occupation, gender, age, marital status, and ethnic background. Patterns of tobacco use amongst socio-demographic subgroups of the Uzbekistan population are unknown.

Objectives We explored socio-demographic differentials in the prevalence of tobacco use among men in Uzbekistan.

Poster presentations: Topic 12, Tuesday March 29 319 Methods Data was analyzed on 1795 men (aged 15+) sampled in a 2006 national household survey designed to explore issues related to tobacco consumption in Uzbekistan. Multivariate regression analyses accounted for the complex sampling design.

Results The prevalence of current cigarette smoking among Uzbek men was estimated to be 19.7%, and 22.5% use nasway (smokeless tobacco). Both forms of tobacco consumption were differen- tially distributed by ethnicity, age, marital status, education level and occupation. The highest smoking rates were noted among men of non-Uzbek origin (25.6%; 18.3% among Uzbek men), 35-54 year old (38.3%), married (27.4%), with highest education (25.8%), and government employed (30.1%). Nasway-use rates were highest among men of Uzbek origin (23.3%; 18.1% among non-Uzbek men), 35-54 year olds (34.4%), married men (31.8%), those with general secondary education (25.6%), and non-government employees (29.4%). The lowest rates of smoking and nasway-use were noted among younger respondents (ages 15-24), single respondents, those in the lowest education category, and students. In multivariate regression, the only factors that retained significant independent associations with smoking were Uzbek-ethnicity (AOR=0.6, 95%CI=0.4-0.8), and age - compared with the youngest age group, 25-34 year olds were more likely to report smoking (AOR=2.4, 95%CI=1.2-4.7) as were 35-54 year olds (AOR=5.4, 95%CI=2.7-10.8). Ethnicity and age were also the only factors significantly associated with nasway-use.

Conclusions The lower prevalence of smoking among older men may be due to smoking-attributable excess mortality, although a birth-cohort effect or smoking cessation in older years cannot be ruled out. The high prevalence of tobacco consumption among 35-54 year olds calls for secondary prevention measures amongst middle-age men alongside primary prevention for younger men. The significant contribution of nasway-use to the overall level of tobacco consumption among Uzbekistan men highlights the need to more fully account for smokeless tobacco use in compiling country-specific tobacco profiles. Future surveys (using larger samples) should address differences in initiation and cessation rates to identify appropriate intervention entry points.

Implementation Findings from the survey were used as evidence in developing a National Tobacco Control Plan in Uzbekistan.

Acknowledgment. This research was possible due to financial support from SIDA Trust Fund, World Bank.

12.14 The German Tobacco Atlas: How to communicate TOBACCO or HEALTH to the public and policy-makers

S.K. Kahnert, M.P.L. Pötschke-Langer, N.K.S. Schneider, U.M. Mons, K.S. Schaller, U.N. Nair, S.S. Schunk German Cancer Research Center, H…ID…LB…RG, Germany

The German Tobacco Atlas “Tabakatlas Deutschland 2009”is an illustrative educational handbook on the social and health aspects related to tobacco use, its consequences and tobacco control measures in Germany. It was released mid-2009 by the German Cancer Research Center (DKFZ) and the German Federal Ministry of Health. With a circulation of 5,000 copies it can

Poster presentations: Topic 12, Tuesday March 29 320 be purchased in bookstores but is also free available on the website of DKFZ Unit Cancer Prevention.

Aim The manual easily conveys knowledge, facts and figures on the subject of tobacco by using mainly self-explanatory illustrations to media, decision-makers and the public. Thus, barely understandable statistical data are readily accessible even for laypersons. Using graphs and maps the publication provides a wealth of information by combining brief text and illustrations.

Contents The Atlas consists of six chapters which cover the topics tobacco products, tobacco consumption and health consequences, passive smoking and health consequences, economic aspects of smoking, tobacco industry and tobacco control policy. While the first chapter gives an overview on tobacco products, including harm reduction, additives and toxicity of tobacco smoke, as well as their manufacturing, including health and environmental aspects during farming, the following two chapters cover the health effects and epidemiology of smoking and passive smoking. Statistical data on smoking prevalence of German adult and youth population and tobacco related deaths are represented in the form of large coloured maps showing regional differences within Germany: In the North, more smokers are living and more people are dying as a consequence of tobacco use. Figures also reveal differences in smoking behaviour or passive smoke exposure regarding gender affiliation and educational, socioeconomic or occupational status. Thereafter, costs of smoking for individuals, for the community and the health care system are analysed. Another chapter addresses cultivation, trade and distribution of tobacco and tobacco products. In the last section it is shown to what extent Germany and other European countries implemented WHO Framework Convention on Tobacco Control articles. It is clear that still more can and must be achieved not only in Germany.

Implementation Due to its simple, illustrative presentation the German Tobacco Atlas is an example how to effectively communicate health issues in an attractive manner. It constitutes a reference book for policy-makers and those responsible in public health institutions, journalists, health professionals, students and for all other interested in tobacco and tobacco control. Tobacco industry front groups refer to the book as the “Mao Bible of tobacco control”.

12.15 Prevalance of Tobacco Use Among Boys in Slums of Delhi

K. Kapil1, V.S. Virendra2 1Sigma Research and Consultancy, N…W D…LHI, India 2IIHMR, N…W D…LHI, India

Background To assess pattern and to determine risk factors associated with tobacco consumption in various forms among boys age group of 10 -18 years in a urban slum in okhala New Delhi.

Objective Objective of the study was to see the prevalence of tobacco use and it’s consequences among boys age group of 10-18 years in urban slums of Delhi.

Method A cross-sectional survey was conducted and 83 age group of 10 -18 years of age were

Poster presentations: Topic 12, Tuesday March 29 321 selected using random sampling as per the availability of the subjects in the area.. A semi- structured pre-tested questionnaire was administered to respondents by investigators. Data on tobacco consumption and other variables such as age, sex, marital status, education, employment and stress and health related symptoms were obtained

Key words Youth, educate, tobacco control.

Result and discussion Total of 48 (58%) reported tobacco consumption. Use of ghutkha was more prevalent (85%). Boys age group of 10-18 those who are engaged with any kind of work they are more likely to consume tobacco even they were aware to harms of tobacco consumption. Boys consuming tobacco also reported some health related problems.

12.16 School programme to prevent smoking

L.S. Spizzichino, D.G. Galeone, M.T.M. Menzano Ministry of Health, Italy, ROM…, Italy

Background The Ministry of Health’s Disease Prevention and Control Centre (CCM) has promoted the implementation of 14 projects to support activities to prevent smoking and to achieve the smoking targets set out in the “Gaining Health”programme. One of the most important is the “Support for smoking prevention initiatives: from regional planning to corporate planning”project.

Objective To foster smoking prevention and health promotion schemes targeted at young people in particular for children in the primary school age, in order to build up a smoking-free society in the near future.

Methods Pilot schemes will be developed under this project in the Healthcare Authorities in 5 specific areas: a. services for giving up smoking b. prevention measures for young people c. a network of welfare/health workers to combat smoking d. community schemes e. the work place.

The Veneto region was selected for project area b) as the lead Region, with the responsibility of coordinating the activities.

Results A survey of all the preventive activities being implemented in schools all over the country has been conducted. Of the 221 projects enumerated, the following examples of ‘best practices”that can easily be reproduced in schools at all levels have been selected: • “A Pass for Sunshine city”for kindergartens • “Infancy in colour /the winners’ Club”for primary schools • “Free to choose”and “Towards an unexplored planet”lower secondary schools • “Smoke-free Class Competition”for lower and upper secondary schools • “Smoking-free schools”for upper secondary schools.

Poster presentations: Topic 12, Tuesday March 29 322 These projects have been distributed to the Health Authority schools identified in each Region. Meetings have been held to present them to the operators concerned and provide them with specific training for them. In the 2008-2009 school year, for example, the “Smoke Free Class Competition”project was run, as an international project promoted by the WHO, in a total of 12 Regions.

Conclusions Italian strategy against smoking is oriented to avoid or almost delay the initiation. Individuation and dissemination of the best practices between all the school based interventions is the first step.

Implementation Continuing the work undertaken in the 2008/2009 school year, it is also planned to disseminate smoking prevention workshops for secondary school pupils along the lines of the benchmark model ‘Smoking pathways’ realized Italian League Against Cancer.

Other initiatives include the “Mamme libere dal fumo”(‘Smoke-free mothers’) project (to which a special session will be dedicated) and the “Genitori piÃ_: sette azioni per la salute del bambino”(‘Parents+: seven actions for children’s health’) programme to sensitise and counsel parents on reasoned and practicable health decisions, incorporating and heightening preventive programmes regarding health care priorities in perinatal and infant environments.

12.17 Risk factors for smoking in Portuguese adolescents by gender

J.A. Precioso, A.C. Samorinha …ducation Institute, BRAGA, Portugal

Objectives 1. To describe the prevalence of smoking in students from 5th to 12th grades; 2. To evaluate the association between individual, micro-social and macro-social determinants and the regular and occasional smoking in the total sample by gender.

Methods The participants of this study are 8764 students (4060 girls and 4704 boys), from 5th to 12th grades from regular state schools in Portugal (including the autonomous regions of Azores and Madeira), with an average age of 14.26 (DP=2.42). The data were gathered with an anonymous and self-filling questionnaire, especially prepared to this project. It has 48 questions and a scale, and evaluates demographic characteristics, actual smoking behaviour of the students and also many determinants supposedly related to smoking. Regarding data analysis, descriptive, Qui-square (Pearson) associations and Odds-Ratio tests were conducted to both girls and boys, using actual smoking behaviour (regular and occasional smoking) as the dependent variable and all the variables about the determinants of smoking as independent ones.

Results The results reveal that smoking increases with age. In 15 years old students, a prevalence of 8.6% (n=53) regular smokers was found in girls and of 12.3% (n=65) in boys. 4.0% (n=25) of the girls and 6.1% (n=32) of the boys are occasional smokers. The main risk factors associated with smoking in Portuguese school-aged adolescents are: to drink alcohol; to perceive that their best friends would approve their smoking (subjective norm); failures at school and to have negative feelings about school; to overestimate the prevalence of smokers; to

Poster presentations: Topic 12, Tuesday March 29 323 have smoking friends, parents, siblings or boyfriend/girlfriend; to be exposed to secondhand smoke by mother, father or siblings; to receive cigarette offers frequently, mostly from friends; not having received information about the consequences of smoking by teachers and the lack of parental involvement in school activities. Dissatisfaction with body image and the belief that tobacco helps to reduce weight are associated with the transition from occasional to regular smoking only in girls.

Conclusions The results of this study, regarding the determinants of smoking, are globally in accordance with previous studies. Most of the (regular and occasional) smoking-related factors are common to both sexes. This leads us to conclude that gender is no longer, as in the past, a protective factor for women.

Implementation Smoking behaviour is multidimensional. Thus, comprehensive programmes aimed at adolescents should continue, with the goal of countering the specific determinants of smoking identified in this and other studies. School preventive approaches and interventions in other contexts of the adolescents’ life are needed.

12.18 Disseminating information on women and tobacco on the internet: the BZgA womens’health internet portal

H. Fleitmann1, M. Koester2 1Indepent Consultant Tobacco Control, DORTMUND, Germany 2BZgA - Federal Health …ducation Centre, KÖLN, Germany

In Germany 26% of women and 34% of men between 25 and 69 are regular smokers. Smoking rates among young women (18-29 years) reach 43%. Smoking rates are highest among young women who are long term unemployed (59%), lone parents (53%) with low educational status (53%) and with low key jobs/ low income (47%). 13% of women continue smoking during pregnancy. Smoking rates during pregnancy are twice as high with young women of low socio economic background. Half of men and one third of women consume more than 1/ pack/day.

In order to support efforts to reduce tobacco consumption among women in Germany, the Federal Centre for Health Education (BZgA) created in 2005 a section on women and tobacco on its internet portal “womens’ health”. http://www.frauengesundheitsportal.de. The”Frauengesundheitsportal’ covers 23 themes related to women’s health”and disseminates relevant information and to provide easy access to evidence based information for both lay persons and experts.

Data collection is based on international quality criteria for internet health portals. It is guided by a handbook for the editors laying down standards to guarantee reliability of data, timeliness, transparency and data protection of the information collected. Specific exclusion criteria apply for traceability of sources/providers, problematic advertising and sponsoring. A multidisciplinary working group of experts advises the Federal Centre for Health Education on development and implementation strategies.

This unique data source on women and tobacco in Germany informs about relevant organisations, scientific publications, reports, brochures, leaflets and campaigns as well as on legal regulations on tobacco control in Germany and internationally. To promote easy access

Poster presentations: Topic 12, Tuesday March 29 324 this section can be searched according to 8 topics: tobacco control policy, health consequences, pregnancy, environmental tobacco smoke, dependence, cessation, product information, smoking at the workplace and tobacco consumption. Information within each section is made available directly, giving information for direct retrieval, preferably by internet links. Today more than 350 data sets are available in the tobacco section. A common “news” module gives up to date information of all of the 23 sections, highlighting special events through special newsflashes.

The poster will show content and structure of the internet portal section “tobacco/smoking”. Through its design and dynamic structure, the database offers an overview of the situation of women and smoking in Germany. It gives information on recent developments, supports discussions and creates demand for further research. By linking women and tobacco to the wider scope of women’s health, synergy has been created with other relevant areas related to tobacco prevention such as nutrition, alcohol, sports, cancer, cardiovascular disease, HIV/Aids etc. This makes it easier to introduce tobacco into the general health agenda and increase knowledge among the general population, programme developers and policy makers.

12.19 Environmental tobacco smoke exposure, pregnancy outcomes and children’s health

P.K. Polanska, H.W. Wojciech Nofer Institute of Occupational medicine, LODZ, Poland

Objectives The aim of the study was to analyze the influence of environmental tobacco smoke exposure on pregnancy outcome and children’s health.

Material and methods The study population consisted of pregnant women and their children followed up to two years of life. Pregnant women were interviewed three times during pregnancy. From all women included into the study the saliva sample was collected three times to verified smoking status. Assessment of child ETS exposure within two years after birth was based on questionnaires conducted with mothers, confirmed by biochemical verification of cotinine level in child urine. Cotinine level in biological samples was analyzed using Liquid Chroma- tography with Tandem Mass Spectrometry. Pregnancy outcome including: birth weight, length, head and chest circumference was noticed by neonatologist. The children’s health focused on anthropometry indicators and the incidences of upper and lower respiratory tract infections, allergy and asthma was performed by pediatricians during the first and second year of life.

Results For the lower cotinine levels in saliva (up to 10 ng/ml) we observed increasing trend in birth weight (p trend <0.001), head and chest circumference (p trend 0.05, p trend <0.001) with the increasing level of cotinine. For the cotinine level higher than 10 ng/ml we noticed decreasing trend for birthweight, head and chest circumference as the level of this biomarker increased. The newborn length decreased with the increasing cotinine level in saliva (p trend <0.001). There were no statistically significant associations between ETS exposure and anthropo- metric measurements within first two years of life. Such exposure increases the risk of pneumonia but the results were not statistically significant.

Poster presentations: Topic 12, Tuesday March 29 325 Conclusions All effort should be taken to eliminate the child ETS exposure both during prenatal and postnatal period.

12.20 Overview of SmokeFree Sports: A multi-dimensional campaign to promote the smoke free message to youth

Ciara McGee1, Lawrence Foweather1, & Gareth Stratton1 1Research Institute for Sport and …xercise Sciences, Liverpool John Moores University - UK

Background Children and young people are highly susceptible to smoking experimentation and addiction. In Liverpool, smoking prevalence among youth is significantly higher than the UK average. Therefore early intervention strategies are required for smoking prevention or cessation. Research has found a negative association between smoking and physical activity. Smoke- Free Sports is an innovative pilot project that aims to explore whether physical activity and sport can be used to promote the smoke free message to children and young people.

Objectives To create a multi-dimensional campaign that incorporates social-marketing strategies alongside the provision of sports and physical activities to: a) de-normalise smoking among youth b) empower youth to stay smokefree, and c) increase awareness of the dangers of smoking using positive messaging.

Participants The target age group are youth aged 7 to 16 years, including those who have experimented with smoking and those who have never smoked.

Setting The campaign will target community settings in the City & North districts of Liverpool, including leisure centres, youth clubs, and voluntary sports clubs.

Intervention The SmokeFree Sports campaign will last for approximately 6 months. The campaign will employ a variety of strategies to promote and deliver the smokefree message including a) publicising the campaign through the local media and via the distribution of promotional material that will incorporate local sport stars, b) training sports coaches to deliver the smoke free message, c) asking children to sign a pledge to be smoke free, d) encouraging voluntary sports clubs to adopt a smoke free policy on their playing fields and e) communi- ity fun days providing a range exciting phsyical activities.

Evaluation The SmokeFree Sports campaign will be evaluated according to the RE-AIM framework. Participants will be asked to complete baseline, post-intervention and 3 month follow-up survey to a) examine smoking prevalence, b) perceptions of smoking norms and c) intention to quit. Focus groups will be conducted with children and young people to evaluate the interventions strategies, while stakeholders and relevant partners will be interviewed for process evaluation and impact assessment.

Conclusion Participation in sports and physical activity offer youth the very benefits they often seek

Poster presentations: Topic 12, Tuesday March 29 326 from smoking such as status with peers, to enjoy the buzz, to relax, and help slim. It is hoped that by highlighting the positive benefits of physical activity and sport the Smokefree Sports campaign will reduce the prevalence of smoking and significantly lower smoking initiation among children and young people.

12.23 Evaluating video testimonials of people who have smoking-related diseases: a randomized trial

J.F.E. Etter University of Geneva, G…N…VA 4, Switzerland

Objective To test the effect of video testimonials of people suffering from smoking-related diseases.

Methods In 2009-2010, 848 people were enrolled on the Internet and randomly assigned either to a group who watched 5 online videos, or to a waiting list control group who did not watch them. Participants answered online follow-up questionnaires on smoking behavior and motivation to quit smoking after 24 hours (n=592, 70%), one week (n=526, 62%) and 4 weeks (n=435, 51%).

Intervention In the videos (one minute each), people said how the disease changed their lives, showed a tracheotomy or a scar from a thoracic operation, one person used oxygen supply.

ResultsParticipants were current (44%) and former (56%) smokers. After 7 days, fear of getting chronic bronchitis (+15% vs 0%, p=0.001), myocardial infarction (+7% vs 0%, p=0.016) and lung cancer (+9% vs -1%, p=0.06) increased more in the video group than in the control group. After 4 weeks, among smokers who were not trying to quit at baseline, there were more quit attempts in the video group than in the control group (32% vs 9%, p=0.03).

Conclusions Brief online video testimonials of people suffering from smoking related diseases had a measurable short-term impact on fear of getting such diseases and on attempts to quit smoking.

Practice implications These videos should be widely shown to smokers.

Poster presentations: Topic 12, Tuesday March 29 327 12.24 SHS exposure and its association with lung carcinogen uptake during pregnancy

C.I.V. Vardavas1, E.F. Fthenou2, E.P. Patelarou2, L.C. Chatzi2, M.B. Bageris2, S.M. Murphy3, N.T. Thompson3, S.H. Hecht3, S.C. Carmella3, G.C. Connolly4, A.K. Kafatos2, A.K. Koutis2, M.K. Kogevinas5 1University of Crete & Harvard School of Public Health, Heraklion Crete & Boston MA, Greece 2University of Crete, Heraklion Crete, Greece 3University of Minnesota, Minnesota, United States of America 4Harvard School of Public Health, Boston, MA, United States of America 5Center for Research in …nvironmental …pidemiology (CR…AL), BARC…LONA, Spain

Objective Exposure to secondhand smoke (SHS) during pregnancy poses a significant threat to the developing fetus with possible ramifications that might continue into childhood. The aim of the current study was to assess the role of exposure to SHS from different sources during pregnancy on the concentrations of urinary cotinine and 4-methylnirosamin-1-(3-pyridyl)- 1-butanone (NNAL) of pregnant women in Crete, Greece.

Methods During 2007-2008, as part of the RHEA cohort, 1291 mother child pairs in Crete, Greece were recruited and followed up from approximately the 12th week of gestation and until birth. Urine cotinine (n=367) and urinary NNAL (n=60) among non smokers was assessed by LC/ MS, while extensive questionnaire data on exposure to SHS was collected.

Results Women exposed to SHS in public places were found to have higher cotinine levels than their non exposed peers (12.1 vs. 8.4 ng/ml) as were those exposed to SHS in the home and the family car (13.1 vs. 5.7 ng/ml and 18.1 vs. 8.0 ng/ml, respectively). Moreover, urinary cotinine and NNAL concentrations were found to increase according to the number of sources of SHS the pregnant woman was exposed to (p<0.001 and p<0.01, respectively). Controlling for other sources of exposure, exposure to SHS in the family car caused the highest increase in urinary cotinine (Beta 8.73, 95% CI: 5.8 to 11.7), and an increase in urinary NNAL levels (Beta 0.018, 95% CI: -0.005 to 0.041). Cotinine concentrations were associated with household exposure (Beta 4.40, 95% CI: 1.4 to 7.4) and exposure to SHS in public places (Beta 2.72, 95% CI: -0.1 to 5.5) however exposure to SHS in public places caused the largest increase in urinary NNAL concentrations (Beta 0.023, 95% CI: 0.001 to 0.044).

Conclusions Exposure to SHS in the family car and in the household were the strongest determinants of circulating cotinine levels, indicating the necessity of adopting smoke free households and cars, at least during pregnancy. Moreover exposure to SHS in public places and at work was a strong determinant of lung carcinogen uptake during pregnancy and thus smoke free legislations should be enacted so as to protect pregnant women’s health.

Implementation Smoke free legislations in public places and in the household are measures needed to protect pregnant women and their fetuses from exposure to tobacco specific carcinogens

Funding Source and Declaration of interest This work was supported by a Flight Attendant Medical Research Institute (FAMRI) grant (CIA 072058), by the EU Integrated Project NewGeneris, 6th Framework Programme, (Contract no.

Poster presentations: Topic 12, Tuesday March 29 328 FOOD-CT-2005-016320) and by the EU funded project HiWATE, 6th Framework Programme (Contract no Food-CT-2006-036224). The authors have no conflict of interest to report.

12.25 A unique competence-based training and assessment programme for smoking cessation practitioners: does it work?

J.A.M. Kenyon, A. McEwen, R. West, S. Michie, L. Brose, F. Lorencatto, M. McDermott NHS Centre for Smoking Cessation and Training, LONDON, United Kingdom

England has a national stop smoking service which was set up in 1999. Ten years after this, in an attempt to improve the quality of behavioural support and reduce the variability in quit rates nationwide, the Department of Health funded the NHS Centre for Smoking Cessation and Training (NCSCT). The NCSCT is helping Local Stop Smoking Services to deliver high quality behavioural support by providing assessment, certification, training and continual professional development for smoking cessation practitioners.

The assessments developed by the NCSCT are based on research into what competences (skills and knowledge) are required by smoking cessation practitioners. This research has identified a set of ‘behaviour change techniques’ that are used when providing behavioural support and has established which of these has the strongest evidence. This has been supplemented by a systematic analysis of guidance documents on competences required for the role of smoking cessation practitioners.

These competences have been used to develop the NCSCT Stage 1 (knowledge) and Stage 2 (skills) Assessments, the Stage 1 and Stage 2 Training Programmes and the learning outcomes for the NCSCT Training Standard.

In September 2010, the online NCSCT Stage 1 Training and Assessment Programme was launched to smoking cessation practitioners in England. By the time of the ECToH, we will be able to report on data for the first six months, including the number of people who have registered with the NCSCT Training and Assessment Programme, the number who have taken the assessments, the number of people who have passed and failed the assessments, the average scores, and the breakdown of scores within different sections of the assessment which will be used to identify the training needs of smoking cessation practitioners.

We will also be able to report on a piece of work that attempts to evaluate the validity of the NCSCT Stage 1 Assessment, by examining to what extent the Stage 1 Assessment scores are associated with measures of practitioner performance and knowledge relevant to their role. This will be done by looking for associations between performance in the Stage 1 Assessment and self-reported and confirmed CO-verified quit rates. A subsample of practitioners will undergo a further knowledge assessment using online short answer questions.

Additionally, we will be able to report on a further piece of work that will evaluate the effectiveness of the NCSCT Stage 1 Training Programme through measuring changes in performance on the Stage 1 Assessment following use of the Stage 1 Training Programme, including performance in specific areas.

The NCSCT is the first national centre for smoking cessation and training in the world and its comprehensive training and assessment programme is the first to be based around evidence-based behaviour change techniques.

Poster presentations: Topic 12, Tuesday March 29 329 12.26 Bidirectional influences within families in smoking behaviour: A longitudinal full family model

K Schuck1, R.O. Otten1, M.K. Kleinjan1, E.D.B. Barker2, R.C.M.E.E Engels1 1Behavioural Science Institute, Radboud University Nijmegen, NIJM…G…N, The Netherlands 2University of London, LONDON, United Kingdom

The present study investigated bidirectional influences between family members in smoking behaviour using a longitudinal, full family design. Participants were 426 families, including mothers, fathers, and two children. Associations were assessed over five waves with yearly intervals by means of structural equation modeling. Results demonstrate that families resemble an interactive system affording smoking contagion across family members. With regard to smoking intensity, partner effects, sibling effects, parent-child effects, and child-parent effects were observed across time. Interestingly, parents appear to be particularly susceptible to influences by their offspring, possibly due to the fact that smoking intensity is more variable in established smokers than in adolescent smokers. In addition to the observed direct effects between family members, we also found (preliminary) support for indirect effects between family members (i.e., effects from one family member to another family member via a third family member). To evaluate the effects of smoking house rules (i.e., allowing smoking inside the home) in family smoking contagion, we examined group differences between strict and lenient families. Results indicate that application of strict house rules does not prevent mother-child influences in smoking behaviour. However, by applying strict house rules, the smoking intensity of mothers as well as fathers becomes unsusceptible to their offspring’s smoking behaviour. Results extend previous research on intergenerational transmission of smoking behaviour by demonstrating the dynamic and interactive influences within family systems. In particular, the present study highlights parental susceptibility to smoking contagion and the preventive effects of applying smoking house rules.

12.27 Live It Up Without Lighting Up 2009

Authors : Felicia Ong Ling Ling and Victor Tan Choon Seng Affiliation: Health Promotion Board, Singapore

Background From the National Health Survey 2007, the highest increase in prevalence of daily smoking was seen in those aged 18 to 29, from 12.3% in 2004 to 17.2% in 2007. The average age when both male and female daily smokers aged 18 to 29 years started experimenting with cigarettes was 16 years.

Objectives To commemorate World No Tobacco Day in Singapore, Health Promotion Board (HPB) ran a three-month smoking control campaign to discourage experimentation of smoking amongst youth and young adults.

Methods & Implementation Key insights on their media consumption patterns and lifestyles showed that radio, out-of-home, social media and online touchpoints are highly recommended. Social and peer influences are their key strong drivers and messages must appeal to their interests and lifestyles for a stronger message takeaway. They see government health communication as being top-down and preachy. Live It Up Without Lighting Up campaign was conceptualised as a social movement to create a

Poster presentations: Topic 12, Tuesday March 29 330 non smoking culture to discourage the experimentation of smoking and inspire the target audience to stay smoke-free. The campaign highlighted the benefits on looks, fitness, spending power and environment, instead of the costs of smoking.

The campaign elements included out-of-home advertising, radio partnerships, conversations through social media and digital influence and engagement via community and school outreach. Local celebrities who appealed to these target group were engaged to host a series of Live It Up Without Lighting Up fashion events and school outreach roadshows to communicate these messages to them.

Results The Student Health Survey surveyed 3,000 target group between July to November 2009 recorded a decline in the percentage of target group who had smoked at least one day in the last 30 days from 9% in 2006 to 6% in 2009. From the post campaign evaluation, it reported a 100% aided recall for any campaign execution, 80% understood the intended key messages of the campaign and 40% of them had the intention to quit smoking.

Conclusions Leveraged on the insights, we effectively engaged the target group and young adults to get them to ‘buy’ into messages rather than top-down approach. This integrated marketing and communications approach was effective in promoting key messages and persuaded them into rethinking about smoking behaviour.

12.28 Youth in tobacco control: example of Lithuania

T.L. Liakina, L.S. Sveikata, P.M. Martinkaityte, L.B. Blažyte Lithuanian medicine students association, KAUNAS, Lithuania

Objectives The purpose of this abstract is to present youth involvement in tobacco control in Lithuania in 2005-2010. In 2006, 44% and 24% of young people of age 20-25 were smoking; another 32% and 23% were exposed to tobacco smoke. This was 5 - 10% above average for rest age groups in Lithuania. As engaged and active future physicians LiMSA in collaboration with “Help - for a life without tobacco”(Help) campaign, established a new approach to tobacco awareness especially targeting young people.

Methods and Results Firstly, for branding of Help campaign (2006 - 2008) we used billboard social ads and postcards, designed by students to target youth. These contained message of harmful effects of both active and passive smoking. The billboards and postcards were distributed in 2 biggest cities in Lithuania in 2008 and 2009, one of the billboards was submitted to a commercial media festival, and also several articles were published in regional press.

Thereafter, we conducted extensive CO measurement and tobacco awareness campaign “Blow bubbles instead of smoke”(2009 - 2010) in schools, universities and during public events. Results of the CO test, age, smoking habits and passive smoking risk were recorded. In total within Help campaign in Lithuania 13148 CO tests were conducted (2006-2010), from those in universities 1902, in schools 469. With personalized approach to young smokers we explained hazards of elevated CO levels and provided consultation on smoking cessation, we also consulted 6 schools about smoking prevention activities.

Poster presentations: Topic 12, Tuesday March 29 331 Furthermore, we coordinated 2 World No Tobacco Day (WNTD) events (2008, 2009), one of them featured first in Lithuania tobacco awareness flash - mob. We provided peer-to-peer tobacco awareness education for students, scholars and children (2010) and also organized “Smoke free party”(2010) that attracted approx. 550 students.

In collaboration with National Youth Council we successfully advocated towards banning of smoking in public places in Lithuania (2006) by creating Youth Tobacco Control Manifesto and presenting it to every member of National Parliament. As a result, law change was introduced and smoking in public areas was prohibited. We also contributed to the creation of European Youth Declaration on Tobacco Control (2010) that was presented and adopted by National Alcohol and Tobacco Control Coalition (NATCC).

Conclusion and Implementation In 5 consecutive years of work in close collaboration with EC Help campaign, Help student network and NATCC, LiMSA gradually developed into a major youth tobacco awareness movement in Lithuania. Basing on our experience in all levels of tobacco control, we see it crucial to sustain and coordinate further youth involvement in tobacco awareness campaigns, tobacco control policy development and tobacco research, both nationally and internationally to build smoke free future for every European citizen.

12.29 Smoking in Movies: Impact on smoking among Italian adolescents

F. Mathis1, R. Gullino2, T. Soldani2, D. Buscemi2, D. Concina2, F. Faggiano2 1Piedmont Centre for Drug Addiction …pidemiology, Grugliasco (TORINO), Italy 2Department of Clinical and …xperimental Medicine - Avogadro University, NOVARA, Italy

Objectives To quantify smoking in Top movies and assess its association with smoking among Italian adolescents.

Methods Cross-sectional study. The Beach method has been used to perform a content analysis on a representative sample of top movies released in Italian cinemas between January 2004 and September 2009, with regard to smoking. Moreover, a population estimate of movie smoking exposure in Italian adolescents has been carried out, based on the results of a survey conducted in secondary and high schools. Attributable risks have been estimated.

Results 134 classes have been involved in the survey. Among 2,953 pupils, 2,668 (90.4%) have filled in the questionnaire: 1,485 (55.7%) boys and 1,179 (44.2%) girls, mean age 13.6 years (SD 1.4). 60.5% declared they have never smoked in their life while 15.4% have tried only a few puffs, 7.4% have smoked less than 20 cigarettes and 16.3% 20 cigarettes or more. Significant differences in smoking can be noticed in different sub-groups (e.g. age and gender). Based on the movies the adolescent has watched, and the amount of smoking in each, a score for exposure to movie smoking has been constructed for each survey participant. Results will be presented as regards attributable risks as well as the quota of smoking among Italian adolescents that may be prevented with a no smoking scenes policy in movies rated for an adolescent public.

Conclusions The results of this study confirm previous U.S.A. and German findings: smoking in movies

Poster presentations: Topic 12, Tuesday March 29 332 appears to be a risk factor for smoking among adolescents. Limiting exposure of young adolescents to movie smoking could have important public health implications.

Implementation The results of this study reinforce evidence of smoking in movies as a risk factor for smoking. Some policy options are under discussion, as also suggested by a recent WHO report. The inclusion of smoking as a criteria in the movie rating system appears as the most promising.

Funding Funding source that supports your study: EU Public Health Executive Agency - Second programme of community action in the field of health (2008- 2013)

12.30 Missed opportunities to educate medical students on smoking and problem drinking

T.R. Raupach1, N.S. Schneider2, H.K. Krampe3, T.B. Bei_barth4, T.P. Pukrop5, S.A. Anders6, R.W. West7, P.N.A. Aveyard8, L.M. Müllner9 1University Medicine Göttingen, GÖTTING…N, Germany 2German Cancer Research Centre, WHO Collaborating Centre for Tobacco Control, H…ID…LB…RG, Germany 3Department of Anesthesiology and Intensive Care Medicine, Charité, B…RLIN, Germany 4Department of Medical Statistics, University Hospital Göttingen, GÖTTING…N, Germany 5Department of Haematology and Oncology, University Hospital Göttingen, GÖTTING…N, Germany 6Department of Legal Medicine, Universitätsklinikum Hamburg-…ppendorf, HAMBURG, Germany 7Cancer Research UK Health Behaviour Research Centre, University College London, LONDON, United Kingdom 8UK Centre for Tobacco Control Studies, University of Birmingham, BIRMINGHAM, United Kingdom 9Department of Cardiology and Pneumology, University Hospital Göttingen, GÖTTING…N, Germany

Background Tobacco smoking and excessive alcohol drinking are among the most important causes of morbidity and mortality worldwide and both are treatable by general physicians. This study assessed the extent to which undergraduate medical education in Germany is equipping graduates with skills and knowledge required to treat tobacco and alcohol use disorders compared with hypertension and diabetes.

Methods In summer 2009, all German undergraduate medical students (Years 1-5) were invited to complete a questionnaire addressing knowledge of disease complications and treatment options for hypertension, diabetes, tobacco and alcohol use disorders. Students were asked to indicate which learning objectives need more attention. In addition, medical schools were asked to provide information on curricular coverage of these four conditions.

Results A total of 19,528 students from 27 medical schools completed the survey. Whereas knowledge of treatment options for hypertension and diabetes was substantially greater in more advanced students (rho = 0.55 and 0.40, respectively), there was evidence of very limited

Poster presentations: Topic 12, Tuesday March 29 333 progression for the treatment of tobacco (rho = 0.04) and alcohol use disorders (rho = 0.15). On the curricular level, there were half as many hours devoted to teaching on tobacco and alcohol use as to diabetes or hypertension. Sixty percent of students in clinical years wished to receive more education on tobacco and alcohol problems.

Conclusions Taken with other literature from all parts of the world, undergraduate medical education does not appear to equip students to deliver effective evidence-based life-saving interventions for tobacco or alcohol problems. Correcting this should be a priority.

12.31 Tobacco specific carcinogens in urine of smoking and ets exposure delivering women.

K. Florek1, P. Piekoszewski1, L. Basior1, K. Kornacka2, P. Lechowicz3, J. Kulza1 1Uniwersity of Meducal Sciences, Laboratory of …nvinronmental Research, POZNAN, Poland 2Neonatology Clinic, University of Medical Sciences, WARSAW, Poland 3Institute of Forensic Research, KRAKOW, Poland

Objectives Smoking during pregnancy is associated with a variety of negative consequences not only for mother bout also for growing fetus. Many studies have shown that carcinogens contained in tobacco smoke permeate across placenta and they are found in fetus. The most important carcinogens of tobacco smoke belongs to two chemical groups; polycyclic aromatic hydro- carbons and N-nitrosamines.

The aim of the study was to apply the biomarkers 1-hydroxypyrene (1-HP), and 4-(methylnirosoamino)-4-(3-pirydyl)-1-butanol (NNAL) for monitoring the exposure of delivering women to PAH and tobacco specific nitrosamines.

Methods One hundred twenty one delivering women took part in the study. On the base of questionnaire and cotinine determination in women’s urine, the studied patients were divided into three groups: 31 women who did not smoke, 28 non-smokers exposed to environmental tobacco smoke (ETS) and 62 smokers admitted for the delivery at the Gynaecological-Obstetric Clinical Hospital of the University of Medical Sciences in Warsaw. A urine sample was taken from each woman to determine cotinine and 1-hydroksypyrene by means of HPLC and NNAL by LC/MS/MS.

Results The questionnaire consisted of eight questions related to demographics, socio-economical data, smoking habit (tobacco smoking during pregnancy, number of cigarettes smoked, place of exposure to ETS) and occupational exposure to carcinogenic compounds.

In the urine of non smoking women, the level of cotinine, tobacco smoke biomarker was below the limit of detection, in women exposed to ETS and smokers were 49,6 and 345,8 ng/mg of creatinine respectively The concentration of 1-HP for smoking women amounted to 0.53 ng/mg of creatinine and was statistically higher than in the case of exposed to ETS and non-smokers (0.23 and 0.19 ng/mg of creatinine respectively). The concentration of NNAL in the urine of smokers amounted to 77.6 pg/mg of creatinine. In the urine of women exposed to ETS concentration of NNAL was 28,8 pg/mg of creatinine and in the urine of non- smokers. In all studied groups no correlations between the concentration of cotinine and NNAL or between NNAL and 1-HP were demonstrated.

Poster presentations: Topic 12, Tuesday March 29 334 Conclusion The results of the study indicate that tobacco smoking is real source of carcinogenic compounds which can cross the placenta and reach the foetus body.

Implementation Information about so high level of the tobacco specific carcinogens in urine of delivering women should be a arguments to convince the pregnant women to stop smoking.

12.32 Protecting Children and Young People from Secondhand Smoke

A. Crossfield, H.A ltwarg Smokefree North West, MANCH…ST…R, United Kingdom

The effects of exposure to secondhand smoke (SHS) in the home and car for children in the UK result in an estimated 300,000 GP referrals and 9,500 hospital admissions each year for children under 16. SHS is linked with cot deaths, meningitis and asthma as well as causing middle ear congestion, bronchiolitis and delayed learning through missed school days. For older children, exposure increases the likelihood of asthma, flu, conjunctivitis, nasal infections and respiratory failure.

Smokefree North West has initiated a whole system project to tackling harm to children and young people resulting from exposure to SHS. The overall aims are: 1. Reduce health impacts of SHS exposure for children and young people in the North West; 2. Reduce primary and secondary care episodes linked with SHS annually in the region; 3. De-normalise tobacco in communities; 4. Reduce uptake of young people smoking; 5. Work with partners to convert 18,090 homes to becoming Smokefree.

Our research has shown that parents expect health and social care professionals to talk to them about their smoking in relation to their child’s health and want clear, consistent messages that ‘tell them the facts’. Extensive insight work demonstrates that around 50% of our audience is ready to take smoking right outside - they have already created rules to try and protect their families from SHS, but are just falling short of what they need to do.

Smokefree North West recognised the need for a strong clear message for the public-facing campaign which would reach the largest of the audience that insight research identified - the ‘mutable’ group - who are ready to take action but needed a clear ‘reason to believe’ and call to action. The core message we needed to deliver to this audience is that making homes completely smokefree by taking smoking right outside is the only effective route to protect children and young people from exposure in enclosed spaces.

The core message of this initial public-facing activity was therefore designed as: To help protect children from Secondhand Smoke, take 7 Steps Out; Because most of the harmful chemicals in cigarette smoke are invisible.

Key Outputs: • Joined-up social marketing campaign including an insight-driven TV campaign; • Joined-up work across NHS, local authorities and Fire and Rescue teams to deliver a public-facing roadshow activity; • Steering group formed of partners from across the region and five county-level stakeholder workshops about whole system convened; • Partnership with University of Liverpool to design new brief intervention guide;

Poster presentations: Topic 12, Tuesday March 29 335 • Extensive research and testing of awareness and attitudes; • Development of materials including a TV advert, leaflets, templates, web banners and other promotional tools, available for use by partners; • Evaluation of campaign with positive outcomes to date.

Poster presentations: Topic 12, Tuesday March 29 336 Topic 16: Implementation of evidence based interventions in daily practice: barriers and facilitating factors

16.1 Change in decisional balance after counseling is associated with improved quit rates in Malaysian smokers

‘The decisional balance (DB), a brief detailing of the advantages and disadvantages of smoking and quitting may serve as an important component in behavior change. We examined the change in DB of smokers after counseling and its impact on quitting during a two month smoking cessation attempt. 185 smokers from two public universities who were interested to quit received equal behavior therapy and counseling on understanding the risks and benefits of quitting (or smoking) in addition to free pharmacological therapy. A DB questionnaire was administered at baseline and 2 months post counseling to determine and assess changes in smoking perception. Results showed that, there was no significant difference in the perceptions of advantages (Pros) and disadvantages (Cons) of smoking across all socio demographic backgrounds and smoking history prior to counseling. After counseling, 72.3% of smokers had reduced their perceptions on the advantages of smoking and 66.4% had increased perceptions of disadvantages of smoking. At eight weeks, 51 participants (27%) had quit. Smokers who had reduced their Pros of smoking had significantly higher quit rates compared to those with no improvement in perception (82.6% vs 17.4%), (OR: 2.47; 95% CI=1.00; 6.10). Smokers with higher change in Cons of smoking post counseling also had higher quit rates than those with no change in perception (67.4% vs 32.6%), but the OR did not reach statistical significance (OR: 1.08; 95% CI= 0.49; 2.35). We conclude that, after counseling, smokers do change their perception of advantages and disadvantages of smoking during the quitting process. These changes are associated with a higher likelihood of smoking cessation. Thus, patients’ decisional balance on smoking may be an important barrier to successful cessation. Emphasizing and managing perceptions of the pros and cons of smoking during counseling may lead to better cessation outcome.

Key words: Smoking cessation; Counseling; Decisional balance; Perception; Malaysian

16.2 Predictors of smoking cessation among staff in public universities in Klang Valley, MALAYSIA

‘Identification of individual characteristics of smoking cessation are limited to the clinic based settings. This study aims to find common predictors of success among staff in work-

Poster presentations: Topic 16, Tuesday March 29 337 sites smoking cessation programmes. We conducted this study in a non-clinic site setting in two major public universities in Klang Valley, Malaysia. All staff from both universities received an open invitation via staff e-mail and letters to participate in this study. At the start of treatment, participants were administered Rhode Island Stress and Coping Questionnaire and Family Support Redding’s Questionnaire. Similar behavior therapies with free Nicotine Replacement Therapy (NRT) were given as treatment. At two months, they were contacted to determine their smoking status. 185 staffs from University A (n=138) and University B (n=47), responded and voluntarily showed interest to quit. There was no significant difference in respondents of both universities with respect to socio demographic characteristics and smoking history. After two months of treatment, quit rates were 24% in University A vs. 38 % in University B, although results were not significantly different. Univariate predictors of cessation were adherence to NRT (p<0.001), smoking fewer cigarettes per day (p<0.05) and the amount of clinic sessions attended (p<0.001). Logistic regression identified 3 significant predictors of smoking cessation. Participants attending more than one clinic sessions (OR= 27; 95% CI : 6.50; 111.57), and having higher pretreatment general stress (OR= 2.15; 95% CI: 1.14; 4.05) were more likely to quit, while a higher number of cigarettes smoked (OR= 0.19: 95% CI: 0.06; 0.59) reduced the likelihood of quitting. Increasing age, ability to cope with stress and family support were not contributive. We conclude that, factors such as the number of counseling sessions, the amount of cigarettes smoked at baseline, adherence to NRT and pretreatment stress are important considerations for a worksite smoking cessation programme.

Keywords: Smoking cessation; predictors; university; worksite; staff

16.3 Awhi Mai Awhi Atu: Indigenous Smoking Cessation Programme for Maori

M.P. Tane Te Hotu Manawa Maori, AUCKLAND, New Zealand

Objectives To increase the number of opportunities that young Maori women experience to quit smoking, and to do so using an evidence based approach of nicotine replacement therapy and motivational support.

Methods A four week quit smoking programme was established in two pilot sites: a high Maori population rural community, with a high proportion of young Maori women and their familiies who smoke, and an urban College, with a high percentage of Maori students (12-18 years of age). Nicotine replacement therapy was provided by non-qualified community workers, who had received an electronic based training programme and cultural support to enable them to provide NRT as part of their weekly support visits to those on the programme.

Results In the rural setting over 50% of the smokers who made a quit attempt have remained abstinent (validated by carbon monoxide expired breath) at 8 weeks.The intervention has proven to be more cost effective and more successful than Aukati Kai Paipa an indigenous smoking cessation funded by the Ministry of Health in New Zealand.

Conclusions The ability to train non-health professionals to support community-based smoking cessation programmes, is a cost-effective approach in increasing opportunities for more Maori to quit smoking.

Poster presentations: Topic 16, Tuesday March 29 338 Implementation Awhi Mai Awhi Atu, a strengths based approach to smoking cessation is being implemented by kaupapa Maori organisations (‘for Maori by Maori’ in all aspects values, philosophy and practice) who have identified smoking as a deterrent to Maori development, and who see smoking cessation as an expression of leadership and tino rangatiratanga (the expression of autonomy, based on a strong sense of Maori identity).’

16.4 The Portugese Quitline effectiveness: comparing results of the 2002 and 2009 evaluations

D. Vitoria1, A. SimÃµes-Raposo2, F. de Pádua2 1Faculdade de Ciências da Saúde - Universidade da Beira Interior, CovilhÃ£, LISBOA, Portugal 2Portuguese Institute of Preventive Cardiology, Lisboa, Portugal, LISBOA, Portugal

Objectives The Portuguese Quitline is part of the National Institute of Preventive Cardiology, a Portuguese NGO, and is partially funded by the General Direction of Health - Ministry of Health. The Portu- guese Quitline operates with a low budget and the service provided is manly reactive (only in 2009 a proactive service has started). The objective of the current paper is to compare results from the evaluation studies conducted in 2002 (when the Quitline started to operate) and in 2009. The main question is to know if an underfunded Quitline with mainly a reactive service is effective.

Methods The Portuguese Quitline evaluation studies were based in two randomized samples of callers that were interviewed by telephone 6 months after calling. At 2002, 115 cases were selected and 107 were interviewed, with an average age of 42 years old (SD=12.6), 45% were women. At 2009, 71 cases were selected and 59 were interviewed, with an average age of 44 years old (SD= 14.6), 61% were women.

The results of the two Portuguese evaluation studies were also compared with the results of the ESCHER (European Smoking Cessation Helplines Evaluation Research) a project conducted in 2005 and 2006) which aimed was to evaluate Quitlines from 9 UE countries.

Results In 2002, 69 (60%) of the callers reported a change in the last six months [53 (46%) had stopped and 16 (14%) had reduced]. The point prevalence of the abstinence six months after the call was 21% (24 cases). In 2009, 28 (39%) of the callers reported a change in the last six months [16 (23%) had stopped and 12 (17%) had reduced]. The point prevalence of the abstinence six months after the call was 10% (7 cases). The ESCHER results of the Portuguese Quitline were between the two evaluations reported: Adjusted point prevalence abstinence (not smoked in the last 7 days) was 18% and adjusted abstinence (not smoked during the last twelve months) was 9%

Conclusions These set of results indicates that the Portuguese Quitline is effective, despite its operation has been underfunded and his service has been manly reactive. However, the observed progressive deterioration of these results suggests the need of an upgrade in the service provided and an additional investment in the Quitline promotion.

Poster presentations: Topic 16, Tuesday March 29 339 Implementation Since even underfunded and reactive Quitlines show to have results, and following the recommendations of the FCTC article 14th guidelines, smokers who wish to quit smoking should have the possibility to call a Quitline in order to receive advice and counselling from trained cessation specialists.

16.5 Tobacco habits among youth in Sweden - a challenge

C.B. Birgersson National Institute of Public Health, ÖST…RSUND, Sweden

Background To get more information about teenager’s knowledge and attitudes to tobacco conducted the Swedish National Institute of Public Health a survey in year 2010 among 13-, 15- and 17 year old boys and girls.

The results showed that in four out of five school yards pupils smoked. Sweden has a tobacco law since1994 which included a smoking ban within school yards i.e. they are smoke free areas, at all time during the day. Four out of ten pupils answered that many pupils smoke on their school yard. No improvement is found about school staff acting against pupils smoking in the school yard since the latest survey 2003. Four out of ten young people say that school staff smoke on their school yard and some say that they are exposed to second hand smoke at school or in the school yard. Finally the survey showed that pupils in Sweden are positive toward restrictions and legislation as tobacco free school hours.

Other important results are that young people in Sweden start to smoke early. Half of the young people who had tried smoking, smoked their first cigarette being 13 years of age or younger. Fewer smokers wanted to quit smoking and fewer had actually tried to quit compared to the last survey from 2003.

Conclusions Smoking among youth in Sweden is still a huge problem but there are things that can be done. Most children and young adults are spending most their time during the week in school. Sweden has a tobacco law but it is not enough since compliance is low. Several international surveys and Swedish experiences show that a school policy is an effective tool, especially if it is part of a broader comprehensive tobacco control strategy. In order to make schools compile with the law and get good policies has the Swedish National Institute of Public Health created National recommendations for a smoke free schoolyard and advocate Tobacco free school hours. We have also started to “empower”the municipalities by development projects based on local conditions. This paper will discuss Swedish experience of tobacco use among youth and what can be done at local level in the municipalities and at the school yards.

Poster presentations: Topic 16, Tuesday March 29 340 16.6 Smoke-free hospitals: determinants of success

D. Petrosyan1, N. Movsisyan1, V. Petrosyan1, A. Harutyunyan1, L. Hepp2, E. Avika-Tang2, M.P.H. Donaldson2, F. Stillman2 1American University of Armenia, Y…R…VAN, Armenia 2Johns Hopkins Bloomberg School of Public Health, BALTIMOR…, United States of America

Aim The aim of this study was to develop an intervention to increase worksite compliance with smoke-free policies and demonstrate its effectiveness through monitoring SHS exposure levels.

Methods The study team used TSI SidePaks AM510 to measure particulate matters (PM2.5) andfilter badges to capture vapor-phase nicotine. Other methods included baseline and follow up surveys and focus group discussions with employees at two hospitals in Yerevan, serving as control and intervention sites (“panel design”).

Intervention The study team shared with the administration of the intervention site the findings from baseline phase and had a number of joint meetings to develop and implement a series of activities. The new institutional non-smoking policy was launched on the National No Tobacco Day that was widely covered by the media. No-smoking signs and posters referring to the national law prohibiting smoking inside health facilities and the fines for breaking this law were posted all over the hospital. All ashtrays were replaced with garbage cans with a no smoking sign on them. The brochures “Why to quit smoking” and “How to quit smoking”were distributed among the nurses, patients and their relatives.

Results Overall 245 and 233 employees participated in baseline and follow up surveys at the intervention and control sites, respectively. The awareness of and the compliance with the worksite smoke-free policy increased statistically significantly between baseline and follow up assessments at the intervention hospital: more respondents rated the air quality (tobacco smoke level) as either excellent or good in the building (18.67% vs. 38.09%); the proportion of respondents reporting that smoking was forbidden anywhere in the hospital was higher (37.55% vs. 62.11%), and more respondents stated that the official policies about smoking in the building were followed at follow up (36.91% vs. 72.61%). PM2.5 concentrations at baseline in both hospitals were as high as concentrations observed in bars in other countries. However, documented concentrations at follow up in intervention site were much lower while it did not change at the control hospital.

Poster presentations: Topic 16, Tuesday March 29 341 and continuing efforts are crucial for successful implementation of tobacco control interventions.

16.7 Developing a Model for Smoke-Free Universities

A. Harutyunyan1, N. Movsisyan1, V. Petrosyan1, D. Petrosyan1, L. Hepp2, E. Avika-Tang2, M.P.H. Donaldson2, F. Stillman2 1American University of Armenia, Y…R…VAN, Armenia 2Johns Hopkins Bloomberg School of Public Health, BALTIMOR…, United States of America

Goal The objective of the study implemented by the American University of Armenia in cooperation with IGTC at Johns Hopkins Bloomberg School of Public Health was to use secondhand smoke (SHS) measurements to develop and test interventions in the educational facilities in Yerevan, Armenia.

Methods The study team selected two universities, Yerevan State Medical University as a control site and Yerevan State Pedagogical University as an intervention site. The data were collected by passive and active air monitoring (PM2.5 and air nicotine), observations, survey and focus group discussions. PM2.5 monitoring was conducted in the public lobbies, cafeterias and student lounges. Surveys were conducted among faculty, administrative staff and students to assess the level of awareness and compliance with smokefree policies before and after the interventions. Stratified random selection was used in the student survey. All faculty and staff members at the randomly selected departments who participated in the baseline survey were given a unique identification number to be followed up after the intervention (panel survey design). The study team conducted focus groups with the staff, students and faculty to develop interventions based on their suggestions.

Intervention After sharing the baseline results of air monitoring with the university stakeholders, the study team, in collaboration with the university administration and student volunteers, developed series of intervention activities. Those included celebration of the National No Tobacco Day, posting “no smoking”signs and posters to inform about the law and fines for breaking this law in the university buildings, replacement of all ashtrays inside the university buildings with garbage cans with a no-smoking sign on them, anti-tobacco essay and cartoon competitions among students, seminars/lecture series for the students, faculty, and staff, distribution of leaflets for raising awareness about the dangers of secondhand smoke and about the ban of smoking.

Results Overall, 1245 students and 211 employees from the intervention site and 1155 students and 237 employees from the control sites participated in baseline and follow-up surveys.

PM2.5 concentrations in both universities at baseline were as high as concentrations observed in bars in other countries, however, the PM2.5 concentrations were signifi-

Poster presentations: Topic 16, Tuesday March 29 342 cantly lower at follow-up than at baseline at the intervention site. Based on survey results, significantly lower proportion of participants observed smoking inside the university buildings (30 day recall). The proportion of survey participants who were aware on the worksite ban of smoking also increased by 30%.

16.8 The physical activity status of smokers on subsequent smoking cessation rate and mortality rate

C.P. Wen, M.K. Tsai National Health Research Institutes, MIAOLI, Taiwan

Background and Objective Regular exercise may help people give up smoking but epidemiological data were insufficient to show the proof. The aim is to assess the different physical activity status of smokers in their subsequent quitting behavior and on their mortality rate.

Method The cohort, 118,115, came from a standard medical screening program since 1996 in Taiwan. Questionnaire on duration and intensity was converted into active and inactive by the amount of MET-hour/week. Those exercised 7.5 MET-hour/week were considered “physically active”. Hazard ratios (HR) were calculated by Cox model. Deaths information was ascertained as of 2007.

Results In an average period of 1.7 years, 19,384 smokers were assessed twice for their smoking status and their physical activity status. Physically active smokers, with 9.28% quit rate, had a 63% increase in quitting than inactive smokers throughout the period, with 5.69%. The inactive smokers, once they became active, the quit rate increased (to 7.81%) by 37%. 51% more smokers who quit in general were active (34.94%) than smokers who continued to smoke (23.13%) Active smokers had significant dose-response reduction of all-cause mortality when compared with inactive smokers.

Conclusion Exercise can significantly improve quit rate and reduce smoker’s mortality rate. Physically active smokers had a higher likelihood of quitting. The inactive smokers also quit more if they changed to physically active status. The more active the smokers, the more the reduction on subsequent all-cause mortality.

Poster presentations: Topic 16, Tuesday March 29 343 16.9 Smoker’s awareness and the effects of smoking or quitting on tuberculosis in a Chinese population

C.P. Wen, T.C.C. Chan, H.T.C. Chan, M.K. Tsai National Health Research Institutes, MIAOLI, Taiwan

Background The role of smoking in aggravating tuberculosis (Tb) has not been fully established from prospective cohort studies, and both clinicians and patients are unaware of the benefits of smoking cessation.

Methods The cohort, consisting of 486,341 adults, participated in standard medical screening programs since 1994, including 5,036 with self-reported Tb history. Within 15,268 deaths identified as of 2007, 77 were coded as Tb. Cox proportional model was used to calculate hazard ratio (HR), adjusted for age, gender, education, and drinking.

Results Awareness of Tb history increased sharply with increasing age. Smokers reported 25% less Tb history but died more from Tb than non-smokers. The HR for current smokers, 3.78 (95% CI: 1.6-9.0), including light smokers, 3.11(95% CI: 1.2-8.3), and ex-smokers, 1.88 (95% CI: 0.6-5.6), along with smoking prevalence, were translated into nearly half (44.6%) of Tb being smoking attributable in Taiwan. Smoking increased 9 folds of Tb mortality among those without Tb history (HR=9.29), but when they quit smoking, the ex-smoker’s risk (HR=2.74) reduced significantly by 74%. Similar pattern was seen for smokers with Tb history.

Conclusion Smokers were less aware of having Tb history than nonsmokers, even though light smoking increased their Tb mortality risks by more than 3-fold. Nearly half of Tb deaths in this Chinese population were attributable to smoking and smokers’ risk of dying from Tb was reduced by half or more when they quit smoking. Clinicians should be more alert toward reducing Tb risk among smokers, as smokers and Tb patients share clinical symptoms.

Poster presentations: Topic 16, Tuesday March 29 344 Thanks to all the conference sponsors and supporters Sponsors

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